Noncalcified pancreatic stone treated with electrohydraulic lithotripsy using SpyGlass pancreatoscopy

Per oral cholangiopancreatoscopy in pancreatico biliary diseases - Expert consensus statements

AIM: To provide consensus statements on the use of per-oral cholangiopancreatoscopy (POCPS).

METHODS: A workgroup of experts in endoscopic retrograde cholangiopancreatography (ERCP), endosonography, and POCPS generated consensus statements summarizing the utility of POCPS in pancreaticobiliary disease. Recommendation grades used validated evidence ratings of publications from an extensive literature review.

RESULTS: Six consensus statements were generated: (1) POCPS is now an important additional tool during ERCP; (2) in patients with indeterminate biliary strictures, POCS and POCS-guided targeted biopsy are useful for establishing a definitive diagnosis; (3) POCS and POCS-guided lithotripsy are recommended for treatment of difficult common bile duct stones when standard techniques fail; (4) in patients with main duct intraductal papillary mucinous neoplasms (IPMN) POPS may be used to assess extent of tumor to assist surgical resection; (5) in difficult pancreatic ductal stones, POPS-guided lithotripsy may be useful in fragmentation and extraction of stones; and (6) additional indications for POCPS include selective guidewire placement, unexplained hemobilia, assessing intraductal biliary ablation therapy, and extracting migrated stents.

CONCLUSION: POCPS is important in association with ERCP, particularly for diagnosis of indeterminate biliary strictures and for intra-ductal lithotripsy when other techniques failed, and may be useful for pre-operative assessment of extent of main duct IPMN, for extraction of difficult pancreatic stones, and for unusual indications involving selective guidewire placement, assessing unexplained hemobilia or intraductal biliary ablation therapy, and extracting migrated stents.

Direct cholangioscopy: the North Shore experience

OBJECTIVE

Endoscopic retrograde cholangiopancreatography (ERCP) has long been a tool utilized by gastroenterologists for many years, but direct cholangioscopy has only recently begun to be available for regular use in clinical practice. The focus of this study was to evaluate the efficacy of a direct cholangioscopy system and its indications within our patient population.

MATERIALS AND METHODS

This retrospective analysis was carried out at North Shore University Hospital. After obtaining institutional review board approval, the charts of patients who had undergone cholangioscopy from January 2007 through October 2011 were reviewed. An excel spreadsheet was created to record demographic information, significant laboratory data, indications for ERCP, ERCP findings, indication for cholangioscopy, findings, interventions, and biopsy results (if performed). A total of 34 cases were included in the final review.

RESULTS

Cholangioscopy indications included incomplete or failed stone removal, biliary stricture evaluation, and retrieval of a migrated biliary stent, among others. Electrohydraulic lithotripsy was utilized with almost complete success in cases of previous failed stone removal. In 12 cases where a cholangioscopy-directed biopsy was performed, adequate tissue was obtained in all cases, and aided in the exclusion of malignancy.

CONCLUSION

Direct cholangioscopy is a new technology whose use is currently limited in clinical practice, but is growing in popularity. Its continued recognition as an important adjunct in the management of biliary and pancreatic disease should prompt further research into its use of a prospective nature. Given the limited number of direct cholangioscopy cases performed every year, large, randomized-controlled studies evaluating its efficacy and effect on outcomes have not yet been performed, but small studies may still continue to yield valuable information on its efficacy and safety.