Direct peroral cholangioscopy简

Peroral cholangioscopy is an important tool for diagnosis and treatment of various biliary disorders. Peroral cholangioscopy can be performed by using a dedicated cholangioscope that is advanced through the accessory channel of a duodenoscope, or by direct insertion of a small-diameter endoscope into the bile duct. Direct peroral cholangioscopy refers to insertion of an ultraslim endoscope directly into the bile duct for visualization of the biliary mucosa and lumen. This approach provides a valuable and economic solution for diagnostic and therapeutic applications in the biliary tree. Compared to ductoscopy using a dedicated cholangioscope, the direct approach has several advantages and disadvantages. In this editorial, I discuss the advantages, disadvantages, and possible future developments pertaining to direct peroral cholangioscopy.     

PERORAL CHOLANGIOSCOPY: AN IMPROVED PROCEDURE

Cholangioscopy provides direct visual assessment of the bile ducts, tissue sampling, and therapeutic interventions. Delineation of intraductal lesions equivocal with direct cholangiography, differentiation between malignant and benign biliary strictures, and assessment of longitudinal extent of cholangiocarcinoma are major indicators for diagnostic cholangioscopy. Peroral cholangioscopy is readily performed at an initial endoscopic retrograde cholangiopancreatography. Owing to substantial refinement in terms of image quality and technical feasibility achieved with the development of a new video cholangioscope, peroral cholangioscopy has become a powerful tool. However, compared with percutaneous cholangioscopy, there remain several disadvantages in peroral cholangioscopy: less favorable maneuverability, small instrumental channel, and limited therapeutic instrumentations. With further advances in endoscopic functions and increasing availability of suitable instruments, peroral cholangioscopy, because of its less invasiveness, will become mandatory for diagnostic and therapeutic biliary endoscopy.     

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 1970 s, 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.     

Therapeutic role of direct peroral cholangioscopy using an ultra-slim upper endoscope

Introduction

Peroral cholangioscopy provides direct visualization of the bile duct and facilitates diagnostic procedures and therapeutic intervention. The currently available mother?Cbaby scope system is not widely used because of its disadvantages. Direct peroral cholangioscopy (POC) with a regular, ultra-slim, upper endoscope can provide a valuable and economic solution for evaluating bile duct lesions, although its therapeutic role in biliary tract disease is uncertain. We assessed the usefulness of direct POC with an ultra-slim endoscope for therapeutic application in patients with biliary diseases.

Methods

Several new techniques and accessories allow therapeutic intervention under direct POC using an ultra-slim upper endoscope with a larger, 2-mm working channel. Intracorporeal laser or electrohydraulic lithotripsy under direct POC is a main therapeutic intervention for patients with bile duct stones resistant to conventional endoscopic procedures. Tumor ablation therapy such as photodynamic therapy and argon plasma coagulation may be performed under direct POC. Direct POC can be applied to guide biliary interventions such as guidewire placement, stone removal, and migrated stent retrieval, using diverse accessories.

Conclusion

Direct POC with an ultra-slim upper endoscope allows therapeutic intervention for patients with biliary diseases. Enhancements of the endoscope and specialized accessories are expected to expand the therapeutic role of direct POC.     

Peroral cholangioscopy for the diagnosis and treatment of biliary diseases

Peroral cholangioscopy with duodenoscopic assistance can allow direct visualization of the bile duct. Several clinical studies suggest the utility of peroral cholangioscopy for the management of various bile duct lesions. Although direct visual observation may be a useful adjunct to endoscopic retro-grade cholangiopancreatography (ERCP) for distinguishing malignant from benign bile duct lesions, the assessment of diagnostic accuracy needs further controlled clinical studies. Intracorporeal lithotripsy with the use of a peroral cholangioscope may be a safe and effective method for difficult-to-treat bile duct stones, including intrahepatic stones. At present, however, the fragility of the fiberscope equipment and technical difficulties hold back its popularity. Preliminary data obtained by using a new videoscope, which provides excellent quality images, are encouraging. Furthermore, it is expected that this videoscope will have longer durability of optical images and better manipulation than previous fiberscopes.     

