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The Learning Curve for Peroral Endoscopic Myotomy in Latin America: A Slide to the Right?
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Michel Kahaleh, Amy Tyberg, Supriya Suresh, Arnon Lambroza, Fernando Rodriguez Casas, Mario Rey, Jose Nieto, Guadalupe Ma Martínez, Felipe Zamarripa, Vitor Arantes, Maria G Porfilio, Monica Gaidhane, Pietro Familiari, Juan Carlos Carames, Romulo Vargas-Rubio, Raul Canadas, Albis Hani, Guillermo Munoz, Bismarck Castillo, Eduardo T Moura, Farias F Galileu, Hannah P Lukashok, Carlos Robles-Medranda, Eduardo G de Moura
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Clin Endosc 2021;54(5):701-705. Published online June 3, 2021
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DOI: https://doi.org/10.5946/ce.2020.290
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 Abstract
 PDF PubReader ePub
- Background
/Aims: Peroral endoscopic myotomy (POEM) has been increasingly used for achalasia in Latin America, where Chagas disease is prevalent, and this makes POEM more challenging. The aim of this study was to determine the learning curve for POEM in Latin America.
Methods
Patients undergoing POEM in Latin America with a single operator were included from a prospective registry over 4 years. Non-linear regression and cumulative sum control chart (CUSUM) analyses were conducted for the learning curve.
Results
A total of 125 patients were included (52% male; mean age, 59 years), of which 80 had type II achalasia (64%), and 38 had Chagas disease (30%). The average pre-procedure and post-procedure Eckardt scores were 6.79 and 1.87, respectively. Technical success was achieved in 93.5% of patients, and clinical success was achieved in 88.8%. Adverse events occurred in 27 patients (22%) and included bleeding (4 patients), pneumothorax (4 patients), mucosal perforation (13 patients), mediastinitis (2 patients), and leakage (4 patients).
The CUSUM chart showed a median procedure time of 97 min (range, 45-196 min), which was achieved at the 61st procedure. Procedure duration progressively decreased, with the last 10 procedures under 50 min approaching a plateau (p-value <0.01).
Conclusions
Mastering POEM in Latin America requires approximately 61 procedures for both POEM efficiency and to accomplish the procedure within 97 minutes.
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Citations
Citations to this article as recorded by  - Experiencia en miotomía endoscópica peroral en un centro de Bogotá, Colombia, entre 2018 y 2022
Tatiana P Barragan Briceño, Paola Stephany Gonzalez Ausique, Carlos Fernando Fuentes Díaz, Jesús Antonio Rodríguez Fajardo, Maria Camila Gomez Ayala
Revista colombiana de Gastroenterología.2024; 39(2): 146. CrossRef - Miotomía endoscópica por vía oral (POEM) como tratamiento para la acalasia pediátrica: estudio multicéntrico y primeros resultados
Carlos Leganés Villanueva, Eduardo Albéniz Arbizu, Ilaria Goruppi, Nuria Brun Lozano, Federica Bianchi, Alberto Pérez Martínez, Sheyla Montori Pina, Ada Yessenia Molina Caballero, Marianette Murzi, Federico Betroletti, Fermin Estremera, Susana Boronat Gue
Gastroenterología y Hepatología.2024; : 502262. CrossRef - Learning curve for esophageal peroral endoscopic myotomy: a systematic review and meta-analysis
Srinivas R. Puli, Mihir S. Wagh, David Forcione, Harishankar Gopakumar
Endoscopy.2023; 55(04): 355. CrossRef - Diagnosis and Management of Achalasia: Updates of the Last Two Years
Amir Mari, Fadi Abu Baker, Rinaldo Pellicano, Tawfik Khoury
Journal of Clinical Medicine.2021; 10(16): 3607. CrossRef - Issues to be Considered for Learning Curve for Peroral Endoscopic Myotomy
Hironari Shiwaku, Haruhiro Inoue
Clinical Endoscopy.2021; 54(5): 625. CrossRef
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Endoscopic Therapy for Pancreatic Fluid Collections: A Definitive Management Using a Dedicated Algorithm
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Ming Ming Xu, Iman Andalib, Aleksey Novikov, Enad Dawod, Moamen Gabr, Monica Gaidhane, Amy Tyberg, Michel Kahaleh
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Clin Endosc 2020;53(3):355-360. Published online December 3, 2019
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DOI: https://doi.org/10.5946/ce.2019.113
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Abstract
PDFPubReaderePub
- Background
/Aims: Endoscopic ultrasonography (EUS)-guided drainage is the preferred approach for infected or symptomatic pancreatic fluid collections (PFCs). Here, we developed an algorithm for the management of pancreatitis complicated by PFCs and report on its effcacy and safety.
