A feasibility study of digital single-operator cholangioscopy for diagnostic and therapeutic procedure (with videos)

Innovative use of a 3-Fr microcatheter for precision guidewire placement with digital single-operator cholangioscopy for pancreaticobiliary drainage (with video)

Biliary and pancreatic tract stenosis are hallmark symptoms in pancreaticobiliary diseases, transcending malignancy. Endoscopic techniques are pivotal for biliary/pancreatic drainage; however, challenging scenarios arise when attempting to pass a guidewire (GW) through obstruction. Cholangioscopy-assisted GW placement has proven valuable, but challenges persist in its execution, particularly in maneuvering the GW through cholangioscopy. Therefore, we explored the integration of a 3-Fr microcatheter into cholangioscopy with the aim of enhancing direct visualization and offering a super-selective approach. When GW manipulation under a digital single-operator cholangioscope (D-SOC) guidance was still unsuccessful in a resistant obstruction, the 3-Fr microcatheter was introduced. This technique was performed in 42 individuals for 37 biliary and 5 pancreatic duct drainages, among which there were 19 malignant, 18 benign, and 4 anastomotic obstructions. In all patients, contrast-filled cholangiography in the target area couldn't be achieved at the pre-microcatheter insertion stage due to obstruction. The technical success rate was 85.7% overall, 89.5% in malignant strictures, 84.2% in benign strictures, and 75.0% in anastomotic obstructions, resulting in a clinical success rate of 78.6%. The use of a 3-Fr microcatheter appears effective for endoscopic drainage performed for obstruction. This technique could pave the way for improved outcomes in patients with pancreaticobiliary diseases.

Digital single-operator cholangioscopy in treating difficult biliary stones: results from a multicenter experience

BACKGROUND

In clinical practice, standard endoscopic treatment of biliary stones fails in up to 10% of patients, and more invasive procedures such as percutaneous trans-hepatic interventions or surgery might become necessary. The aim of this multicenter retrospective study, based on prospectively-collected data, was to evaluate both the efficacy and the safety of digital-single operator cholangioscopy (D-SOC) to treat difficult biliary stones in cases with a previous failure of conventional endoscopic methods.

METHODS

Only patients with a previous failure of endoscopic standard treatment and a D-SOC-based biliary stone treatment using electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) were included. The primary endpoint was to evaluate the stone clearance rate per procedure and per patient.

RESULTS

Out of 1258 ERCP performed at our centers, 31 cholangioscopes in 21 patients were solely performed for the treatment of difficult biliary stones using EHL or LL. A complete biliary stone removal was achieved in 67.7% (21/31) of all procedures including initial and repeated examinations, while in 35.4% (11/31) of all procedures an incomplete removal was accomplished of which 36.3% had a partial stone removal. In 22 procedures EHL was adopted as techniques to fragment and remove biliary stones, while in 9 procedures LL was used. In both the techniques, the complete stone removal rate and the incomplete stone removal rate were similar (75% vs. 77.7%, P>0.05). Furthermore, the success rate of digital D-SOC to treat difficult biliary stones was assessed per patient: overall, 100% of patients with difficult biliary stones were successfully treated using D-SOC. Only one patient experienced mild cholangitis classified ad mild adverse event following ASGE (American Society of Gastrointestinal Endoscopy) lexicon.

CONCLUSIONS

Our data indicate that digital D-SOC assisted biliary stone treatment is highly efficient for the treatment of difficult biliary stones even in such patients in whom previous conventional endoscopic methods to treat biliary stones have failed. Therefore, D-SOC might be considered the new standard of care for these patients, being both, effective and safe.

