Interventional radiology-operated endoscopy using the LithoVue disposable endoscope: Approach, technical success, clinical outcomes, and complications

Research Priorities in Percutaneous Image and Endoscopy Guided Interventions for Biliary and Gallbladder Diseases: Proceedings from the Society of Interventional Radiology Foundation Multidisciplinary Research Consensus Panel

Recent technological advancements including the introduction of disposable endoscopes have enhanced the role of interventional radiology (IR) in the management of biliary/gallbladder diseases. There are unanswered questions in this growing field. The Society of Interventional Radiology Foundation convened a virtual Research Consensus Panel consisting of a multidisciplinary group of experts, to develop a prioritized research agenda regarding percutaneous image and endoscopy guided procedures for biliary and gallbladder diseases. The panelists discussed current data, opportunities for IR and future efforts to maximize IR's ability and scope. A recurring theme throughout the discussions was to find ways to reduce the total duration of percutaneous drains and to improve the patients' quality of life. Following the presentations and discussions, research priorities were ranked based on their clinical relevance and impact. The research ideas ranked top three were as follows: 1- Percutaneous multimodality management of benign anastomotic biliary strictures (Laser vs endobiliary ablation vs cholangioplasty vs drain upsize protocol alone); 2- Ablation of intraductal cholangiocarcinoma with and without stenting; and 3- Cholecystoscopy/choledochoscopy and lithotripsy in non-surgical patients with calculous cholecystitis. Collaborative retrospective and prospective research studies are essential to answer these questions and to improve the management protocols for patients with biliary/gallbladder diseases.

Safety and feasibility of single use cholecystoscopy for guiding laser or mechanical cholelithotripsy, and mechanical cholelithotomy

PURPOSE Patients with acute calculus cholecystitis and contraindications to cholecystectomy receive cholecystostomy drainage catheters, many of which remain in place until end of life. This study aims to assess safety, feasibility, and early clinical outcomes of percutaneous cholecystoscopy using the LithoVue endoscope, laser/mechanical cholelithotripsy, and mechanical cholelithotomy for management of symptomatic cholelithiasis. METHODS This was a single-institute retrospective analysis of 17 patients with acute calculus cholecystitis who had contraindications to cholecystectomy, underwent cholecystostomy catheter placement between 2015 and 2017, and stone removal between 2017 and 2018. The LithoVue 7.7- 9.5 F endoscope was used in combination with laser/mechanical cholelithotripsy, mechanical retrograde, and balloon-assisted anterograde cholelithotomy to remove gallstones and common bile duct stones. Surgical contraindications ranged from cardiopulmonary disease to morbid obesity to neoplastic processes. Timing and number of interventions, as well as technical and clinical successes, were assessed. RESULTS The median time interval from cholecystostomy catheter placement to cholelithotripsy was 58 days, after an average of 2 tube exchange procedures. Technical and clinical success were achieved in all patients (stone-free gallbladder and cholecystostomy tube removal). On average, three sessions of cholecystoscopy and laser and mechanical cholelithotripsy were required for complete gallstone extraction. The mean interval time between the first cholelithotripsy session and removal of cholecystostomy was 71.8±60.8 days. There were neither major nor minor procedure-related complications. CONCLUSION Percutaneous cholecystoscopy using the LithoVue endoscope, in combination with laser/ mechanical cholelithotripsy and mechanical cholelithotomy, is feasible, safe, well-tolerated, and was able to remove the cholecystostomy tube in the patients with contraindication to cholecystectomy.

Single-Use Versus Reusable Endoscopes for Percutaneous Biliary Endoscopy with Lithotripsy: Technical Metrics, Clinical Outcomes, and Cost Comparison

PURPOSE

To compare procedure and fluoroscopy time, technical and clinical success, and costs between single-use and reusable endoscopes in patients undergoing percutaneous biliary endoscopy (PBE) with lithotripsy.

MATERIAL AND METHODS

In this retrospective study, we included 34 patients (67 procedures) treated with PBE for gallstone removal from October 24, 2014, through February 12, 2020, using reusable (28 procedures) or single-use (39 procedures) endoscopes. We compared 1) procedure time, 2) fluoroscopy time, 3) technical success rate (accessing the biliary system and locating the gallstone), 4) clinical success rate (at least partial gallstone removal), 5) complication rate, and 6) cost of use. Alpha = 0.05.

RESULTS

Mean (± standard deviation) procedure time was not significantly different between single-use (136 ± 45 minutes) and reusable endoscopes (136 ± 51 minutes) (p = 0.47). Mean fluoroscopy time was significantly shorter for single-use endoscopes (11 ± 8.4 minutes) than for reusable endoscopes (18 ± 12 minutes) (p = 0.01). When comparing single-use vs. reusable endoscopes, rates were not significantly different for technical success (N=37, 95% vs. N=26, 93%) or clinical success (N=35, 90% vs. N=21, 75%) (both, p>0.05). Only 1 complication was noted in the reusable endoscope group (p=0.42). Cost per case was lower for single-use ($1500) than for reusable ($3987) endoscope procedures, primarily due to differences in capital costs and costs due to repair.

CONCLUSION

Single-use endoscopes offer the potential for less radiation exposure to the patient and lower cost per case, which may reduce financial barriers to offering PBE in interventional radiology practices. Clinical and technical success rates did not differ by endoscope type.

Percutaneous Access of the Modified Hutson Loop for Retrograde Cholangiography, Endoscopy, and Biliary Interventions

PURPOSE

The purpose of this study was to present the institutional experience of performing endoscopy, cholangiography, and biliary interventions through the modified Hutson loop by interventional radiology.

MATERIALS AND METHODS

A total of 61 of 64 modified Hutson loop access procedures were successful. This single-center retrospective study included 61 successful procedures of biliary interventions using existing modified Hutson loops (surgically affixed subcutaneous jejunal limb adjacent to biliary anastomosis or anastomoses) for diagnostic or therapeutic purposes in 21 patients. Seventeen of 21 patients (81%) had undergone liver transplantation. Indications included biliary strictures (n = 18) and biliary leaks (n = 3). The clinical success and complications were evaluated.

RESULTS

There were 3 of 26 modified Hutson loop retrograde biliary intervention failures (12%) before introduction of endoscopy and no failures (0 of 38 [0%]) subsequently (P = .06). Endoscopy or cholangioscopy was performed in 19 procedures by interventional radiologists. Retrograde biliary interventions included diagnostic cholangiography (n = 26), cholangioplasty (n = 25), stent placement (n = 29), stent retrieval (n = 25), and biliary drainage catheter placement (n = 5). No procedure-related mortality occurred. There was 1 major complication (duodenal perforation) (1.6%) and 12 minor complications (19%). In the 9 patients undergoing therapeutic interventions for biliary strictures, there was a significant decrease in median alkaline phosphatase (288.5 to 174.5 U/L; P = .03). There was a trend toward decrease in median bilirubin levels (1.7 to 1 mg/dL; P = .06) at 1 month post-intervention.

CONCLUSIONS

The modified Hutson loop provided interventional radiologists a safe and effective alternative access to manage biliary complications in patients with biliary-enteric anastomoses. Introduction of the endoscope in interventional radiology has improved the success rate of these procedures.