Methods
Between September 2011 and October 2017, patients were prospectively managed according to the algorithm. PFCs were classified as poorly organized fluid collections (POFCs), pancreatic pseudocysts (PPs), or walled-off pancreatic necrosis (WOPN). Clinical success was defined as a decrease in PFC size by ≥50% of the maximal diameter or to ≤2 cm.
Results
A total of 108 patients (62% male; mean age, 53 years) were included: 13 had POFCs, 43 had PPs, and 52 had WOPN. Seventytwo patients (66%) required a pancreatic duct (PD) stent, whereas 65 (60%) received enteral feeding. A total of 103 (95%) patients achieved clinical success. Eight patients experienced complications including bleeding (n=6) and surgical intervention (n=2). Patients with enteral feeding were 3.4 times more likely to achieve resolution within 60 days (p=0.0421), whereas those with PD stenting was five times more likely to achieve resolution within 90 days (p=0.0069).
Conclusions
A high PFC resolution rate can be achieved when a dedicated algorithm encompassing EUS-guided drainage, PD stenting, and early enteral feeding is adopted.
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Citations
Citations to this article as recorded by - Novel classification system for walled-off necrosis: a step toward standardized nomenclature and risk-stratification framework
Serge Baroud, Vinay Chandrasekhara, Andrew C. Storm, Ryan J. Law, Eric J. Vargas, Michael J. Levy, Tala Mahmoud, Fateh Bazerbachi, Aliana Bofill-Garcia, Rabih Ghazi, Daniel B. Maselli, John A. Martin, Santhi Swaroop Vege, Naoki Takahashi, Bret T. Petersen
Gastrointestinal Endoscopy.2023; 97(2): 300. CrossRef - Endoscopic versus percutaneous drainage for pancreatic fluid collection after pancreatic surgery: An up-to-date meta-analysis and systematic review
Liang Chen, Ting Li, Bin Wang, Yunxiao Cheng, Sicong Zhao, Yunxiao Lyu
Asian Journal of Surgery.2022; 45(8): 1519. CrossRef - Transluminal and retroperitoneal minimally invasive necrosectomy in acute pancreatitis
A. V. Fedorov, V. N. Ektov, M. A. Khodorkovskiy
Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery.2022; 27(3): 81. CrossRef - Endoscopic transluminal interventions in the treatment of acute necrotizing pancreatitis
A.V. Fedorov, V.N. Ektov, M.A. Khodorkovsky
Khirurgiya. Zhurnal im. N.I. Pirogova.2021; (9): 85. CrossRef - Hydrogen peroxide assisted endoscopic necrosectomy for walled-off pancreatic necrosis: A systematic review and meta-analysis
Rajat Garg, Shradha Gupta, Amandeep Singh, Marian T. Simonson, Tarun Rustagi, Prabhleen Chahal
Pancreatology.2021; 21(8): 1540. CrossRef - The Diagnostic Dilemma of Malignant Biliary Strictures
Robert Dorrell, Swati Pawa, Yi Zhou, Neeraj Lalwani, Rishi Pawa
Diagnostics.2020; 10(5): 337. CrossRef - Importance of Pancreatic Duct Stenting and Enteral Feeding in Treatment Algorithm of Pancreatic Fluid Collections
Seong-Hun Kim, Eun Ji Shin
Clinical Endoscopy.2020; 53(3): 253. CrossRef - Role of pancreatography in the endoscopic management of encapsulated pancreatic collections – review and new proposed classification
Igor Mendonça Proença, Marcos Eduardo Lera dos Santos, Diogo Turiani Hourneaux de Moura, Igor Braga Ribeiro, Sergio Eiji Matuguma, Spencer Cheng, Thomas R McCarty, Epifanio Silvino do Monte Junior, Paulo Sakai, Eduardo Guimarães Hourneaux de Moura
World Journal of Gastroenterology.2020; 26(45): 7104. CrossRef
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Reverse Endoscopic Ultrasound-Guided Gastrojejunostomy for the Treatment of Superior Mesenteric Artery Syndrome: A New Concept
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Ming-ming Xu, Enad Dawod, Monica Gaidhane, Amy Tyberg, Michel Kahaleh
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Clin Endosc 2020;53(1):94-96. Published online December 3, 2019
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DOI: https://doi.org/10.5946/ce.2018.196
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Abstract
PDF
 Supplementary MaterialPubReaderePub
- Superior mesenteric artery syndrome (SMAS) causes compression and partial or complete obstruction of the duodenum, resulting in abdominal pain, nausea, vomiting, and weight loss. If conservative therapy fails, the patient is typically referred for enteral feeding or laparoscopic gastrojejunostomy.