SEED Consensus Document on SpyGlass-DS

Endoscopic retrograde cholangiopancreatography (ERCP) is the technique of choice for the treatment of biliopancreatic pathology. However, fluoroscopic imaging does not always allow an adequate diagnosis. On the other hand, some large stones cannot be removed by the usual methods. In these situations, cholangioscopy has proven to be an essential tool for the diagnosis of biliary strictures and the treatment of large stones. Its role in pancreatic pathology is also increasing. The development of a single-operator, disposable cholangioscope has made it possible to expand the technique to a large number of hospitals that perform ERCP. For this reason, the Spanish Society of Digestive Endoscopy has developed this consensus document on the use of the Spyglass-DS cholangioscope. The document has been prepared by a group of endoscopists with expertise in cholangioscopy, reviewing the scientific evidence on the main current indications for cholangiopancreatoscopy.

Utility of Digital Single-operator Video Cholangioscopy for the Endoscopic Management of Biliary Complications After Liver Transplantation-A Single-center Experience

BACKGROUND

Liver transplant recipients (LTRs) frequently develop biliary complications, and endoscopy is crucial for their subsequent management. Recently, single-operator video cholangioscopy (SOVC) with digital imaging quality was introduced. This study evaluated the utility of digital SOVC for the management of biliary complications in LTRs.

METHODS

This observational study retrospectively analyzed all LTRs undergoing digital SOVC between 2015 and 2019 at a tertiary referral center. Endpoints included the assessment of biliary strictures, performance of selective guidewire passage across biliary strictures, and diagnosis and treatment of biliary stone disease.

RESULTS

In total, 79 digital SOVCs performed in 50 LTRs were identified. Fifty-eight percent of the procedures were performed for biliary stricture assessment, and using visual signs or guided biopsies, SOVC excluded malignancy in all cases (100%). Of all the examinations, 29.1% (23/79) were performed solely because of a previous failure of conventional endoscopic methods to pass a guidewire across a biliary stricture. Using SOVC, guidewire passage was successfully performed in 73.9% of these examinations, enabling subsequent endoscopic therapy. Furthermore, biliary stones were found in 16.5% (13/79) of the examinations. In 38.5% of these cases, standard fluoroscopy failed to detect stones, which were only visualized using digital SOVC. Biliary stone treatment was successful in 92% (12/13) of the examinations. Complications occurred in 11.4% of all SOVCs. No procedure-associated mortalities were observed.

CONCLUSIONS

Digital SOVC is effective and safe for the endoscopic management of biliary complications in LTRs and offers unique diagnostic and therapeutic opportunities that strongly impact the clinical course in selected cases.

Digital single-operator video cholangioscopy improves endoscopic management in patients with primary sclerosing cholangitis-a retrospective observational study

BACKGROUND

Patients with primary sclerosing cholangitis (PSC) are at a high risk of developing cholestatic liver disease and biliary cancer, and endoscopy is crucial for the complex management of these patients.

AIM

To clarify the utility of recently introduced digital single-operator video cholangioscopy (SOVC) for the endoscopic management of PSC patients.

METHODS

In this observational study, all patients with a history of PSC and in whom digital SOVC (using the SpyGlass DS System) was performed between 2015 and 2019 were included and retrospectively analysed. Examinations were performed at a tertiary referral centre in Germany. In total, 46 SOVCs performed in 38 patients with a history of PSC were identified. The primary endpoint was the evaluation of dominant biliary strictures using digital SOVC, and the secondary endpoints were the performance of selective guidewire passage across biliary strictures and the diagnosis and treatment of biliary stone disease in PSC patients.

RESULTS

The 22 of 38 patients had a dominant biliary stricture (57.9%). In 4 of these 22 patients, a cholangiocellular carcinoma was diagnosed within the stricture (18.2%). Diagnostic evaluation of dominant biliary strictures using optical signs showed a sensitivity of 75% and a specificity of 94.4% to detect malignant strictures, whereas SOVC-guided biopsies to gain tissue for histopathological analysis showed a sensitivity of 50% and a specificity of 100%. In 13% of examinations, SOVC was helpful for guidewire passage across biliary strictures that could not be passed by conventional methods (technical success rate 100%). Biliary stone disease was observed in 17.4% of examinations; of these, in 37.5% of examinations, biliary stones could only be visualized by SOVC and not by standard fluoroscopy. Biliary stone treatment was successful in all cases (100%); 25% required SOVC-assisted electrohydraulic lithotripsy. Complications, such as postinterventional cholangitis and pancreatitis, occurred in 13% of examinations; however, no procedure-associated mortality occurred.

