Peroral cholangioscopy in the new millennium

Digital single-operator cholangioscopy in diagnostic and therapeutic bilio-pancreatic diseases: A prospective, multicenter study

BACKGROUND AND AIM

Digital single-operator cholangioscopy (D-SOC) is an endoscopic procedure that is increasingly used for the management of bilio-pancreatic diseases. We aimed to investigate the efficacy and safety of D-SOC for diagnostic and therapeutic indications.

METHODS

This is a multicenter, prospective study(January 2016-June 2019) across eighteen tertiary centers. The primary outcome was procedural success of D-SOC. Secondary outcomes were: D-SOC visual assessment and diagnostic yield of SpyBite biopsy in cases of biliary strictures, stone clearance rate in cases of difficult biliary stones, rate of adverse events(AEs) for all indications.

RESULTS

D-SOC was performed in 369 patients (201(54,5%) diagnostic and 168(45,5%)therapeutic). Overall, procedural success rate was achieved in 360(97,6%) patients. The sensitivity, specificity, PPV, NPV and accuracy in biliary strictures were: 88,5%, 77,3%, 83,3%, 84,1% and 83,6% for D-SOC visual impression; 80,2%, 92,6%, 95,1%, 72,5% and 84,7% for the SpyBite biopsy, respectively. For difficult biliary stones, complete duct clearance was obtained in 92,1% patients (82,1% in a single session). Overall, AEs occurred in 37(10%) cases.The grade of AEs was mild or moderate for all cases, except one which was fatal.

CONCLUSION

D-SOC is effective for diagnostic and therapeutic indications.Most of the AEs were minor and managed conservatively, even though a fatal event has happened that is not negligible and should be considered before using D-SOC.

Rare cause of obstructive haemobilia with recurrent biliopancreatic complications: a paradigmatic case

Haemobilia is an unusual but significant cause of upper gastrointestinal bleeding. Two-thirds of haemobilia cases are secondary to invasive hepato-biliopancreatic procedures. Biliary angiodysplasia is exceptionally unusual, with only three cases reported. Herein, we report the case of an autonomous 80-year-old woman with a history of cholecystectomy 5 years ago and cardiovascular disease-hypertension, heart failure, acute myocardial infarction, stroke and non-valvular atrial fibrillation, anticoagulated with apixaban 2.5 mg two times per day. Since July 2019, she had four episodes of acute cholangitis of mild-to-moderate severity, having undergone broad spectrum antibiotics treatment and endoscopic retrograde cholangiopancreatography (ERCP), with sphincterotomy and bile sludge extraction. After 3 months, the patient presented with a new episode of acute cholangitis, this time with haemobilia (Quincke's triad). An abdominal CT angiography showed no evidence of active bleeding, with plastic biliary prosthesis left by ERCP. The patient continued presenting new episodes of acute cholangitis with haemobilia, some of them with associated pancreatitis. A cholangioscopy with Spyglass DS II was performed, showing an angiodysplasia occupying half of the luminal circumference of the middle choledoccus, without active haemorrhage. After a multidisciplinary meeting and given the high haemorrhagic/thrombotic risk (CHA2DS2-VASc 8), closure of the left atrial appendage was considered. However, relapse of the condition after beginning the antiaggregation protocol for cardiovascular intervention made it unfeasible. Another cholangioscopy with an ultra-thin endoscope for argon-plasma coagulation was attempted, without success. The abdominal CT angiography was repeated, this time with identification of dilated ramifications of the gastroduodenal and inferior pancreatic arteries. After embolisation of these aberrant vessels with microcoils, the patient went well, with no recurrence of bleeding or biliopancreatic complications. We present a case of obstructive haemobilia with multiple biliopancreatic complications, secondary to an extremely rare cause-choledochal angiodysplasia. Cholangioscopy had a decisive role in the diagnosis and therapeutic guidance. The diagnostic/therapeutic challenge associated with haemobilia stands out, with the need for a personalised and multidisciplinary approach.

Digital Single-operator Cholangioscopy (DSOC) Improves Interobserver Agreement (IOA) and Accuracy for Evaluation of Indeterminate Biliary Strictures: The Monaco Classification

BACKGROUND

Visual characteristics seen during digital single-operator cholangioscopy (DSOC) have not been validated. The aim of this 2-phase study was to define terminology by consensus for the visual diagnosis of biliary lesions to develop a model for optimization of the diagnostic performance of DSOC.

MATERIALS AND METHODS

In phase 1 (criteria identification), video-cholangioscopy clips were reviewed by 12 expert biliary endoscopists, who were blinded to the final diagnosis. Visual criteria were consolidated into the following categories: (1) stricture, (2) lesion, (3) mucosal features, (4) papillary projections, (5) ulceration, (6) abnormal vessels, (7) scarring, (8) pronounced pit pattern.During the second phase (validation), 14 expert endoscopists reviewed DSOC (SpyGlass DS, Boston Scientific) clips using the 8 criteria to assess interobserver agreement (IOA) rate.

RESULTS

In phase 1, consensus for visual findings were categorized into 8 criteria titled the "Monaco Classification." The frequency of criteria were: (1) presence of stricture-75%, (2) presence of lesion type-55%, (3) mucosal features-55%, (4) papillary projections-45%, (5) ulceration-42.5%, (6) abnormal vessels-10%, (7) scarring-40%, and (8) pronounced pit pattern-10%. The accuracy on final diagnosis based on visual impression alone was 70%.In phase 2, the IOA rate using Monaco Classification criteria ranged from slight to fair. The presumptive diagnosis IOA was fair (κ=0.31, SE=0.02), and overall diagnostic accuracy was 70%.

CONCLUSIONS

The Monaco classification identifies 8 visual criteria for biliary lesions on single-operator digital cholangioscopy. Using the criteria, the IOA and diagnostic accuracy rate of DSOC is improved compared with prior studies.

