Direct cholangioscopy and pancreatoscopy

Adverse events of the single-operator cholangioscopy system: a Manufacturer and User Facility Device Experience database analysis

BACKGROUND AND AIMS

The SpyGlass (Boston Scientific, Marlborough, Mass, USA) single-operator cholangioscopy (SOC) system is generally considered to be safe but adds additional risks to those associated with standard ERCP.

METHODS

We evaluated adverse events (AEs) associated with the SpyGlass system reported in the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience database between January 2016 and August 2023.

RESULTS

From the database, 2311 device problems (SpyGlass DS, 1301; SpyGlass DS II, 1010) were reported. An optical problem was the most reported issue (SpyGlass DS, 83; SpyGlass DS II, 457). Patient-related events were found in 62 of 1743 reports (3.5%): 33 with the SpyGlass DS and 29 with the SpyGlass DS II. The most common AEs were bleeding/hemorrhage followed by perforation; infection, fever, or sepsis; and pancreatitis.

CONCLUSIONS

Our findings add to the existing literature and provide a fuller picture of potential problems associated with the SpyGlass SOC.

Novel peroral cholangioscopy-directed lithotripsy using an ultraslim upper endoscope for refractory Mirizzi syndrome: A case report

RATIONALE

Mirizzi syndrome (MS) is an uncommon condition characterized by common hepatic duct (CHD) compression by an impacted gallbladder or cystic duct stones or adjacent inflammation. To date, a standardized therapeutic strategy for MS has not been established yet, owing to its complex clinical presentation. Thus, researchers still have to develop new optimized approaches to solve this problem. Herein, we describe a patient with refractory MS who underwent a successful treatment by novel hybrid anchoring balloon-guided direct peroral cholangioscopy (POC) using an ultraslim endoscope.

PATIENT CONCERNS

A 56-year-old man with a history of biliary stone was referred to our hospital for complaints of discomfort in the right upper quadrant of the abdomen and obstructive jaundice. Endoscopic retrograde cholangiopancreatography showed an 18-mm impacted stone at the level of the cystic duct, which compressed the CHD. The CHD had local stricture, with its upstream and intrahepatic bile duct dilation.

DIAGNOSES

He was diagnosed with type I MS.

INTERVENTIONS

Initially, the patient received an endoscopic major sphincterotomy. However, conventional stone extraction, including mechanical lithotripsy, was unsuccessful. Then, after signing the informed consent form for further treatment, he was successfully treated with novel hybrid anchoring balloon-guided direct POC.

OUTCOMES

The patient had no operative complications and was discharged with cleared ducts. At the 3-year follow-up, he was asymptomatic.

LESSONS

Our novel hybrid anchoring balloon-guided direct POC may be an effective alternative treatment approach for difficult gallbladder cases, such as refractory MS.

A new hybrid anchoring balloon for direct peroral cholangioscopy using an ultraslim upper endoscope

BACKGROUND AND AIM

Large impacted or residual invisible common bile duct (CBD) stones after mechanical lithotripsy are challenging. We aimed to evaluate the feasibility and success rate of a new hybrid anchoring balloon-guided direct peroral cholangioscopy (POC) for these conditions using an ultraslim endoscope.

METHODS

Sixty-five patients with large or residual invisible CBD stones for direct POC from July 2012 to July 2016 were identified, including six cases in whom an additional interventional procedure was required. There were altogether 55 cases undergoing a procedure with our new device, with a 0.021-inch guidewire tied to a balloon catheter at its distal end in this single-center retrospective study. Technical success, procedure time, diagnostic and therapeutic efficacy of direct POC, and procedure-related complications were studied.