The last few years have seen increasing use of endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) for gastric obstruction indications. EUS-GJ involves the creation of a gastric bypass via an echoendoscope in cases in which the small intestine can be punctured under ultrasonographic visualization, resulting in an incision-free, efficient, and safe procedure.
In this case report, we present the first case of SMAS treated using a reverse EUS-GJ, and describe the steps and advantages of the procedure in this particular case.
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Citations
Citations to this article as recorded by - Endoscopic Treatment of Gastric Outlet Obstruction
Andrew Canakis, Shayan S. Irani
Gastrointestinal Endoscopy Clinics of North America.2024; 34(1): 111. CrossRef - Endoscopic ultrasound (EUS)-guided gastrojejunostomy for management of superior mesenteric artery (SMA) syndrome
Joanna Jiang, Mitchell Ramsey, Tessa Crilley, Jordan Burlen
BMJ Case Reports.2024; 17(11): e260757. CrossRef - New frontiers for therapeutic endoscopic ultrasound in children
Valerio Balassone, Simona Faraci, Chiara Imondi, Paola De Angelis, Tamara Caldaro, Luigi Dall'Oglio
International Journal of Gastrointestinal Intervention.2023; 12(1): 1. CrossRef - Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline
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Raluca Cristina Apostu, Lucian Chira, Doina Colcear, Andrei Lebovici, Georgiana Nagy, Radu Razvan Scurtu, Radu Drasovean
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O. V. Galimov, V. O. Khanov, H.M. H. Karkhani, Sh. Bhawna, T. R. Ibragimov
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Andrew C. Storm, Tala Mahmoud, Karl Akiki, Ryan J. Law
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Laurent Monino, Marc Barthet
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Abdul Kouanda, Rabindra Watson, Kenneth F. Binmoeller, Andrew Nett, Christopher Hamerski
VideoGIE.2021; 6(1): 14. CrossRef - Novel Uses of Lumen-apposing Metal Stents
Prashant Bhenswala, Muhddesa Lakhana, Frank G. Gress, Iman Andalib
Journal of Clinical Gastroenterology.2021; 55(8): 641. CrossRef
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Endoscopic Ultrasound (EUS)-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography or EUS: Mid-Term Analysis of an Emerging Procedure
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Amy Tyberg, Jose Nieto, Sanjay Salgado, Kristen Weaver, Prashant Kedia, Reem Z. Sharaiha, Monica Gaidhane, Michel Kahaleh
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Clin Endosc 2017;50(2):185-190. Published online September 19, 2016
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DOI: https://doi.org/10.5946/ce.2016.030
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Abstract
PDFPubReaderePub
- Background
/Aims: Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone Rouxen-Y gastric bypass (RYGB) is challenging. Standard ERCP and enteroscopy-assisted ERCP are associated with limited success rates. Laparoscopy- or laparotomy-assisted ERCP yields improved efficacy rates, but with higher complication rates and costs. We present the first multicenter experience regarding the efficacy and safety of endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) or EUS.
Methods
All patients who underwent EDGE at two academic centers were included. Clinical success was defined as successful ERCP and/or EUS through the use of lumen-apposing metal stents (LAMS). Adverse events related to EDGE were separated from ERCP- or EUS-related complications and were defined as bleeding, stent migration, perforation, and infection.