Soft Liver Phantom with a Hollow Biliary System

Hepatobiliary interventions are regarded as difficult minimally-invasive procedures that require experience and skills of physicians. To facilitate the surgical training, we develop a soft, high-fidelity and durable liver phantom with detailed morphology. The phantom is anatomically accurate and feasible for the multi-modality medical imaging, including computer tomography (CT), ultrasound, and endoscopy. The CT results show that the phantom resembles the detailed anatomy of real livers including the biliary ducts, with a spatial root mean square error (RMSE) of 1.7 ± 0.7 mm and 0.9 ± 0.2 mm for the biliary duct and the liver outer shape, respectively. The sonographic signals and the endoscopic appearance highly mimic those of the real organ. An electric sensing system was developed for the real-time quantitative tracking of the transhepatic puncturing needle. The fabrication method herein is accurate and reproducible, and the needle tracking system offers a robust and general approach to evaluate the centesis outcome.

Efficacy of digital single-operator cholangioscopy and factors affecting its accuracy in the evaluation of indeterminate biliary stricture

BACKGROUND AND AIMS

Indeterminate biliary stricture remains a significant diagnostic challenge. The current method of ERCP with bile duct brush cytology has substantial room for improvement. We aimed to determine the efficacy of a digital single-operator cholangioscopy (DSOC) in evaluation of indeterminate biliary stricture.

METHODS

An observational cohort study was conducted among the patients who underwent DSOC for the indication of indeterminate biliary stricture at a tertiary academic medical center. The outcomes of interests were the accuracy of DSOC in visual interpretation and bile duct sample and identification of any factor(s) that could influence its effectiveness.

RESULTS

One hundred five patients were included. The overall accuracy of DSOC in visual interpretation was 89.5%, whereas the accuracy of bile duct sample was 83.2%. The sensitivities of visual impression and bile duct sample were 89.1% and 69.8% and their specificities were 90% and 97.9%, respectively. The degree of endoscopists' experience with fewer than 25 cases and the severity of hyperbilirubinemia negatively impacted the accuracy of DSOC. Among 55 patients with definitive diagnosis of malignant stricture, the sensitivity of combined intraductal forceps biopsy sampling and brush cytology was 80.6%, whereas the sensitivity of brush cytology alone was 47.1%.

CONCLUSIONS

DSOC augments ERCP in evaluating indeterminate biliary stricture. The acquisition of intraductal forceps biopsy samples should be a requisite in evaluation of indeterminate biliary stricture with DSOC. Discovery of modifiable factors such as the degree of endoscopists' expertise and the severity of hyperbilirubinemia, which can influence the accuracy of DSOC, warrants further studies on patient preprocedure optimization and an endoscopic training program that will cultivate procedural competency.

Use of SpyGlass for peroral cholangioscopy in the diagnosis and treatment of hepatobiliary diseases in over five years follow-up: A single centre experience

BACKGROUND/AIMS

The use of cholangioscopy for the diagnosis and treatment of hepatobiliary diseases is gradually becoming more common. We aimed to review our peroral cholangioscopy interventions, using the first-generation SpyGlass Direct Visualization System (SDVS) and summarize our experience in terms of procedures and results.

MATERIALS AND METHODS

Forty-one patients who underwent this procedure at our Gastroenterology Clinic between February 2010 and October 2014 were included in this study. Patients were monitored for a median (IQR) of 44 (range 38-72) months. Demographic characteristics of these patients, results of the radiological and biochemical evaluation performed prior to the procedure, cholangioscopy findings together with the data relating to the procedure, histopathological diagnosis, clinical findings and results, and their effects on patient prognosis were assessed.

RESULTS

In total, 41 patients underwent 46 cholangioscopy procedures. Of them, 21 (51.2%) were male. The most frequent clinical indications for cholangioscopy was the need to further investigate indeterminate stricture (n=16; 39%) and indeterminate filling defect (n=7; 17.1%). The procedure was considered successful in 39 patients with 41 (95.1%) receiving diagnostic and 33 (80.5%) receiving therapeutic benefits. The sensitivity and specificity for SVDS-guided biopsies and brush cytology were 80% and 87.5%; 26.6% and 75%, respectively. Complications related to the procedure occurred in a total of three patients (7.3%), two with cholangitis and one with perforation of gall bladder.

CONCLUSION

Our experience shows that cholangioscopy procedures, performed with SDVS, are clinically applicable and safe in the diagnosis and treatment of hepatobiliary diseases.

Digital Pancreaticocholangioscopy for Mapping of Pancreaticobiliary Neoplasia: Can We Alter the Surgical Resection Margin?

INTRODUCTION

In patients with pancreaticobiliary lesions anticipating surgical resection, digital pancreaticocholangioscopy can be used to identify the extent of disease. This presurgical"mapping" could change the surgical plan and optimize patient care.

MATERIALS AND METHODS

Patients with pancreaticobiliary lesions anticipating surgery who underwent endoscopic retrograde cholangiopancreatography with digital pancreaticocholangioscopy from 9 international centers were included. Primary outcome was whether pancreaticocholangioscopy altered the surgical plan. Secondary outcome was correlation between surgical and endoscopic histology and adverse events.

RESULTS

A total of 118 patients were included (64% male, mean age 69 y): cholangioscopy in 105 patients (89%), pancreatoscopy in 13 patients (11%). Pancreaticocholangioscopy changed the surgical plan in 39 (34%) of patients: 8 of 13 in the pancreatic duct, 32 of 105 in the bile duct. In the bile duct, 6 patients (5%) had less extensive surgery, 26 patients (25%) avoided surgery. In the pancreatic duct, 4 patients (31%) had more extensive surgery and 4 patients (31%) had less extensive surgery. Four patients with downstaged surgery had positive margins on surgical resection; 1 required additional surgical intervention. Overall correlation between endoscopy and surgical histology was 88%. Adverse events included post endoscopic retrograde cholangiopancreatography pancreatitis in 3 patients (2.5%).

CONCLUSION

Digital pancreaticocholangioscopy can be effectively used as a mapping tool to delineate the degree of involvement of biliary lesions before surgical resection, in some cases altering the surgical plan. Prospective studies are needed, especially when downstaging surgery.