RESULTS

The hybrid anchoring balloon-guided direct POC was successful in 51/55 (92.7%) procedures, including 18 cases in whom the conventional wire-guided method failed within 25 min. Mean time for technical success by our method was 12.4 ± 3.4 min. In total, of the 43 cases with previous removal of CBD stones, seven (16.3%) were found to have residual stones ≥4 mm, excluding three cases in whom direct POC failed. In another 25 cases for difficult stones, 24 lithotripsies were carried out, resulting in 23 complete fragmentations. No significant procedure-related complications were observed.

CONCLUSION

The new hybrid anchoring balloon device performs well in facilitating direct POC using an ultraslim endoscope for evaluation and extraction of residual or large impacted CBD stones.

Per-oral video cholangiopancreatoscopy with narrow-band imaging for the evaluation of indeterminate pancreaticobiliary disease

BACKGROUND AND AIMS

Cholangiopancreatoscopy for evaluating pancreaticobiliary pathology is currently limited by suboptimal optics. The aim of this study was to characterize the operating characteristics of per-oral video cholangiopancreatoscopy with narrow-band imaging (POVCP) findings in indeterminate pancreaticobiliary disease and to describe their association with neoplasia.

METHODS

Data from consecutive patients undergoing POVCP for the evaluation of indeterminate pancreaticobiliary disease at a single tertiary care center were analyzed. Two experienced investigators had previously agreed on POVCP findings and terminology that were documented in endoscopy reports. Endoscopic procedural data from POVCPs performed between January 2006 and April 2015 and clinical data were abstracted from the endoscopic database and electronic medical records. Study endpoints included tissue-proven neoplasia or benign disease with ≥1 year of follow-up.

RESULTS

A total of 109 patients were identified; 13 were excluded because of the presence of stone disease, known pancreaticobiliary malignancy, or presumed benign disease with ≤1 year of follow-up. Most patients (85%) underwent POVCP for biliary disease and 15% underwent POVCP for a pancreatic cause. Tortuous and dilated vessels (P < .001), infiltrative stricture (P < .001), polypoid mass (P = .003), and the presence of fish-egg lesions (P = .04) were found to be significantly associated with neoplasia. The overall POVCP impression had a high sensitivity (85%) and negative predictive value (89%) in assessing for the presence of neoplasia.

CONCLUSIONS

Per-oral video cholangiopancreatoscopy is effective in the evaluation of indeterminate pancreaticobiliary disease. Tortuous and dilated vessels, infiltrative stricture, polypoid mass, and the presence of fish-egg lesions are significantly associated with neoplasia.

Clinical application of a single-operator direct visualization system improves the diagnostic and therapeutic yield of endoscopic retrograde cholangiopancreatography

BACKGROUND

Single-operator cholangioscopy enables direct diagnostic visualization and therapeutic intervention in the biliary tree. There is increasing evidence of its clinical utility in the assessment of biliary strictures and treatment of difficult stones.

OBJECTIVE

To describe the first reported Canadian experience with managing biliary disease using single-operator cholangioscopy.

METHODS

The present study was a retrospective analysis of data collected from all sequential patients undergoing single-operator cholangioscopy for assessment of biliary strictures and treatment of biliary stones. The main outcome measures were the ability to make an overall diagnosis of stricture (based on visual appearances and tissue histology), and to fragment and extract biliary stones.

RESULTS

Thirty patients (17 women), mean age 66 years (range 41 to 89 years) underwent single-operator cholangioscopy. In biliary strictures (20 patients), overall accuracy for visual and tissue diagnosis was 84% and 81%, respectively. Successful electrohydraulic lithotripsy with stone clearance was achieved in 90% of the 10 patients who failed previous conventional therapy. The mean (± SD) procedure time was 61±21 min (range 20 min to 119 min). One patient developed mild postendoscopic retrograde cholangioscopy pancreatitis.

CONCLUSION

The results of this experience reaffirms the clinical utility and safety of single-operator cholangioscopy for the management of biliary pathology. Further improvements can be achieved with increasing operator experience and refinements in optical technology.