CONCLUSION

Digital SOVC is effective and safe for the endoscopic management of PSC patients and may be regularly considered an additive tool for the complex endoscopic management of these patients.

Peroral cholangioscopy: Update on the state-of-the-art

Peroral cholangioscopy (POC) is an endoscopic procedure that allows direct intraductal visualization of the biliary tract. POC has emerged as a vital tool for indeterminate biliary stricture evaluation and treatment of difficult biliary stones. Over several generations of devices, POC has fulfilled additional clinical needs where other diagnostic or therapeutic modalities have been inadequate. With adverse event rates comparable to standard endoscopic retrograde cholangioscopy and unique technical attributes, the role of POC is likely to continue expand. In this frontiers article, we highlight the existing and growing clinical applications of POC as well as areas of ongoing research.

Clinical Outcomes of Digital Cholangioscopy-Guided Procedures for the Diagnosis of Biliary Strictures and Treatment of Difficult Bile Duct Stones: A Single-Center Large Cohort Study

Although Spy DS (SpyGlass DS Direct Visualization System) is considered to be useful for the diagnosis of bile duct strictures and the treatment of bile duct stones, there is limited data to date validating its efficacy. We hence retrospectively evaluated the clinical outcomes of the use of Spy DS in a large number of patients. A total of 183 patients who underwent Spy DS-guided procedures for indeterminate bile duct strictures (n = 93) and bile duct stones (n = 90) were analyzed retrospectively. All patients (93/93) with bile duct strictures successfully underwent visual observation, and 95.7% (89/93) of these patients successfully underwent direct biopsy. The sensitivity, specificity, and overall accuracy were 94.7%, 83.3%, and 90.3%, respectively, for visual impression; 80.9%, 100%, and 89.2%, respectively, for histopathological analysis of a direct biopsy; and 96.5%, 91.7%, and 94.6%, respectively, for visual impression combined with biopsy. Successful visualization of the stones was achieved in 98.9% (89/90) of the patients, and complete stone removal was achieved in 92.2% (83/90) of the patients, with an average of 3.3 procedures. The adverse events rate was 17.5% (32/183; cholangitis in 15 patients, fever the following day in 25, pancreatitis in 1, hemorrhage in 1, and gastrointestinal perforation in 1). No administration of antibiotics before the procedure was found to be a statistically significant risk factor for the development of fever after the procedure (p < 0.01). Spy DS-guided procedures are effective for the diagnosis and treatment of bile duct lesions and can be performed with a low risk of serious adverse events.

Recent advances in the management of difficult bile-duct stones: a focus on single-operator cholangioscopy-guided lithotripsy

The most effective and the standard treatment for bile duct stones (BDSs) is endoscopic retrograde cholangiopancreatography (ERCP). However, in 10% to 15% of patients with BDSs, the stones cannot be removed by conventional ERCP, which involves endoscopic sphincterotomy followed by balloon or basket extraction. Additional techniques or devices are often necessary to remove these difficult bileduct stones, including endoscopic papillary large balloon dilatation to make a larger papillary opening and/or mechanical lithotripsy to fragment the stones. Advances in cholangioscopy have made possible electrohydraulic or laser lithotripsy under direct cholangioscopic visualization during ERCP. Cholangioscopy-guided lithotripsy could be another good option in the armamentarium of techniques for removing difficult BDSs. Here we review endoscopic techniques based on single-operator cholangioscopy for the management of difficult BDSs.