Treatment Using the SpyGlass Digital System in a Patient with Hepatolithiasis after a Whipple Procedure

An 89-year-old man was referred to our hospital for treatment of hepatolithiasis causing recurrent cholangitis. He had undergone a prior Whipple procedure. Computed tomography demonstrated left-sided hepatolithiasis. First, we conducted peroral direct cholangioscopy (PDCS) using an ultraslim endoscope. Although PDCS was successfully conducted, it was unsuccessful in removing all the stones. The stones located in the B2 segment were difficult to remove because the endoscope could not be inserted deeply into this segment due to the small size of the intrahepatic bile duct. Next, we substituted the endoscope with an upper gastrointestinal endoscope. After positioning the endoscope, the SpyGlass digital system (SPY-DS) was successfully inserted deep into the B2 segment. Upon visualizing the residual stones, we conducted SPY-DS-guided electrohydraulic lithotripsy. The stones were disintegrated and completely removed. In cases of PDCS failure, a treatment strategy using the SPY-DS can be considered for patients with hepatolithiasis after a Whipple procedure.

Prospective evaluation of the short access cholangioscopy for stone clearance and evaluation of indeterminate strictures

BACKGROUND

Peroral cholangioscopy facilitates diagnosis and therapy of biliary disorders. This study prospectively evaluated a new short access cholangioscopy.

METHODS

Consecutive patients were included as follows: difficult stones (group 1) underwent cholangioscopy with electrohydraulic lithotripsy and indeterminate biliary strictures (group 2) were evaluated with macroscopic assessment and cholangioscopy guided biopsy sampling. We evaluated the complete stone clearance rate (group 1) and diagnostic accuracy (group 2). Follow-up was performed over a median of 13 and 16 months, respectively.

RESULTS

Group 1 (n=21): complete stone clearance defined as lack of stones in cholangiography and stone removal during cholangioscopy was achieved in 15 (71.4%) patients. Clinical stone clearance defined as lack of symptoms, laboratory abnormalities and hospital visits during follow-up, irrespective of stone clearance was evident in 17 (81.0%) patients. One serious adverse event occurred (bile duct perforation). Group 2 (n=28): malignancy was confirmed in 15 patients. Sensitivity, specificity and diagnostic accuracy of cholangioscopy were 85.7%, 75.0% and 80.7%, respectively. Sensitivity, specificity and diagnostic accuracy of biopsies were 54.5%, 100.0% and 72.2%, respectively. No serious adverse events occurred, and one patient was lost to follow-up.

CONCLUSIONS

The novel system enabled complex stone treatment and biliary stricture diagnosis. Cholangioscopy outperformed direct biopsy regarding characterization of indeterminate strictures.

Hemobilia from Biliary Angiodysplasia Diagnosed with Cholangioscopy

Biliary angiodysplasia is extremely rare. Our background search revealed only a few case reports in the English literature. We present a case of angiodysplasia of the proximal common bile duct in a patient with subacute upper gastrointestinal bleeding and symptomatic anemia. A standard esophagogastroduodenoscopy with subsequent dedicated duodenoscopy revealed blood-stained bile draining from the major ampulla orifice. A contrast-enhanced magnetic resonance cholangiopancreatography was unrevealing for any pancreaticobiliary pathology. The patient subsequently underwent an endoscopic retrograde cholangiopancreatography and SpyGlass® cholangioscopy, which demonstrated intermittent bleeding from angiodysplasia in the proximal common bile duct.

Advances in Therapeutic Cholangioscopy

Nowadays, cholangioscopy is an established modality in diagnostic and treatment of pancreaticobiliary diseases. The more widespread use and the recent development of new technologies and accessories had renewed the interest of endoscopic visualization of the biliary tract, increasing the range of indications and therapeutic procedures, such as diagnostic of indeterminate biliary strictures, lithotripsy of difficult bile duct stones, ablative techniques for intraductal malignancies, removal of foreign bodies and gallbladder drainage. These endoscopic interventions will probably be the last frontier in the near future. This paper presents the new advances in therapeutic cholangioscopy, focusing on the current clinical applications and on research areas.

The efficacy of peroral cholangioscopy for difficult bile duct stones and indeterminate strictures: a systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

Current evidence supporting the efficacy of peroral cholangioscopy (POC) in the evaluation and management of difficult bile duct stones and indeterminate strictures is limited. The aims of this systematic review and meta-analysis were to assess the following: the efficacy of POC for the therapy of difficult bile duct stones, the diagnostic accuracy of POC for the evaluation of indeterminate biliary strictures, and the overall adverse event rates for POC.

PATIENTS AND METHODS

Patients referred for the removal of difficult bile duct stones or the evaluation of indeterminate strictures via POC were included. Search terms pertaining to cholangioscopy were used, and articles were selected based on preset inclusion and exclusion criteria. Quality assessment of the studies was completed with a modified Newcastle-Ottawa Scale. After critical literature review, relevant outcomes of interest were analyzed. Meta-regression was performed to examine potential sources of between-study variation. Publication bias was assessed via funnel plots and Egger's test.

RESULTS

A total of 49 studies were included. The overall estimated stone clearance rate was 88 % (95 % confidence interval [95 %CI] 85 % - 91 %). The accuracy of POC was 89 % (95 %CI 84 % - 93 %) for making a visual diagnosis and and 79 % (95 %CI 74 % - 84 %) for making a histological diagnosis. The estimated overall adverse event rate was 7 % (95 %CI 6 % - 9 %).

CONCLUSIONS

POC is a safe and effective adjunctive tool with endoscopic retrograde cholangiopancreatography (ERCP) for the evaluation of bile duct strictures and the treatment of bile duct stones when conventional methods have failed. Prospective, controlled clinical trials are needed to further elucidate the precise role of POC during ERCP.

Role of balloon-assisted cholangioscopy in a multiethnic cohort to assess complex biliary disease (with videos)

BACKGROUND

Cholangioscopy is used to diagnose and treat various biliary lesions. Balloon-assisted cholangioscopy (BAC) has mostly been reported in Asian patients with large bile ducts.

OBJECTIVE

To assess the feasibility and accuracy of performing BAC in complex biliary diseases in Australian patients.

DESIGN

Prospective observational study.

SETTING

A single Australian tertiary referral hospital.

PATIENTS

Fifty-nine consecutive patients (55 non-Asian ethnicity).

INTERVENTIONS

BAC using ultrathin endoscopes.