Direct peroral cholangioscopy using an ultraslim upper endoscope for biliary lesions

BACKGROUND

The development of direct peroral cholangioscopy (DPOC) using an ultraslim endoscope simplifies biliary cannulation. The conventional techniques are cumbersome to perform and require advanced skills. The recent introduction of the guidewires and balloons has improved the therapeutic outcomes. Here we describe an effective and easier method for performing DPOC using an ultraslim upper endoscope.

METHODS

Indications for DPOC were the presence of stones on follow-up of patients who had previously undergone complete sphincteroplasty, including endoscopic sphincterotomy or endoscopic papillary large balloon dilatation. Fifteen patients underwent DPOC. An ultraslim endoscope was inserted perorally and was advanced into the major papilla. The ampulla of Vater was visualized by retroflexing the endoscope in the distal second portion of the duodenum, and then DPOC was performed using a wire-guided cannulation technique with an anchored intraductal balloon catheter.

RESULTS

One patient failed in the treatment due to looping of the endoscope in the fornix of the stomach. Fourteen (93.3%) were successfully treated with our modified DPOC technique. Only one patient (6.7%) experienced an adverse event (pancreatitis) who responded well to conservative management. Residual stones of the common bile duct were completely removed in 3 patients.

CONCLUSION

The modified method of DPOC is simple, safe and easy to access the bile duct.

Prospective randomized comparison of short-access mother-baby cholangioscopy versus direct cholangioscopy with ultraslim gastroscopes

BACKGROUND

Mother-baby technologies, the criterion standard for cholangioscopy, have several limitations. A novel, short-access, mother-baby (SAMBA) system may improve this technique. Direct cholangioscopy (DC) was recently developed as an alternative to mother-baby cholangioscopy.

OBJECTIVE

Comparison of success rates with SAMBA and DC.

DESIGN

Single-center, randomized, controlled trial.

SETTING

Academic tertiary-care referral center.

PATIENTS

Sixty patients with suspected cholangiopathies randomized to either SAMBA (n = 30) or DC (n = 30).

INTERVENTION

Cholangioscopy under deep sedation.

MAIN OUTCOME MEASUREMENTS

Technical success rate of diagnostic or therapeutic procedure.

RESULTS

A total of 24 and 21 diagnostic procedures were performed in the SAMBA and DC groups, respectively. There were no significant differences in the overall technical success rates between SAMBA (90.0%) and DC (86.7%) (P = 1.0). There was better correlation between the endoscopic prediction and histologic findings in DC (P = .013). Procedure times were shorter in DC (P < .03). In patients without significant stenoses, SAMBA allowed intrahepatic bile duct exploration in all cases, compared with 10.5% of cases in DC (P < .01). No differences regarding adverse event rates between the groups occurred (10.0% both groups).

LIMITATIONS

Small sample size. Heterogeneous indications for cholangioscopy. DC requires advanced skills of the endoscopist. The study is not replicable.

CONCLUSION

SAMBA and DC offer high technical success rates for diagnostic and therapeutic interventions. The advantages of DC consist of superior imaging, shorter total procedure time, and a wider working channel for adequate tissue sampling. SAMBA is better than DC with regard to intraductal stability and accessibility of the intrahepatic bile ducts.

Single-step direct cholangioscopy by freehand intubation using standard endoscopes for diagnosis and therapy of biliary diseases

OBJECTIVES

Commercially available 10F cholangioscope systems have limitations in examination of the biliary tree. Further, they are not readily available in all endoscopy units. Direct cholangioscopy (DC) using slim and ultraslim gastroscopes have been utilized to detect and treat bile duct (BD) diseases. It often requires initial duodenoscope introduction, followed by over-the-wire exchange to a gastroscope for BD intubation. We report a novel single-step DC technique using forward-viewing endoscopes without requiring tandem-scope exchange.