Results
Sixteen patients were included in the study. Technical success was 100%. Clinical success was 90% (n=10); five patients were awaiting maturation of the fistula tract prior to ERCP or EUS, and one patient had an aborted ERCP due to perforation. One perforation occurred, which was managed endoscopically. Three patients experienced stent dislodgement; all stents were successfully repositioned or bridged with a second stent. Ten patients (62.5%) had their LAMS removed. The average weight change from LAMS insertion to removal was negative 2.85 kg.
Conclusions
EDGE is an effective, minimally invasive, single-team solution to the difficulties associated with ERCP in patients with RYGB.
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Citations
Citations to this article as recorded by - American Society for Gastrointestinal Endoscopy guideline on the role of therapeutic EUS in the management of biliary tract disorders: methodology and review of evidence
Neil B. Marya, Swati Pawa, Nikhil R. Thiruvengadam, Saowanee Ngamruengphong, Todd H. Baron, Anthony Yuen Bun Teoh, Christopher K. Bent, Wasif Abidi, Omeed Alipour, Stuart K. Amateau, Madhav Desai, Jean M. Chalhoub, Nayantara Coelho-Prabhu, Natalie Cosgrov
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Khaled Elfert, Michel Kahaleh
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Hafiz Muzaffar Akbar Khan, Azhar Hussain, Vishnu Charan Suresh Kumar, Dennis Yang, Muhammad Khalid Hasan
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Ru-Yi Wang, Zhen Fan
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Swati Pawa, Neil B. Marya, Nikhil R. Thiruvengadam, Saowanee Ngamruengphong, Todd H. Baron, Anthony Yuen Bun Teoh, Christopher K. Bent, Wasif Abidi, Omeed Alipour, Stuart K. Amateau, Madhav Desai, Jean M. Chalhoub, Nayantara Coelho-Prabhu, Natalie Cosgrov
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Rishi Pawa, Troy Pleasant, Chloe Tom, Swati Pawa
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Prashant Bhenswala, Muhddesa Lakhana, Frank G. Gress, Iman Andalib
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Ilaria Tarantino, Giacomo Emanuele Maria Rizzo
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Alberto Tringali, Deborah Costa, Alessandro Fugazza, Matteo Colombo, Kareem Khalaf, Alessandro Repici, Andrea Anderloni
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Endoscopic Gallbladder Drainage for Acute Cholecystitis
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Jessica Widmer, Paloma Alvarez, Reem Z. Sharaiha, Sonia Gossain, Prashant Kedia, Savreet Sarkaria, Amrita Sethi, Brian G. Turner, Jennifer Millman, Michael Lieberman, Govind Nandakumar, Hiren Umrania, Monica Gaidhane, Michel Kahaleh
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Clin Endosc 2015;48(5):411-420. Published online September 30, 2015
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DOI: https://doi.org/10.5946/ce.2015.48.5.411
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Abstract
PDFPubReaderePub
- Background/Aims
Surgery is the mainstay of treatment for cholecystitis. However, gallbladder stenting (GBS) has shown promise in debilitated or high-risk patients. Endoscopic transpapillary GBS and endoscopic ultrasound-guided GBS (EUS-GBS) have been proposed as safe and effective modalities for gallbladder drainage. MethodsData from patients with cholecystitis were prospectively collected from August 2004 to May 2013 from two United States academic university hospitals and analyzed retrospectively. The following treatment algorithm was adopted. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and cystic duct stenting was initially attempted. If deemed feasible by the endoscopist, EUS-GBS was then pursued. ResultsDuring the study period, 139 patients underwent endoscopic gallbladder drainage. Among these, drainage was performed in 94 and 45 cases for benign and malignant indications, respectively. Successful endoscopic gallbladder drainage was defined as decompression of the gallbladder without incidence of cholecystitis, and was achieved with ERCP and cystic duct stenting in 117 of 128 cases (91%). Successful endoscopic gallbladder drainage was also achieved with EUS-guided gallbladder drainage using transmural stent placement in 11 of 11 cases (100%). Complications occurred in 11 cases (8%). ConclusionsEndoscopic gallbladder drainage techniques are safe and efficacious methods for gallbladder decompression in non-surgical patients with comorbidities.