MAIN OUTCOME MEASUREMENTS

Procedural success rates, diagnostic accuracy, and adverse event rates.

RESULTS

Fifty-nine patients underwent 76 BAC procedures for indeterminate biliary lesions, ampullary adenomas, and difficult stone disease. The technical success rate was 93%. The median bile duct diameter was 7 mm (range, 2-20). Of 34 indeterminate biliary strictures, 22 appeared benign and 12 malignant on BAC appearance alone. All benign-appearing strictures were confirmed benign, whereas 9 of 12 malignant-appearing strictures were confirmed malignant by biopsy sampling or follow-up (sensitivity 100% [95% CI, 66%-100%], specificity 88% [95% CI, 69%-97%], positive predictive value 75% [95% CI, 42%-93%], negative predictive value 100% [95% CI, 82%-100%]). BAC appearance correctly diagnosed indeterminate masses as benign (4/4) or malignant (3/3). Eight patients were assessed for bile duct extension of ampullary adenomas and 5 of 6 had biliary stones cleared directly or with holmium laser lithotripsy. Adequate histopathologic specimens were obtained from 31 of 39 (79%) attempted biopsy specimens. The adverse event rate was 8%.

LIMITATIONS

A single-center, single endoscopist experience.

CONCLUSIONS

In a largely non-Asian cohort with smaller bile ducts, BAC can be performed with high success and acceptable adverse event rates. BAC is particularly useful in differentiating benign from malignant indeterminate biliary lesions.

Volatile organic compounds in bile can diagnose malignant biliary strictures in the setting of pancreatic cancer: a preliminary observation

BACKGROUND

Ascertaining the nature of biliary strictures is challenging. The role of volatile organic compounds (VOCs) in bile in determining the cause of biliary strictures is not known.

OBJECTIVE

To identify potential VOCs in the headspaces (gas above the sample) of bile in patients with malignant biliary strictures from pancreatic cancer.

DESIGN

Prospective cross-sectional study.

SETTING

Referral center.

PATIENTS

Prospective study in which bile was aspirated in 96 patients undergoing ERCP for benign and malignant conditions.

MAIN OUTCOME MEASUREMENTS

Selected ion flow tube mass spectrometry (VOICE200R SIFT-MS instrument; Syft Technologies Ltd, Christchurch, New Zealand) was used to analyze the headspace and to build a predictive model for pancreatic cancer.

RESULTS

The headspaces from 96 bile samples were analyzed, including 24 from patients with pancreatic cancer and 72 from patients with benign biliary conditions. The concentrations of 6 compounds (acetaldehyde, acetone, benzene, carbon disulfide, pentane, and trimethylamine [TMA]) were increased in patients with pancreatic cancer compared with controls (P < .05). By using receiver-operating characteristic curve analysis, we developed a model for the diagnosis of pancreatic cancer based on the levels of TMA, acetone, isoprene, dimethyl sulfide, and acetaldehyde. The model [10.94 + 1.8229* log (acetaldehyde) + 0.7600* log (acetone) - 1.1746* log (dimethyl sulfide) + 1.0901* log (isoprene) - 2.1401 * log (trimethylamine) ≥ 10] identified the patients with pancreatic cancer (area under the curve = 0.85), with 83.3% sensitivity and 81.9% specificity.

LIMITATIONS

Sample size.

CONCLUSIONS

The measurement of biliary fluid VOCs may help to distinguish malignant from benign biliary strictures. Further studies are warranted to validate these observations. (Clinical Trial Registration Number NCT01565460.).

Interobserver agreement for single operator choledochoscopy imaging: can we do better?

Background. The SpyGlass Direct Visualization System (Boston Scientific, Natick, MA) is routinely used during single operator choledochoscopy (SOC) to identify biliary lesions or strictures with a diagnostic accuracy up to 88%. The objective of this study was to determine the interobserver agreement (IOA) of modified scoring criteria for diagnosing biliary lesions/strictures. Methods. 27 SPY SOC video clips were reviewed and scored by 9 interventional endoscopists based on published criteria that included the presence and severity of surface structure, vasculature visualization, lesions, and findings. Results. Overall IOA was "slight" for all variables. The K statistics are as follows: surface (K = 0.12, SE = 0.02); vessels (K = 0.14, SE = 0.02); lesions (K = 0.11, SE = 0.02); findings (K = 0.08, SE = 0.03); and final diagnosis (K = 0.08, SE = 0.02). The IOA for "findings" and "final diagnosis" was also only "slight." The final diagnosis was malignant (11), benign (11), and indeterminate (5). Conclusion. IOA using the modified criteria of SOC images was slight to almost poor. The average accuracy was less than 50%. These findings reaffirm that imaging criteria for benign and malignant biliary pathology need to be formally established and validated.

Role of SpyGlass peroral cholangioscopy in the evaluation of indeterminate biliary lesions

BACKGROUND

Accurate diagnosis of indeterminate biliary lesions is essential for treatment planning. The currently available techniques have some limitations in evaluating indeterminate biliary lesions. SpyGlass single-operator peroral cholangioscopy system has been developed to overcome these limitations.

AIM

The aim of this retrospective study was to evaluate the diagnostic accuracy of SpyGlass visual assessment and SpyBite biopsy in patients with indeterminate biliary lesions.

METHODS

We conducted a retrospective analysis of data from 36 patients with indeterminate biliary strictures or filling defects who had inconclusive results on the cross-sectional imaging study from September 2010 to October 2013. Four patients were excluded because of the presence of a metastatic mass and an ampulla of Vater cancer.

RESULTS

Thirty-two patients (19 men, mean age 63.7 years) with indeterminate biliary lesions underwent SpyGlass cholangioscopy. The cholangioscopy procedure with SpyGlass was technically successful in all of the cases except for one case because of the intraprocedural breakage of the SpyGlass optic probe (96.8%, 31/32). The biopsy specimens from nineteen patients were obtained using SpyBite forceps. The sensitivity, specificity, and overall accuracy of SpyGlass visual assessment and SpyBite biopsy for the diagnosis of malignancy were 100% (21/21) and 64.2% (9/14), 90% (9/10) and 100% (5/5), and 96.7% (30/31) and 73.6% (14/19), respectively. Procedure-related complications were noted in three cases; postsphincterotomy bleeding in one case and mild pancreatitis in two cases.