METHODS

In patients with native papilla, a "J" maneuver, accomplished by retroflexing the endoscope in the second portion of the duodenum and withdrawing the retroflexed scope into the BD, was used to achieve free intubation. A variety of readily available standard endoscopes were used. For biliary-enteric anastomoses, balloon dilation, if necessary followed by enteroscope advancement, was utilized for BD visualization.

RESULTS

A total of 18 patients underwent 22 DC procedures (8 male, 10 female, mean age 69 years). Direct intubation was successful in all procedures. Indications included BD stone (n=10), BD stricture or tumor (n=8). A native papilla was present in 13 patients and biliary-enteric anastomoses in 5; 8 patients had altered gastrointestinal anatomy. Sphincterotomy was required in 12/13 native papilla patients to facilitate DC. Free intubation of the BD was accomplished in 19 of 22 exams, and 3 facilitated by guidewire (over-the-wire in 2 and alongside a guidewire in 1). Overtube-assisted enteroscopy was used to reach the BD in four patients. The findings were stones (n=6), strictures or tumors (n=7), abnormal mucosa (n=5), a dilated duct confirming stone clearance without stricture (n=3), and retained stent (n=1). Interventions were biopsy (n=8), stone extraction (n=5), electrohydraulic lithotripsy (n=3), chromoendoscopy (n=2), narrow-band imaging (n=2), through the scope stricture dilation (n=2), and argon-plasma coagulation of biliary tumor (n=1). Complications were cholangitis managed with intavenous antibiotics (n=1).

CONCLUSIONS

Single-step DC can be achieved without using tandem-scope exchange, and may be clinically useful for diagnostic and therapeutic purposes in managing select biliary tract diseases.

Therapeutic role of direct peroral cholangioscopy using an ultra-slim upper endoscope

INTRODUCTION

Peroral cholangioscopy provides direct visualization of the bile duct and facilitates diagnostic procedures and therapeutic intervention. The currently available mother-baby scope system is not widely used because of its disadvantages. Direct peroral cholangioscopy (POC) with a regular, ultra-slim, upper endoscope can provide a valuable and economic solution for evaluating bile duct lesions, although its therapeutic role in biliary tract disease is uncertain. We assessed the usefulness of direct POC with an ultra-slim endoscope for therapeutic application in patients with biliary diseases.

METHODS

Several new techniques and accessories allow therapeutic intervention under direct POC using an ultra-slim upper endoscope with a larger, 2-mm working channel. Intracorporeal laser or electrohydraulic lithotripsy under direct POC is a main therapeutic intervention for patients with bile duct stones resistant to conventional endoscopic procedures. Tumor ablation therapy such as photodynamic therapy and argon plasma coagulation may be performed under direct POC. Direct POC can be applied to guide biliary interventions such as guidewire placement, stone removal, and migrated stent retrieval, using diverse accessories.

CONCLUSION

Direct POC with an ultra-slim upper endoscope allows therapeutic intervention for patients with biliary diseases. Enhancements of the endoscope and specialized accessories are expected to expand the therapeutic role of direct POC.

New options of cholangioscopy

In the evaluation of biliary diseases, cholangioscopy is considered as complementary procedure to radiographic imaging. Direct visualization of the bile duct is the premier advantage of cholangioscopy over indirect imaging techniques. However, cholangioscopy has not gained wide acceptance because of several technical limitations such as scope fragility, impaired steerability, limited irrigation, and suction capabilities, as well as the need for two experienced endoscopists. Recent innovations such as the implementation of electronic video cholangioscopes and the development of single-operator systems facilitate the procedure, and promise to increase the diagnostic and therapeutic yield of cholangioscopy.

Direct peroral cholangioscopy using an ultra-slim upper endoscope for the treatment of retained bile duct stones

OBJECTIVES

Intracorporeal lithotripsy must be used under direct visual control with an additional endoscope in order to ensure safety and precise targeting during the removal of difficult-to-extract bile duct stones using conventional methods. The currently available "mother-baby" scope system has several disadvantages. We evaluated the feasibility and efficacy of direct peroral cholangioscopy (POC) using an ultra-slim upper endoscope for electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) for the treatment of difficult-to-extract bile duct stones.