Digital per-oral cholangioscopy to diagnose and manage biliary duct disorders: a single-center retrospective study

Background and study aims  Digital, per-oral cholangioscopy (POCS) allows diagnosis of biliary ducts disorders and treatment for complicated stones. We aimed to determine the diagnostic accuracy of digital POCS systems for stricture lesions and the factors precluding complete biliary stone clearance. Patients and methods  We performed a retrospective analysis of a prospective database of 265 consecutive patients referred for POCS between December 2016 and July 2018. We first analyzed the diagnostic accuracy of digital POCS for malignant and benign stricture lesions in 147 patients. Then, we analyzed the factors associated with complete or partial biliary stone clearance achieved with electrohydraulic lithotripsy (EHL) delivered via POCS in 118 patients. Results  In the diagnostic group, digital POCS achieved 91 % visual-impression sensitivity, 99 % specificity, 99 % positive and 91 % negative predictive values, and 63.64 positive and 0.09 negative likelihood ratios for malignancy diagnosis. In the therapeutic group, complete biliary stone clearance was achieved by EHL in 94.9 % patients; the mean stone size was 20 mm (10-40 mm). In multivariable analyses, a stone size > 20 mm (OR: 1.020, P  < 0.001) and the number of stones ≥ 3 (OR: 1.276, P  < 001) was associated with partial biliary stone clearance. Adverse events were reported in 3.3 % patients; no deaths were reported 30 days after the procedure. Conclusions  Digital POCS has excellent diagnostic efficacy for biliary lesions. EHL via POCS is effective for complicated biliary stone clearance. Stone size (> 20 mm) and the number of stones (≥ 3) are associated with partial biliary stone clearance.

Digital single-operator video cholangioscopy in treating refractory biliary stones: a multicenter observational study

BACKGROUND

Standard endoscopic treatment might fail to treat biliary stone disease. Here, we investigated the efficacy and safety of recently introduced digital single-operator video cholangioscopy (SOVC) for the treatment of difficult biliary stones.

METHODS

Digital SOVC procedures, performed in two tertiary referral centers between 2015 and 2018, were retrospectively analyzed. Only patients with a previous failure of endoscopic standard treatment and a SOVC-based biliary stone treatment using electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) were included. The primary endpoint was to evaluate the stone removal rate per procedure and per patient.

RESULTS

In total, 75 examinations with a digital SOVC-assisted biliary stone treatment, performed in 60 patients, were identified. Biliary stones were mainly located extrahepatic (64%) and less frequently intrahepatic (36%). The median stone size was 20 mm (interquartile range [IQR]: 10-25 mm) and the median stone number was 1 (IQR: 1-2). Digital SOVC-based treatment of biliary stone disease was successful in 95% of patients and 15% needed at least two treatment sessions. Evaluated per procedure, a complete stone removal was accomplished in 67% of all examinations (including initial and repeated procedures), while an incomplete stone removal was observed in 33% of cases. The per procedure analyzes revealed that the success rates for a complete stone removal were similar between LL and EHL (66% vs. 68%; p = 0.87). Complications, such as postinterventional cholangitis and pancreatitis occurred in 16% of examinations; however, except from one case, all were mild or moderate and no procedure-associated mortality occurred.

CONCLUSIONS

Digital SOVC-assisted biliary stone treatment is highly effective even in cases with difficult biliary stones and might be considered the new standard of care for these patients. Furthermore, mild up to moderate complications were intermittently observed which might document the complexity of our included cases.

Biliary interventions using single-operator cholangioscopy

Cholangioscopy provides an opportunity to directly visualize the bile duct for diagnosing biliary lesions and for therapeutic interventions. Although there are different cholangioscopy techniques available, single-operator cholangioscopy has gained widespread acceptance as the standard technique for interventions in the biliary system because of its ease of use and widespread availability. Single-operator cholangioscopy can be used for both diagnostic and therapeutic indications in the biliary tract. Diagnostic cholangioscopy is used for direct evaluation of indeterminate bile duct strictures with biopsies, diagnosing filling defects in the bile ducts observed during endoscopic retrograde cholangiography (ERC) imaging, preoperative mapping of the precise location and extension of tumors of the biliary tract, and diagnosis of intraductal neoplasms. Therapeutic cholangioscopy is used for visually guided treatment of biliary stones that have failed extraction with conventional ERC techniques, residual or impacted stones by using intraductal lithotripsy, ablation of biliary tumors and for facilitation of guidewire advancement into selective intrahepatic ducts for adequate biliary drainage. In this review, we will focus on advances in the single-operator cholangioscopy techniques in the diagnosis and management of biliary disorders.