CONCLUSIONS

SpyGlass cholangioscopy with SpyBite biopsy is highly accurate and safe for differentiating malignant lesions from benign lesions in patients with indeterminate biliary lesions.

Pre- and post-training session evaluation for interobserver agreement and diagnostic accuracy of probe-based confocal laser endomicroscopy for biliary strictures

BACKGROUND AND AIM

Current diagnostic modalities for indeterminate biliary strictures offer low accuracy. Probe-based confocal laser endomicroscopy (pCLE) permits microscopic assessment of mucosal structures by obtaining real-time high-resolution images of the mucosal layers of the gastrointestinal tract. Previously, an interobserver study demonstrated poor to fair agreement even among experienced confocal endomicroscopy operators. Our objective was to assess interobserver agreement and diagnostic accuracy upon completion of a pCLE training session.

METHODS

Forty de-identified pCLE video clips of indeterminate biliary strictures were sent to five endoscopists at four tertiary care centers for scoring. Observers subsequently attended a teaching session by an expert pCLE user that included 20 training clips and rescored the same pCLE video clips, which were randomized and renumbered.

RESULTS

Pre-training interobserver agreement for all observers was 'fair' (Κ: 0.31, P-value: <0.0001) and diagnostic accuracy was 72% (55-80%). Post-training interobserver agreement for all observers was 'substantial' (Κ: 0.74, P-value: <0.0001) and diagnostic accuracy was 89% (80-95%). Using a paired t-test, we observed an increase of 17% (95% CI 7.6-26.4) in post-training diagnostic accuracy (t = 5.01, df = 4, P-value 0.007).

CONCLUSIONS

Interobserver agreement and diagnostic accuracy improved after observers underwent training by an expert pCLE user with a specific sequence set. Users should participate in such training programs to maximize diagnostic accuracy of pCLE evaluation.

Interobserver agreement for evaluation of imaging with single operator choledochoscopy: what are we looking at?

BACKGROUND

Single operator choledochoscopy is a platform used to assist in the confirmation of diagnosis of biliary lesions. However, there are little data regarding the interobserver agreement of imaging interpretation. Our objective was to assess the interobserver agreement in single operator choledochoscopy interpretation.

METHODS

38 De-identified SPY Choledochoscopy video clips were sent to 7 interventional endoscopists. They were asked to score the videos on presence of four criteria selected by the investigators: growth, stricture, hyperplasia, and ulceration. Observers also chose a final diagnosis from the categories of cancer, hyperplasia, inflammation, or normal. Kappa scores were calculated for the scoring of the four criteria and for the selection of the final diagnosis.

RESULTS

The overall interobserver agreement was fair in scoring for the presence of a growth (K=0.28, SE 0.035) and stricture (K=0.32, SE 0.035). Scoring for ulceration was slight to fair (K=0.17, SE 0.035). There was only slight agreement for the presence of hyperplasia (K=0.11, SE 0.035); and presumed final diagnosis based on imaging (K=0.18, SE 0.022).

CONCLUSION

The results of this study support the need for an effort to identify and validate cholangioscopy imaging criteria for biliary pathology. This may assist in improving the reliability of the diagnostic value of cholangioscopy as its use becomes more widespread.

Lipidomic profiling of bile in distinguishing benign from malignant biliary strictures: a single-blinded pilot study

OBJECTIVES

Ascertaining the benign or malignant nature of biliary strictures may be challenging. Oxidized phospholipids (oxPLs) play an important role in tumor apoptosis and may be elevated in malignant biliary strictures. The objective of the study was to investigate whether oxPLs are enriched in the bile of malignant biliary strictures.

METHODS

In this prospective single-blinded study, bile was obtained from 46 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis and management of biliary strictures, including 17 with pancreatic cancer, 6 with primary sclerosing cholangitis (PSC), 8 with cholangiocarcinoma (CCA), and 15 with benign biliary conditions (sphincter of Oddi dysfunction (SOD) or choledocholithiasis or chronic pancreatitis). Bile samples were stored under conditions to minimize artificial oxidation. Levels of 10 different oxPLs were measured blindly by one investigator using liquid chromatography electrospray ionization tandem mass spectrometry (LC-ESI-MS/MS).

RESULTS

Of the 10 different phospholipids measured, the levels of two phosphatidylcholines (PCs; i.e., ON-PC and S-PC) were elevated in CCA as compared with other biliary strictures. Among these, ON-PC was most useful and a cutoff value of 6,020.1 nm distinguished CCA from other biliary strictures with a sensitivity and specificity of 85.7% and 80.3%, respectively (area under curve (AUC) 0.86). A combination of ON-PC and S-PC at a cutoff value of 6,032.2 nm distinguished CCA from other biliary strictures with a sensitivity and specificity of (100% and 83.3%, respectively (AUC 0.91).

CONCLUSIONS

The measurement of specific oxPL products may help to distinguish CCA from other biliary strictures. Measurement of these products in bile may enhance the endoscopic diagnosis of indeterminate biliary strictures.

Diagnostic and therapeutic cholangiopancreatoscopy: performance of a new digital cholangioscope

BACKGROUND

High-definition cholangioscopes provide excellent images of the pancreatobiliary ductal system and may play a significant role in diagnosis and treatment of various pancreatobiliary disorders.

OBJECTIVE

To assess the performance of a new digital cholangioscope for diagnosis and treatment of pancreatobiliary disorders in clinical practice.

DESIGN

Prospective study.

SETTING

Academic hospital, tertiary-care referral center.

PATIENTS

Consecutive patients with suspected pancreatobiliary disorders.

INTERVENTION

Diagnostic or therapeutic high-definition digital cholangiopancreatoscopy.

MAIN OUTCOME MEASUREMENTS

Satisfactory visualization of the ductal mucosa and lumen and treatment of pancreatobiliary disorders when indicated.