METHODS

A total of 18 patients who were unsuccessfully treated for common bile duct (CBD) stones using conventional endoscopy, including mechanical lithotripsy (ML), underwent EHL or LL under intraductal balloon-guided direct POC using an ultra-slim upper endoscope. The balloon catheter was used to maintain access while an ultra-slim upper endoscope was advanced directly into the bile duct. EHL or LL was performed until it became possible to capture the fragmented stones in a basket. Endoscopic removal of stone fragments by duodenoscopy was attempted in the same session.

RESULTS

The overall success rate of bile duct clearance by lithotripsy under direct POC by a single endoscopist was 88.9% (16 of 18). Stone fragmentation under direct POC was successfully performed in nine patients using EHL and in seven patients using LL. The average number of treatment sessions required to complete stone removal was 1.6. ML was performed to complete stone removal in 5 of 18 (27.8%) patients. Procedure-related complications were not observed.

CONCLUSIONS

Lithotripsy with EHL or LL under direct POC involving the use of an ultra-slim endoscope by a single endoscopist seems to be an effective and safe treatment for select patients with difficult-to-extract CBD stones.

Intraductal balloon-guided direct peroral cholangioscopy with an ultraslim upper endoscope (with videos)

BACKGROUND

Peroral cholangioscopy (POC) provides direct visualization of the bile duct and facilitates diagnostic procedures and therapeutic intervention. The currently available mother-baby endoscope system is not widely used because of several limitations. Although direct cholangioscopy with an ultraslim upper endoscope with a guidewire has been reported, success is not always guaranteed.

OBJECTIVE

To evaluate the feasibility and success rate of direct POC using an ultraslim endoscope with an intraductal balloon to maintain access compared with the guidewire method.

DESIGN

Prospective, observational clinical feasibility study.

SETTING

Tertiary referral center.

MAIN OUTCOME MEASUREMENTS

We compared overall procedure success rates and complications. A successful procedure was defined as one in which the endoscope was advanced into the bifurcation or stenotic segment of the biliary system.

PATIENTS AND METHODS

Twenty-nine patients with biliary disease underwent direct POC. All patients had previously undergone an endoscopic sphincterotomy or papillary balloon dilation with a large balloon. Eleven patients underwent wire-guided direct POC. Intraductal balloon-guided direct POC was performed in 21 patients. The balloon catheter was used to maintain access while an ultraslim upper endoscope was advanced over the balloon catheter, through the ampulla of Vater, and directly into the bile duct.

RESULTS

Wire-guided direct POC was successful in 5 of 11 (45.5%) patients. In contrast, the success rate of intraductal balloon-guided direct POC was 95.2% (20/21 patients, P < .05). Forceps biopsies under direct visualization of the intraductal lesion and therapeutic intervention, including laser lithotripsy or electrohydraulic lithotripsy, were performed successfully. Procedure-related complications were not observed.

LIMITATIONS

A small number of patients and no comparison with conventional cholangioscopy.

CONCLUSIONS

Intraductal balloon-guided direct POC with an ultraslim upper endoscope allows the direct visual examination and therapeutic intervention of bile ducts in patients with biliary disease. Further development of the endoscopic apparatus and specialized accessories are expected to facilitate this procedure.