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Peroral Endoscopic Myotomy: Establishing a New Program
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Nikhil A. Kumta, Shivani Mehta, Prashant Kedia, Kristen Weaver, Reem Z. Sharaiha, Norio Fukami, Hitomi Minami, Fernando Casas, Monica Gaidhane, Arnon Lambroza, Michel Kahaleh
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Clin Endosc 2014;47(5):389-397. Published online September 30, 2014
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DOI: https://doi.org/10.5946/ce.2014.47.5.389
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Abstract
PDFPubReaderePub
Achalasia is an esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter (LES) and aperistalsis of the esophageal body. Treatment of achalasia is aimed at decreasing the resting pressure in the LES. Peroral endoscopic myotomy (POEM), derived from natural orifice transluminal endoscopic surgery (NOTES) and advances in endoscopic submucosal dissection (ESD), presents a novel, minimally invasive, and curative endoscopic treatment for achalasia. POEM involves an esophageal mucosal incision followed by creation of a submucosal tunnel crossing the esophagogastric junction and myotomy before closure of the mucosal incision. Although the procedure is technically demanding and requires a certain degree of skill and competency, treatment success is high (90%) with low complication rates. Since the first described POEM in humans in 2010, it has been used increasingly at centers worldwide. This article reviews available published clinical studies demonstrating POEM efficacy and safety in order to present a proposal on how to establish a dedicated POEM program and reach base proficiency for the procedure. -
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Pancreatic Fluid Collection Drainage by Endoscopic Ultrasound: An Update
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Shashideep Singhal, Stephen R. Rotman, Monica Gaidhane, Michel Kahaleh
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Clin Endosc 2013;46(5):506-514. Published online September 30, 2013
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DOI: https://doi.org/10.5946/ce.2013.46.5.506
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Abstract
PDFPubReaderePub
Endoscopic management of symptomatic pancreatic fluid collections (PFCs) is now considered to be first line therapy. Expanded use of endoscopic ultrasound (EUS) techniques has resulted in increased applicability, safety, and efficacy of endoscopic transluminal PFC drainage. Steps include EUS-guided trangastric or transduodenal fistula creation into the PFC followed by stent placement or nasocystic drain deployment in order to decompress the collection. With the remarkable improvement in the available accessories and stents and development of exchange free access device; EUS drainage techniques have become simpler and less time consuming. The use of self-expandable metal stents with modifications to drain PFC has helped in overcoming some previously encountered challenges. PFCs considered suitable for endoscopic drainage include collection present for greater than 4 weeks, possessing a well-formed wall, position accessible endoscopically and located within 1 cm of the duodenal or gastric walls. Indications for EUS-guided drainage have been increasing which include unusual location of the collection, small window of entry, nonbulging collections, coagulopathy, intervening varices, failed conventional transmural drainage, indeterminate adherence of PFC to the luminal wall or suspicion of malignancy. In this article, we present a review of literature to date and discuss the recent developments in EUS-guided PFC drainage. -
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Endoscopic Guided Biliary Drainage: How Can We Achieve Efficient Biliary Drainage?
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Prashant Kedia, Monica Gaidhane, Michel Kahaleh
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Clin Endosc 2013;46(5):543-551. Published online September 30, 2013
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DOI: https://doi.org/10.5946/ce.2013.46.5.543
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Abstract
PDFPubReaderePub
Currently, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred procedure for biliary drainage for various pancreatico-biliary disorders. ERCP is successful in 90% of the cases, but is unsuccessful in cases with altered anatomy or with tumors obstructing access to the duodenum. Due to the morbidity and mortality associated with surgical or percutaneous approaches in unsuccessful ERCP cases, biliary endoscopists have been using endoscopic ultrasound-guided biliary drainage (EUS-BD) more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that incorporates various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS-BD techniques. Indications for EUS-BD include failed conventional ERCP, altered anatomy, tumor preventing access into the biliary tree and contraindication to percutaneous access (i.e., ascites, etc.). EUS-BD utilizing EUS-guided rendezvous technique is conducted by creating a tract from either the stomach or the duodenum into the bile duct. Although EUS-BD has rapidly been gaining attraction and popularity in the endoscopic world, the indications and methods have yet to be standardized. There are several access routes and techniques that are employed by advanced endoscopists throughout the world for BD. This article reviews the indications and currently practiced EUS-BD techniques, including indications, technical details (intrahepatic or extrahepatic approach), equipment, patient selection, complications, and overall advantages and limitations. -
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Piero Boraschi
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7,996
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87
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27
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Technical Advances in Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition for Pancreatic Cancers: How Can We Get the Best Results with EUS-Guided Fine Needle Aspiration?