RESULTS

A total of 28 cholangioscopy and 4 pancreatoscopy procedures were completed before breakdown of the cholangioscope. Excellent views of the ductal lumen and mucosa were obtained in all patients. In the 18 patients with indeterminate biliary strictures, high-definition cholangioscopy identified all cholangiocarcinomas but labeled as malignant only 1 of 4 strictures caused by pancreatic cancer (sensitivity 73%). All benign strictures were correctly labeled (specificity 100%). Cholangioscopy proved helpful in evaluation of various biliary disorders and lithotripsy of pancreatic stones under direct vision.

LIMITATIONS

Single center, small number of patients.

CONCLUSION

High-definition cholangioscopy is a useful adjunct to ERCP in the diagnosis and treatment of pancreatobiliary disorders. Although fragility of the cholangioscope remains a problem, the changes made in the construction of this prototype digital cholangioscope have significantly increased its durability.

Predictors for detection of cancer in patients with indeterminate biliary stricture and atypical cells on endoscopic retrograde brush cytology

OBJECTIVE

The management of atypical cells on endoscopic retrograde brush cytology (ERBC) in patients with indeterminate biliary stricture is unclear. This study aimed to investigate the detection of cancer (pancreatic and biliary carcinoma) in patients with atypical cells on ERBC and the factors predicting it.

METHODS

From a prospectively maintained cytology database in a tertiary care center, patients with indeterminate biliary stricture and atypical cells on ERBC from 1996 to 2012 were studied. The date of the initial ERBC with atypical cells was identified as time zero. The primary outcome was to study the incidences and Kaplan-Meier estimates for detecting cancer.

RESULTS

In all, 104 patients with 182.8 person-years of follow-up were identified. In 38 (36.5%) patients cancer was detected (19 cholangiocarcinoma, 15 pancreatic cancer, three ampullary cancer and one gallbladder carcinoma) over a mean follow-up of 4.4 months. On Cox regression analysis, the presence of clinical jaundice (hazard ratio [HR] 4.08, 95% CI 1.41-11.8), active alcohol consumption (HR 7.33, 95% CI 1.85-29.1) and elevated carbohydrate antigen 19-9 (CA19-9) level (>33 U/mL) (HR 8.42, 95% CI 1.75-40.6) at the time of ERBC were associated with increased risk for the detection of cancer. Detection of cancer was more common during the first 6 months of follow-up than at any time period thereafter.

CONCLUSION

Elevated CA19-9 level, the presence of clinical jaundice and current alcohol consumption are associated with increased detection of cancer in patients with indeterminate biliary stricture and atypical cells on ERBC.

Vascular endothelial growth factor levels in bile distinguishes pancreatic cancer from other etiologies of biliary stricture: a pilot study

BACKGROUND

Determining the benign or malignant nature of biliary strictures can be challenging. Vascular endothelial growth factor (VEGF) plays an important role in tumor angiogenesis.

OBJECTIVE

The purpose of this study was to investigate whether VEGF levels in bile aspirated during endoscopic retrograde cholangiography (ERCP) can distinguish pancreatic cancer from other causes of biliary stricture.

METHODS

Bile was directly aspirated in 53 consecutive patients from March 2012 to October 2012 during ERCP from the common bile duct including 15 with pancreatic cancer, 18 with primary sclerosing cholangitis (PSC), nine with cholangiocarcinoma (CCA), and 11 with benign biliary conditions (sphincter of Oddi and choledocholihiasis). Levels of VEGF in bile were measured. The diagnostic performance was then validated in a second, independent validation cohort of 18 patients (pancreatic cancer n = 10, benign n = 8).

RESULTS

A total of 53 consecutive patients were recruited. The median bile VEGF levels were significantly elevated in patients with pancreatic cancer (1.9 ng/ml (interquartile range [IQR] 0.7, 2.2) compared to those with benign biliary conditions (0.3 ng/ml [IQR 0.2, 0.6]; p < 0.001), PSC (0.7 ng/ml [IQR 0.5, 0.9]; p = 0.02) or CCA (0.4 ng/ml [IQR 0.1, 0.5]; p < 0.001). A VEGF cut-off value of 0.5 ng/ml distinguished pancreatic cancer from CCA with a sensitivity and specificity of 93.3 and 88.9 %, respectively, and area under curve (AUC) of 0.93, and from benign conditions with a sensitivity and specificity of 93.3 and 72.7 %, respectively, with AUC of 0.89. The diagnostic accuracy of biliary VEGF was confirmed in the second independent validation cohort.

CONCLUSIONS

This study suggests that measurement of biliary VEGF-1 levels distinguishes patients with pancreatic cancer from other etiologies of biliary stricture. This may be particularly relevant in approaching patients with indeterminate biliary stricture.

Residual common bile duct stones on direct peroral cholangioscopy using ultraslim endoscope

AIM: To detect and manage residual common bile duct (CBD) stones using ultraslim endoscopic peroral cholangioscopy (POC) after a negative balloon-occluded cholangiography.

METHODS: From March 2011 to December 2011, a cohort of 22 patients with CBD stones who underwent both endoscopic retrograde cholangiography (ERC) and direct POC were prospectively enrolled in this study. Those patients who were younger than 20 years of age, pregnant, critically ill, or unable to provide informed consent for direct POC, as well as those with concomitant gallbladder stones or CBD with diameters less than 10 mm were excluded. Direct POC using an ultraslim endoscope with an overtube balloon-assisted technique was carried out immediately after a negative balloon-occluded cholangiography was obtained.

RESULTS: The ultraslim endoscope was able to be advanced to the hepatic hilum or the intrahepatic bile duct (IHD) in 8 patients (36.4%), to the extrahepatic bile duct where the hilum could be visualized in 10 patients (45.5%), and to the distal CBD where the hilum could not be visualized in 4 patients (18.2%). The procedure time of the diagnostic POC was 8.2 ± 2.9 min (range, 5-18 min). Residual CBD stones were found in 5 (22.7%) of the patients. There was one residual stone each in 3 of the patients, three in 1 patient, and more than five in 1 patient. The diameter of the residual stones ranged from 2-5 mm. In 2 of the patients, the residual stones were successfully extracted using either a retrieval balloon catheter (n = 1) or a basket catheter (n = 1) under direct endoscopic control. In the remaining 3 patients, the residual stones were removed using an irrigation and suction method under direct endoscopic visualization. There were no serious procedure-related complications, such as bleeding, pancreatitis, biliary tract infection, or perforation, in this study.