Application of per oral cholangiopancreatoscopy in pancreatobiliary diseases

Pancreaticobiliary ductal diseases are largely investigated by indirect imaging techniques. Therefore, the pathology of up to 30% of cases remains undetermined. Cholangiopancreatoscopy allows direct visualization of ductal abnormalities with the ability to sample tissue and deliver a number of endotherapies. The technique can be broadly categorized into either two-operator or single-operator systems. Both systems provide important diagnostic information in the investigation of undetermined biliary or pancreatic strictures, intraductal papillary mucinous neoplasia, occult ductal malignant changes in patients with primary sclerosing cholangitis and occult intraductal stones in patients with complex biliary stone diseases. Therapeutically, cholangiopancreatoscopy-guided endotherapies provide a highly effective and safe alternative to surgery for patients with difficult extrahepatic and intrahepatic ductal stones that are not amenable to conventional endoscopic extraction by endoscopic retrograde cholangiopancreatography. The clinical application of cholangiopancreatoscopy, however, will be limited unless the technology is further refined to improve its durability, image quality, therapeutic capability and technical feasibility.

Overtube-balloon-assisted direct peroral cholangioscopy by using an ultra-slim upper endoscope (with videos)

BACKGROUND

The "mother-baby" endoscope system currently used for peroral cholangioscopy (POC) has several limitations. Endoscopic direct cholangioscopy when using an ultra-slim upper endoscope with a guidewire to maintain access has been reported, but appropriate accessories are required to increase the success rate. Herein, we describe a novel method, overtube-balloon-assisted endoscopy, for direct POC.

OBJECTIVE

To evaluate the feasibility and usefulness of direct POC when using an ultra-slim upper endoscope with an overtube balloon to maintain access.

SETTING

A single center.

DESIGN

Case series.

PATIENTS

Twelve patients with biliary disease.

INTERVENTIONS

Direct POC by using an ultra-slim upper endoscope and diagnostic and/or therapeutic procedures.

MAIN OUTCOME MEASUREMENTS

Success rate of this technique, diagnostic or therapeutic feasibility, and complications.

RESULTS

Overtube-balloon-assisted direct POC was performed successfully in 10 of 12 patients (83.3%). The procedure revealed 4 common bile duct (CBD) stones, 4 benign biliary strictures, 1 polypoid tumor, and 1 cholangiocarcinoma. Five patients underwent forceps biopsy under direct visualization of the intraductal lesion. Laser lithotripsy was successfully performed in 1 patient. No procedure-related complication occurred.

LIMITATIONS

A small number of patients and no comparison with conventional cholangioscopy.

CONCLUSIONS

The overtube balloon appears to be a useful accessory in direct POC when using an ultra-slim upper endoscope. However, further development of a slim overtube or other accessories is necessary to improve the success rate of direct POC.

SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study (with video)

BACKGROUND

Clinical implementation of cholangioscopy for direct visual examination of bile ducts, tissue sampling, and therapeutic maneuvers has been slowed by limitations in available technology. With 4-way deflected steering and dedicated irrigation channels, the single-operator SpyGlass peroral cholangiopancreatoscopy system is designed to overcome some of these limitations.

OBJECTIVE

To evaluate the clinical utility and safety of the SpyGlass system for diagnostic and therapeutic endoscopic procedures in bile ducts.

DESIGN

Prospective observational clinical feasibility study.

SETTING

Two tertiary referral centers.

MAIN OUTCOME MEASUREMENTS

Procedural success rate defined as the proportion of SpyGlass procedures in which the diagnostic or therapeutic objectives of the procedure were achieved.

RESULTS

SpyGlass procedures were performed in 35 patients: 22 with indeterminate strictures (63%), 5 with indeterminate filling defects (14%), 5 with stones (14%), 2 with cystic lesions (6%), and 1 patient with an indication for gallbladder stent placement (3%). The rate of procedural success was 91% (95% confidence interval 77%-98%). Twenty patients underwent SpyGlass-directed biopsy, and the specimens procured from 19 patients (95%) were found adequate for histologic evaluation. The preliminary sensitivity and specificity of SpyGlass-directed biopsy to diagnose malignancy were 71% and 100%, respectively. SpyGlass-directed electrohydraulic lithotripsy succeeded in 5 of 5 patients (100%). Procedure-related complications occurred in 2 patients (6%) and resolved uneventfully.