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.     

Direct insertion of an ultra‐slim upper endoscope for cholangioscopy in patients undergoing choledochoduodenostomy

Direct peroral cholangioscopy (POC) using an ultra‐slim upper endoscope is one modality of POC for intraductal endoscopic evaluation and treatment of the bile duct. Choledochoduodenostomy (CDS) is one modality of biliary bypass surgery that provides a new route to the bile duct. We carried out direct POC using an ultra‐slim upper endoscope without the use of accessories in 10 patients (four sump syndromes, three bile duct strictures and three intrahepatic duct stones) previously undergoing surgical CDS. Direct POC was successful in all patients. The use of an intraductal balloon catheter was required in one patient for advancement of the endoscope into the bile duct. Distal bile ducts with sump syndromes were cleared using baskets and water irrigation under direct POC. Cholangiocarcinoma was diagnosed in one patient with hilar bile duct stricture after cholangioscopic evaluation and a targeting forceps biopsy under direct POC. Intrahepatic duct stones were successfully extracted after intraductal fragmentation under direct POC. Oozing bleeding occurred during intraductal lithotripsy but stopped spontaneously. Direct POC using an ultra‐slim upper endoscope without the assistance of accessories can easily be carried out in patients undergoing CDS.     

Novel peroral direct digital cholangioscopy‐assisted lithotripsy using a monorail technique through the overtube in patients with surgically altered anatomy (with video)

Efficacy of cholangioscopy‐assisted lithotripsy for difficult stones such as huge stones, multiple large stones and an impacted stone in patients with non‐altered anatomy has been reported. Herein, we describe peroral direct digital cholangioscopy (PDCS)‐assisted electrohydraulic lithotripsy (EHL) with a new technique in patients with surgically altered anatomy. Five patients received PDCS‐assisted EHL with the monorail technique due to failed conventional stone extraction. Balloon enteroscope was removed, leaving the stiff guidewire in the bile duct and an overtube with inflated balloons. The cholangioscope was then inserted into the bile duct over the wire through the overtube. After direct visualization of the stone, PDCS‐assisted EHL was carried out. This technique was named the ‘monorail technique’. Complete removal of biliary stones in one session was accomplished in four patients and only one case required two sessions. There was no adverse event in any of the cases. PDCS‐assisted EHL using the monorail technique was effective and safe for difficult biliary stones in patients with surgically altered anatomy.     

DIRECT PERORAL CHOLANGIOSCOPY AND PANCREATOSCOPY FOR DIAGNOSIS OF A PANCREATOBILIARY FISTULA CAUSED BY AN INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM OF THE PANCREAS: A CASE REPORT

Here, we report a case of a pancreatobiliary (PB) fistula caused by an intraductal papillary mucinous neoplasm (IPMN) of the pancreas. The PB fistula was suspected after endoscopic retrograde cholangiopancreatography (ERCP) and diagnosed after direct visualization with a direct peroral cholangioscopy and pancreatoscopy by using an ultra‐slim endoscope. No previous reports exist on the precise diagnosis of a PB fistula with direct peroral cholangioscopy and pancreatoscopy. In our case report, a 69‐year‐old man underwent an ERCP because of a pancreatic head mass and biliary tract obstruction. During ERCP, a fistula between the common bile duct (CBD) and main pancreatic duct (MPD) was suspected. After endoscopic sphincterotomy, we examined both the CBD and MPD with an ultra‐slim videoendoscope (GIF‐N260; Olympus Optical Co, Tokyo, Japan) under direct visualization and biopsy of the mass. The analysis of the biopsy specimen confirmed this mass to be an IPMN of the pancreas. When we examined the CBD, one fistula with copious mucin secretion was identified at the distal CBD. In conclusion, direct peroral cholangioscopy and pancreatoscopy using the ultra‐slim endoscope is an efficient tool for diagnosis of PB fistula and pancreatic IPMN.     