CONCLUSION: Direct POC using an ultraslim endoscope appears to be a useful tool for both detecting and treating residual CBD stones after conventional ERC.

Advanced techniques for endoscopic biliary imaging: cholangioscopy, endoscopic ultrasonography, confocal, and beyond

Cholangioscopy, endosonography, and confocal microscopy represent important technologies that expand biliary imaging beyond a level previously realized by noninvasive modalities (ultrasonography, computed tomography, and magnetic resonance cholangiopancreatography) and endoscopic retrograde cholangiopancreatography. Endoscopic ultrasonography has shown efficacy for the evaluation of indeterminate biliary strictures; however, this modality seems most reliable for distal bile duct abnormalities and in the setting of a moderate to high pretest probability for malignancy. Further refinement of these technologies, validation of their respective diagnostic criteria, and study within the context of comparative, randomized trials are needed and will contribute greatly to expedient patient care.

Potential role of peroral cholangioscopy for preoperative diagnosis of cholangiocarcinoma

BACKGROUND/PURPOSE

We evaluated the utility of peroral cholangioscopy (POCS) for preoperative diagnosis of cholangiocarcinoma.

METHODS

POCS was performed to assess the horizontal extension of the carcinoma. We compared the results of assessment with those of histologic analysis of 44 surgically resected specimens.

RESULTS

Cholangiocarcinoma types were described as filling defects and strictures in 16 and 28 patients, respectively, using cholangiography. Endoscopic retrograde cholangiography (ERC) identified tumor extension in 5 and 15 patients with filling defects (31.25%) and strictures (53.57%), respectively. ERC+POCS identified tumor extension in 15 and 16 patients with filling defects (93.75%) and strictures (60.71%), respectively. ERC+POCS was significantly useful for patients with filling defects compared with ERC alone (P=0.002). ERC+POCS was not significantly useful for patients with strictures compared with ERC alone.

CONCLUSIONS

POCS is a useful preoperative examination modality for assessing tumor extension in cholangiocarcinoma patients, especially in those with filling defects.

Endoscopic lithotripsy with peroral direct cholangioscopy using a conventional endoscope

Recently, peroral direct cholangioscopy (PDCS) using an ultra-slim endoscope has come into the spotlight. However, the working channel is too small to use various devices for lithotripsy. We report a case of endoscopic lithotripsy with PDCS using a conventional endoscope as a cholangioscope. Computed tomography scan on an 80-year-old female who was admitted with acute cholangitis showed two large stones in the bile duct. Endoscopic retrograde cholangiopancreatography was attempted first. However, mechanical lithotripsy failed because the stone was too large for the basket catheter. Finally, electric hydraulic lithotripsy with PDCS using a conventional endoscope was performed allowed the stones to be cleared completely. In conclusion, PDCS using a conventional endoscope can be an alternative solution for endoscopic lithotripsy for patients with large stones in the dilated bile duct.

Endoscopic management of difficult common bile duct stones

Endoscopy is widely accepted as the first treatment option in the management of bile duct stones. In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones. Most biliary stones can be removed with an extraction balloon, extraction basket or mechanical lithotripsy after endoscopic sphincterotomy. Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients. Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed. Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.

SpyGlass single-operator peroral cholangioscopy in the evaluation of indeterminate biliary lesions: a single-center, prospective, cohort study

BACKGROUND

SpyGlass single-operator peroral cholangioscopy appears to be a promising technique to overcome some limitations of conventional peroral cholangioscopy. We aimed to prospectively evaluate the SpyGlass system in a cohort of patients with indeterminate biliary lesions.

METHODS

Patients with indeterminate strictures or filling defects at endoscopic retrograde cholangiopancreatography (ERCP) were consecutively enrolled. After SpyGlass visual evaluation, targeted biopsies were taken with the SpyBite and histopathological assessment was made by two experienced gastrointestinal pathologists. SpyBite-targeted biopsy results were evaluated by assessing agreement with surgical specimens and by evaluation of final, clinical follow-up-based diagnosis.

RESULTS

Fifty-two patients participated in the study. In 7 cases, definite diagnosis (stones, varices) was made by SpyGlass endoscopic evaluation. In 42 of the remaining 45 cases, material suitable for histopathology assessment was provided by the SpyBite. Overall, a definite diagnosis was made in 49 (7 + 42; 94 %) cases. Agreement of SpyBite biopsy results with surgical specimen diagnosis was found in 38/42 (90 %) cases; sensitivity, specificity, and positive and negative predictive values were 88, 94, 96, and 85 %, respectively. Procedure-related complications consisted of one case of mild cholangitis and one case of mild pancreatitis.

CONCLUSIONS

In our series, the SpyGlass system allowed adequate biopsy sampling and definite diagnosis with high accuracy in the vast majority of patients with indeterminate biliary lesions. Its use was associated with a low complication rate. Further refinements of the technique are warranted, but the SpyGlass system has the potential to become a diagnostic standard for the assessment of indeterminate biliary lesions.

The usefulness of SpyGlass™ choledochoscopy in the diagnosis and treatment of biliary disorders

Peroral choledochoscopy was first described in the 1970s, but the use of earlier generation choledochoscopes was significantly limited by complex equipment setup and fragility resulting in high repair costs. In late 2006, the SpyGlass Direct Visualization System (Boston Scientific Corp, Natick, MA, USA) was introduced to the market. It is a single-operator cholangioscopy platform and improves upon many shortcomings of the dual-operator systems. Currently, the two main indications for its use are evaluation of indeterminate biliary strictures and lithotripsy for difficult-to-remove biliary stones. Recently published prospective data reconfirm that the overall success rates for adequate tissue sampling and bile duct stone clearance are around 90 %, with an acceptable safety profile. The sensitivity for detecting cancer in intrinsic biliary strictures (e.g., cholangiocarcinoma) is superior to that of standard ERCP sampling modalities, but a limited yield has been noted when sampling extrinsic malignant biliary strictures (e.g., pancreatic cancer). The two main limitations of the SpyGlass system are image quality that is impeded by the use of fiberoptic technology and a relatively small accessory channel providing passage only for dedicated miniaccessories. Nevertheless, the SpyGlass platform has made single-operator cholangioscopy feasible and refined the technique in a number of important ways. This innovation has significantly expanded our diagnostic and therapeutic ERCP armamentarium. An upgraded digital imaging version is currently in development.