LIMITATIONS

No control group was included. Follow-up for determining preliminary sensitivity and specificity was limited.

CONCLUSIONS

SpyGlass procedures proved to be clinically feasible, provided adequate samples for histologic diagnosis, and successfully guided stone therapy. The procedures were safe and well tolerated. Prospective multicenter clinical trials of the system are underway.

Preclinical characterization of the Spyglass peroral cholangiopancreatoscopy system for direct access, visualization, and biopsy

BACKGROUND

Current cholangioscopes are restricted to 2 deflection angles and require more than 1 operator. The newly developed Spyglass peroral cholangiopancreatoscopy system provides 4-way deflected steering by a single operator.

OBJECTIVE

To evaluate access and biopsy in all simulated biliary-duct quadrants with the Spyglass system, high-level disinfection of the reusable Spyglass optical probe, and feasibility of in vivo biopsy.

DESIGN

Laboratory simulations comparing biliary-duct access and biopsy with the Spyglass versus a conventional system, laboratory determination of high-level disinfection effectiveness, and observational investigation of biopsies in a porcine model.

SETTING

Research laboratories.

MAIN OUTCOME MEASUREMENTS

Rate ratios (RR) and 95% confidence intervals (CI) for successful access to all quadrants and simulated biopsy.

RESULTS

Success rates for access in all quadrants were significantly higher with the Spyglass system than with the control system, both without (RR 1.71, 95% CI 1.39-2.29) and with (RR 2.00, 95% CI 1.56-2.78) biopsy forceps loaded. Higher success rates were also attained by using the Spyglass system to access biopsy targets (RR 2.09, 95% CI 1.60-2.91) and to perform simulated biopsies (RR 2.94, 95% CI 2.05-4.52). Microbial species log reductions of 6.0 to 7.0 were achieved by high-level disinfection of Spyglass optical probes. In 31 in vivo porcine biopsies yielding adequate gross specimens, the quality for histologic examination was excellent to adequate for 90% of specimens.

LIMITATIONS

Study procedures were performed by a single nonblinded operator. All data were collected ex vivo or in animals, and clinical applicability remains to be determined.

CONCLUSIONS

The Spyglass system allows access and biopsy in all quadrants and merits clinical investigation.

Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study

BACKGROUND

The search for an easier and less cumbersome technique to perform direct visual examination of the biliary tree is still underway.

OBJECTIVE

To assess the feasibility of performing endoscopic direct cholangioscopy utilizing an ultra-slim upper endoscope designed for pediatric patients.

DESIGN

Prospective, observational, pilot study.

SETTING

Tertiary referral center.

PATIENTS

Three patients who underwent endoscopic retrograde cholangiography for evaluation and treatment of choledocholithiasis.

METHODS

Following the completion of the endoscopic retrograde cholangiography, a 0.035-inch diameter super-stiff Jagwire (Boston Scientific Corp, Natick, Mass) was placed in the common bile duct. Using the wire to maintain access, we removed the duodenoscope and backloaded the wire onto an ultra-slim upper endoscope (GIF-XP 160, Olympus America Inc, Melville, NY), which was advanced over the guidewire under fluoroscopic and endoscopic control into the duodenum and then across the ampulla of Vater into the common bile duct and upstream.

RESULTS

Endoscopic direct cholangioscopy was attempted and successfully completed in all 3 patients. One patient was found to have persistent large amount of sludge and stones, and was referred for surgery. In the other two patients, endoscopic direct cholangioscopy demonstrated complete duct clearance, obviating the need for stent placement and repeat endoscopic retrograde cholangiography procedures.

LIMITATIONS

Small sample size, pilot study.

CONCLUSIONS

Endoscopic direct cholangioscopy with an ultra-slim upper endoscope originally designed for pediatric use is feasible. Future advances in endoscope development, as well as specifically designed accessories, could lead to the next generation of intraductal diagnosis and therapy.