Choledochoscopic photodynamic therapy combined with biliary stent implantation for the treatment of unresectable hilar cholangiocarcinoma
Photodynamic therapy (PDT) has emerged as a prominent modality in the therapeutic armamentarium against malignant tumors, particularly those originating from the cutaneous and mucosal tissues (1). The principle of PDT involves the administration of a photosensitizing agent that selectively accumulates within neoplastic cells (2). Upon exposure to laser light of specific wavelengths, the photosensitizer becomes activated, triggering the generation of reactive oxygen species (ROS) such as oxygen radicals (3). This process culminates in cellular damage and subsequent tumor destruction. PDT holds promise as a localized therapeutic option for unresectable or recurrent cholangiocarcinomas (4).
A 59-year-old female patient presented with unresectable hilar cholangiocarcinoma following prior choledochotomy with exploration, during which a T-drainage was inserted. Subsequently, the patient underwent systemic chemotherapy with gemcitabine and oxaliplatin, supplemented by sulfatinib and tislelizumab. However, hepatic dysfunction ensued post-systemic therapy, necessitating the adoption of PDT as a localized therapeutic intervention. The patient received intravenous administration of hiporfin 48 hours prior to PDT. Prior to treatment initiation, the T-drainage was removed, and a choledochoscope was advanced through the sinus into the bile duct. Subsequently, optical fibers were introduced via the working channel of the choledochoscope and positioned at the intra-biliary lesions. Laser light at a wavelength of 630 nm was then delivered, irradiating the lesions for 15 minutes with 30-second intervals every 5 minutes. Choledochoscopic examination was performed 24 hours post-PDT, during which necrotic tissue resulting from the therapy was cleared, and three metal stents were deployed within the bile duct to prevent stenosis (Video 1). Choledochal drainage was subsequently reestablished. Post-procedure, the patient was advised to avoid exposure to intense light for a duration of 4 weeks.
The patient experienced prompt recovery and was discharged two days post-PDT. Subsequent management comprised additional rounds of chemotherapy and targeted therapy. Follow-up choledochoscopic examination at 8 weeks post-PDT revealed absence of residual lesions or stenosis.
PDT represents a safe and efficacious therapeutic modality for managing unresectable or recurrent cholangiocarcinomas (5). Its complementarity with systemic treatments can potentially enhance overall therapeutic outcomes (6). Choledochoscopic PDT offers the advantage of direct visualization of lesions and the normal bile duct wall, thereby facilitating precise biopsy procedures (7). Concurrent placement of choledochal stents is feasible, albeit requiring the establishment of a percutaneous sinus into the bile duct, which may be achieved via percutaneous transhepatic cholangiodrainage (PTCD) or T-drainage techniques (8). In cases where ERCP may not be able to intubate through hilar lesions, choledochoscopic PDT and stent implantation would be considered even better.
Acknowledgments
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Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-123/coif). The authors report that this work was supported by the Natural Science Foundation of Hunan Province (2024JJ4095), Scientific Research Project of Hunan Provincial Health Commission (202204010011 and B202303027830) and Project Program of National Clinical Research Center for Geriatric Disorders (2022LNJJ19). The authors have no other conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The experimental protocol was established, according to the ethical guidelines of the Declaration of Helsinki and its subsequent amendments, and was approved by the Human Ethics Committee of Xiangya Hospital.
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