The Role of Peroral Cholangioscopy in Evaluating Indeterminate Biliary Strictures

Biliary strictures are considered indeterminate when the initial radiologic evaluation and endoscopic retrograde cholangiopancreatography with brush cytology and/or forceps biopsy do not reveal diagnostic findings. Evaluation of these strictures is challenging and often requires a multidisciplinary approach and multiple procedures. Peroral cholangioscopy allows direct visualization of these lesions and targeted tissue acquisition using miniature biopsy forceps. In the past decade, there have been significant improvements in the field of cholangioscopy. These advances have allowed higher-quality image acquisition, easy setup, operation by a single operator, easy maneuverability, and excellent targeted tissue sampling performance. However, the interpretation of cholangioscopic visual findings remains challenging. In this review, we discuss the role of peroral cholangioscopy in the evaluation of indeterminate biliary strictures.

Peroral cholangioscopy by SpyGlass DS versus CHF-B260 for evaluation of the lateral spread of extrahepatic cholangiocarcinoma

Background and study aims  A newly developed peroral cholangioscopy (POCS) system, SpyGlassDS has high maneuverability. This study aimed to evaluate acceptability of the accuracy of SpyGlassDS accompanied by simultaneous POCS-guided biopsy compared with that of a traditional POCS scope, CHF-B260, to diagnose the lateral extent of extrahepatic cholangiocarcinoma (LEC). Patients and methods  Patients who underwent surgical resection after preoperative examinations to diagnose LEC were evaluated. POCS by CHF-B260 was performed if there was discrepancy between preceding fluoroscopy-guided biopsy findings and other examinations between January 2004 and September 2015 (group A, n = 56); and POCS plus POCS-guided mapping biopsy by SpyGlassDS was performed in all surgical candidates between October 2015 and December 2017 (group B, n = 20). The main outcome measure was the accuracy of overall preoperative diagnosis (OPD) of LEC defined based on all examinations, including POCS. Results  Accuracy of OPD for the liver side and the ampullary side was 93 % and 100 %, respectively, in group A, and 84 % and 100 %, respectively, in group B ( P  = 0.37 for the liver side; P , not available for the ampullary side). Diagnostic accuracy of simple optical evaluation by POCS for the liver side and the ampullary side was 83 % and 100 %, respectively, in group A, and 58 % and 88 %, respectively, in group B ( P  = 0.29 for the liver side; P  = 0.40 for the ampullary side). Conclusions  POCS by SpyGlassDS was found to be acceptable and could be a standard approach for diagnosis of LEC.

Role of SpyGlass-DStm in the preoperative assessment of pancreatic intraductal papillary mucinous neoplasm involving the main pancreatic duct

BACKGROUND/OBJECTIVES

It is often difficult to determine an adequate resection line during pancreatectomy for intraductal papillary mucinous neoplasm involving the main pancreatic duct during partial pancreatectomy. The aim of this study was to evaluate the usefulness of improved peroral pancreatoscopy using SpyGlass-DS^tm in the preoperative assessment of intraductal papillary mucinous neoplasm involving the main pancreatic duct.

METHODS

We collected and retrospectively analyzed clinicopathological data from seven consecutive patients who underwent preoperative assessment of intraductal papillary mucinous neoplasm involving the main duct using SpyGlass-DS^tm.

RESULTS

Good imaging quality of the intraductal protruding lesion was obtained in all seven patients, and only one adverse event was noted wherein a patient had mild pancreatitis. Six patients underwent pancreatectomy. In one patient, masked-type concomitant pancreatic ductal adenocarcinoma and low-length dysplastic lesion was found near the surgical margin, which was not detected by preoperative imaging modalities including SpyGlass-DS^tm. The sensitivity of targeting biopsy during SpyGlass-DS^tm to diagnose high-grade dysplasia was 0%.