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Prashant Kedia, Monica Gaidhane, Michel Kahaleh
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Clin Endosc 2013;46(5):552-562. Published online September 30, 2013
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DOI: https://doi.org/10.5946/ce.2013.46.5.552
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Abstract
PDFPubReaderePub
Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is one of the least invasive and most effective modality in diagnosing pancreatic adenocarcinoma in solid pancreatic lesions, with a higher diagnostic accuracy than cystic tumors. EUS-FNA has been shown to detect tumors less than 3 mm, due to high spatial resolution allowing the detection of very small lesions and vascular invasion, particularly in the pancreatic head and neck, which may not be detected on transverse computed tomography. Furthermore, this minimally invasive procedure is often ideal in the endoscopic procurement of tissue in patients with unresectable tumors. While EUS-FNA has been increasingly used as a diagnostic tool, most studies have collectively looked at all primary pancreatic solid lesions, including lymphomas and pancreatic neuroendocrine neoplasms, whereas very few studies have examined the diagnostic utility of EUS-FNA of pancreatic ductal carcinoma only. As with any novel and advanced endoscopic procedure that may incorporate several practices and approaches, endoscopists have adopted diverse techniques to improve the tissue procurement practice and increase diagnostic accuracy. In this article, we present a review of literature to date and discuss currently practiced EUS-FNA technique, including indications, technical details, equipment, patient selection, and diagnostic accuracy. -
Citations
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Kosuke Takahashi, Ichiro Yasuda, Nobuhiko Hayashi, Takuji Iwashita, Mitsuru Okuno, Tsuyoshi Mukai, Masatoshi Mabuchi, Seiji Adachi, Shinpei Doi, Johji Imura, Eisuke Ozawa, Hisamitsu Miyaaki, Kazuhiko Nakao
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Photodynamic Therapy in Unresectable Cholangiocarcinoma: Not for the Uncommitted
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Jayant P. Talreja, Marisa DeGaetani, Kristi Ellen, Timothy Schmitt, Monica Gaidhane, Michel Kahaleh
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Clin Endosc 2013;46(4):390-394. Published online July 31, 2013
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DOI: https://doi.org/10.5946/ce.2013.46.4.390
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Abstract
PDFPubReaderePub
- Background/Aims
Photodynamic therapy (PDT) in unresectable cholangiocarcinoma has been associated with improved survival. We report a single tertiary care center experience over the past 6 years. MethodsFifty-five patients with unresectable cholangiocarcinoma received PDT between 2004 and 2010. Plastic stents were placed after PDT to prevent cholangitis. ResultsTwenty-seven patients (49%) showed Bismuth type IV, 22 (41%) showed Bismuth type III, and six (10%) showed Bismuth type I and II. Twenty patients (37%) received chemotherapy and radiation therapy, five (9%) received chemotherapy only; and one (2%) received radiation therapy only. Mean number of PDT sessions was 1.9±1.5 sessions (range, 1 to 9). Mean survival duration was 293±266 days (median, 190; range, 25 to 1,332). PDT related complications included three (5%) facial burn, three (5%) photosensitivity, and two (3%) rash. Kaplan-Meier analysis comparing the survival means of patients who received PDT and chemotherapy/radiation therapy (median survival 257 days; 95% confidence interval [CI], 166 to 528) versus who received PDT only (median survival 183 days; 95% CI, 129 to 224) showed no significant difference (log-rank p=0.20). ConclusionsPDT has a measurable impact on survival in unresectable cholangiocarcinoma but requires aggressive stenting posttherapy.
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