Peroral direct cholangioscopy with an ultraslim gastroscope in combination with a short double-balloon enteroscope for reconstructed biliary anatomy

Current status of peroral cholangioscopy in biliary tract diseases

Peroral cholangioscopy (POC) is an important tool for the management of a selected group of biliary diseases. Because of its direct visualization, POC allows targeted diagnostic and therapeutic procedures. POC can be performed using a dedicated cholangioscope that is advanced through the accessory channel of a duodenoscope or via the insertion of a small-diameter endoscope directly into the bile duct. POC was first described in the 1970s, but the use of earlier generation devices was substantially limited by the cumbersome equipment setup and high repair costs. For nearly ten years, several technical improvements, including the single-operator system, high-quality images, the development of dedicated accessories and the increased size of the working channel, have led to increased diagnostic accuracy, thus assisting in the differentiation of benign and malignant intraductal lesions, targeting biopsies and the precise delineation of intraductal tumor spread before surgery. Furthermore, lithotripsy of difficult bile duct stones, ablative therapies for biliary malignancies and direct biliary drainage can be performed under POC control. Recent developments of new types of conventional POCs allow feasible, safe and effective procedures at reasonable costs. In the current review, we provide an updated overview of POC, focusing our attention on the main current clinical applications and on areas for future research.

Cholangioscopy: the biliary tree never looked so good!

PURPOSE OF REVIEW

Endoscopists have long awaited advances in the equipment and techniques for cholangiopancreatoscopy. Since the turn of the millennium, endoscopists have witnessed an explosion in the development and refinement of the capabilities of cholangioscopes as they move from being almost exclusive to tertiary care academic settings to a wider range of practices.

RECENT FINDINGS

Studies have tested and constructively critiqued the procedure, hoping to increase the success rate of diagnostic and therapeutic interventions. Many have found significant improvement upon the limitations of radiographic imaging in diagnosing diseases and achieving full clearance of biliary stones. Image quality has improved with a range of features. However, most of these still need to be studied further. The addition of balloon catheters and overtubes has improved stability and access to the biliary ducts, but comes with complications that need to be studied further.

SUMMARY

Although we still have improvements to yearn for, the future looks bright. As endoscopists continue their commitment to the promise of direct visualization of the biliary trees and the complementary tools for diagnosis and treatment, we are continuing to raise quality of care for patients with complicated biliary diseases.