CONCLUSIONS

SpyGlass-DS^tm can be safely performed in patients with intraductal papillary mucinous neoplasm involving the main duct, and has excellent visualization of the target lesion. However, challenges include poor diagnostic ability of targeting biopsy, and, therefore, intraoperative frozen section is still needed to obtain negative surgical margins.

Diagnostic and therapeutic single-operator cholangiopancreatoscopy with SpyGlassDS™: results of a multicenter retrospective cohort study

BACKGROUND AND AIMS

The aim of the study was to evaluate the usefulness and diagnostic and therapeutic outcome of the single-operator cholangiopancreatoscopy (SOC) with SpyGlassDS™.

METHODS

In a retrospective multicenter study between November 2015 and January 2017, SpyGlassDS™ procedures were analyzed in participating centers. Indications, accuracy of SOC-guided biopsies, management of large bile duct stones, and complications were analyzed. Follow-up was 4 months.

RESULTS

Two hundred and six patients out of 250 examinations were evaluated. Indications were biliary stones (n = 132), bile duct stenosis (n = 93), stones and stenosis combined (n = 24), and bile duct leakage (n = 1). Of the 117 cases which were suspicious of malignancy, in 99 cases the lesion could be stratified into benign (n = 55) or malignant (n = 44) indicating a sensitivity of 95.5% and a specificity of 94.5% for the indication tumor. SOC-guided biopsies revealed a sensitivity of 57.7% with a specificity of 100%. In 107 examinations, biliary stones were visualized and could be completely removed in 91.1% with a need of three procedures (range 1-6) to achieve final stone clearance. In 75 cases, lithotripsy was performed and was successful in 71 cases (95%). Four out of 45 patients (8.9%) underwent cholecystectomy with surgical bile duct revision as a final therapy. Adverse Event (AE) occurred in 33/250 patients (13.2%) and Serious Adverse Event (SAE) occurred in 1/250 patients (0.4%). Cholangitis was 1% (n = 102) after peri-interventional administration of antibiotics and 12.8% (n = 148) without antibiotic prophylaxis (p < 0.001).

CONCLUSIONS

SOC with SpyGlassDS™ became a new standard for the diagnosis of indefinite biliary lesions and therapy of large bile duct stones. The diagnostic yield of SOC-guided biopsies facilitated a definite diagnosis in most cases and should be improved by standardized biopsy protocols. SOC-guided interventions allowed removal of large biliary stones by SOC-guided lithotripsy. The complication rate of 13.2% can be considerably reduced by use of a single-shot antibiotic treatment.

Safety, diagnostic accuracy and therapeutic efficacy of digital single-operator cholangioscopy

Background

Digital single-operator cholangioscopes (digital SOCs), equipped with an improved image quality, have been recently introduced.

Objective

The aim of this study is to evaluate the safety and diagnostic and therapeutic efficacy of digital SOCs (Spyglass™ DS).

Methods

Sixty-seven digital SOC procedures performed between 2015 and 2017 were retrospectively analyzed.

Results

The most frequent indications for examination were indeterminate biliary strictures (61.2%) and biliary stone disease (23.9%). In 25 patients (37.3), visual findings predicted malignancy with a sensitivity of 88.9%, a specificity of 97.6%, a positive predictive value (PPV) of 96.0% and a negative predictive value (NPV) of 92.9%. For histological analysis, forceps biopsies were performed in 29 patients (43.2%). Compared with visual findings, forceps biopsies yield a lower diagnostic efficacy in diagnosing malignancy (sensitivity 62.5%, specificity 90.0%, PPV 90.9%, NPV 60.0%). Therapeutic interventions were performed in 19 patients with a technical success rate of 89.4%. Adverse events were observed in 17 patients (25.4%). Of these, 11 patients (16.4%) suffered from severe adverse events (pancreatitis, cholangitis or major bleeding), which led to a prolonged hospital stay.

Conclusion

Digital SOCs have excellent diagnostic and therapeutic efficacies, but are accompanied by high rates of adverse events; therefore, physicians should use digital SOCs in carefully selected cases.