Interpretation of probe-based confocal laser endomicroscopy of indeterminate biliary strictures: is there any interobserver agreement?

BACKGROUND

Probe-based confocal laser endomicroscopy (pCLE) has enabled in vivo histopathology by obtaining high resolution images of the mucosal layers of the gastrointestinal tract. For indeterminate bile duct strictures, biopsy, cytologic brushing and needle aspiration have low levels of diagnostic accuracy.

AIM

The objective of this multi-center pilot study was to assess the interobserver agreement in interpretation of pCLE imaging.

METHODS

Twenty-five de-identified pCLE video clips of indeterminate biliary strictures were sent to 6 observers at 5 institutions. Miami Classification was used to standardize image interpretation. Seven variables were assessed for interobserver agreement using the Fleiss kappa statistic which included: presence of thick (>20 μm) or thin (<20 μm) dark or white bands, dark clumps, epithelium including glandular structures, interstitial fluorescein leakage, ease of interpretation, and final diagnosis. Based on operator experience, observers were categorized into 3 categories of experience (Category 1: 0-10; Category 2: 11-20; Category 3: >21 cases).

RESULTS

Upon stratification, Category 1 interobserver agreement ranged from "Poor" to "Fair" (κ = 0.277, κ = -0.079, κ = -0.025, κ = -0.066, κ = 0.128, κ = 0.088), and for the final diagnosis variable, the agreement was slight (κ = 0.033). Category 2 and 3 interobserver agreement ranged from "Poor" to "Fair" (κ = 0.211, κ = 0.181, κ = 0.347, κ = 0.238, κ = -0.050, κ = 0.092), and for the final diagnosis variable, the agreement was slight (κ = 0.195).

CONCLUSION

The overall interobserver agreement for pCLE image interpretation in indeterminate biliary strictures ranges from poor to fair. Interpretation criteria as well as training require further standardization toward improving inter-rater reliability.

Current endoscopic approach to indeterminate biliary strictures

Biliary strictures are considered indeterminate when basic work-up, including transabdominal imaging and endoscopic retrograde cholangiopancreatography with routine cytologic brushing, are non-diagnostic. Indeterminate biliary strictures can easily be mischaracterized which may dramatically affect patient’s outcome. Early and accurate diagnosis of malignancy impacts not only a patient’s candidacy for surgery, but also potential timely targeted chemotherapies. A significant portion of patients with indeterminate biliary strictures have benign disease and accurate diagnosis is, thus, paramount to avoid unnecessary surgery. Current sampling strategies have suboptimal accuracy for the diagnosis of malignancy. Emerging data on other diagnostic modalities, such as ancillary cytology techniques, single operator cholangioscopy, and endoscopic ultrasonography-guided fine needle aspiration, revealed promising results with much improved sensitivity.

Spyglass direct visualization system

Although endoscopic retrograde cholangiopancreatography is considered the gold standard to manage biliary disorders, it has its own limitations. The single-operator cholangioscopy (SOC) system (Spyglass) may offer an interesting compromise for most advanced biliary endoscopists, in terms of size (10 Fr diameter) and complexity of use. SOC is a great step toward intraductal visualization and therapy but the best is yet to come.

Diagnostic and therapeutic direct peroral cholangioscopy using an intraductal anchoring balloon

AIM: To report our experience using a recently introduced anchoring balloon for diagnostic and therapeutic direct peroral cholangioscopy (DPOC).

METHODS: Consecutive patients referred for diagnostic or therapeutic peroral cholangioscopy were evaluated in a prospective cohort study. The patients underwent DPOC using an intraductal anchoring balloon, which was recently introduced to allow consistent access to the biliary tree with an ultraslim upper endoscope. The device was later voluntarily withdrawn from the market by the manufacturer.

RESULTS: Fourteen patients underwent DPOC using the anchoring balloon. Biliary access with an ultraslim upper endoscope was accomplished in all 14 patients. In 12 (86%) patients, ductal access required sphincteroplasty with a 10-mm dilating balloon. Intraductal placement of the ultraslim upper endoscope allowed satisfactory visualization of the biliary mucosa to the level of the confluence of the right and left hepatic ducts in 13 of 14 patients (93%). Therapeutic interventions by DPOC were successfully completed in all five attempted cases (intraductal biopsy in one and DPOC guided laser lithotripsy in four). Adverse events occurred in a patient on immunosuppressive therapy who developed an intrahepatic biloma at the site of the anchoring balloon. This required hospitalization and antibiotics. Repeat endoscopic retrograde cholangiopancreatography 8 wk after the index procedure showed resolution of the biloma.

CONCLUSION: Use of this anchoring balloon allowed consistent access to the biliary tree for performance of diagnostic and therapeutic DPOC distal to the biliary bifurcation.

Heterotopic gastric mucosa in the hilar bile duct mimicking hilar cholangiocarcinoma: report of a case

We herein report a case of heterotopic gastric mucosa in the hilar bile duct. An asymptomatic 58-year-old male was noted to have mild liver dysfunction in March 2009 during the follow-up for angina pectoris. Abdominal-enhanced CT revealed wall thickening from the upper common hepatic bile duct to the left hepatic bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) showed stenosis at the junction of the left hepatic bile duct. Although the patient's serum tumor markers were all within the normal ranges, the possibility of malignant disease of the biliary tree could not be ruled out. Left hepatectomy with the caudate lobe and resection of the extrahepatic bile duct were performed. Histopathologically, the resected specimen showed a polypoid lesion measuring 2 × 2 cm in size that projected into the lumen of the left hepatic bile duct. Microscopic examination revealed this polypoid lesion to be composed of mucous glands resembling gastric fundic glands, with parietal and chief cells. We also review eight other reports of heterotopic gastric mucosa in the biliary tree previously published in the English literature.

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