Early bile duct cancer detected by direct peroral cholangioscopy with narrow-band imaging after bile duct stone removal

Cholangioscopy not only enables the direct visualization of the biliary tree, but also allows for forceps biopsy to diagnosis early cholangiocarcinoma. Recently, some reports have suggested the clinical usefulness of direct peroral cholangioscopy (POC) using an ultra-slim endoscope with a standard endoscopic unit by a single operator. Enhanced endoscopy, such as narrow band imaging (NBI), can be helpful for detecting early neoplasia in the gastrointestinal tract and is easily applicable during direct POC. A 63-year-old woman with acute cholangitis had persistent bile duct dilation on the left hepatic duct after common bile duct stone removal and clinical improvement. We performed direct POC with NBI using an ultra-slim upper endoscope to examine the strictured segment. NBI examination showed an irregular surface and polypoid structure with tumor vessels. Target biopsy under direct endoscopic visualization was performed, and adenocarcinoma was documented. The patient underwent an extended left hepatectomy, and the resected specimen showed early bile duct cancer confined to the ductal mucosa.     

THE ROLE OF PERORAL CHOLANGIOSCOPY FOR BILE DUCT LESIONS

We reviewed the current status of peroral cholangioscopy under duodenoscopic assistance, which allows direct visualization of the bile duct. Direct visual assessment may be a useful adjunct to endoscopic retrograde cholangiopancreatography (ERCP) for distinguishing malignant from benign bile duct lesions. Several clinical studies suggest the efficacy of peroral cholangioscopy for various bile duct lesions. However, solely cholangioscopic examination may be insufficient to confirm accurate differential diagnosis between benign and malignant strictures or tumor extension of bile duct carcinoma. Directed tissue acquisition in biliary strictures by using peroral cholangioscopy is another application that has not been properly studied because of the limited maneuverability of the long babyscope. Further improvement of suitable instruments and cholangioscopes are needed.     

Bile-Duct Stone Removal under Direct Transnasal Cholangioscopy Using an Ultraslim Upper Endoscope

The transnasal endoscopic examination using an ultraslim upper endoscope may be more comfortable and less stressful than the peroral approach. Transnasal endoscopic retrograde cholangiopancreatography (ERCP), endoscopic nasobiliary drainage, and direct peroral cholangioscopy using an ultraslim upper endoscope have recently been reported. An 82-year-old woman with a previous history of endoscopic sphincterotomy and stone removal was admitted with acute cholangitis. Instead of conventional ERCP, we performed direct transnasal cholangioscopy (TNC) using an ultraslim upper endoscope for biliary decompression and stone removal because of her unstable vital signs. Direct TNC using an ultraslim upper endoscope may be useful in selected patients with biliary disease.     

Single operator peroral cholangioscopic guided therapy of bile duct stones

Since the introduction of endoscopic sphincterotomy, stone clearance of the bile duct can be achieved by conventional endoscopic means in up to 90% of patients with stone disease. Several endoscopic therapies for difficult bile duct stones have been introduced. Laser therapy for stone fragmentation under direct visual control via the peroral insertion of a cholangioscope (POCS) in the bile duct has proven to be highly effective, further raising the success rate of endoscopic biliary stone clearance. However, conventional POCS has not gained wide acceptance because of several technical limitations such as fragility, impaired steerability and the need for two endoscopists. These limitations may be overcome with a newly developed single operator peroral cholangioscope, the SpyGlass(?) Direct Visualization System. First clinical data of SpyGlass guided intraductal stone fragmentation with EHL or laser fibers report high safety and efficacy of the procedure.     

Intraductal papillary mucinous neoplasm of the bile duct with gastric and duodenal fistulas

Intraductal papillary mucinous neoplasm (IPMN) of the bile duct is still rare and not yet understood despite of its increased incidence and similar clinicopathologic characteristics compared with IPMN of the pancreas. The fistula formation into other organs can occur in IPMN, especially the pancreatic type. To our knowl-edge, only two cases of IPMN of the bile duct with a choledochoduodenal fistula were reported and we have recently experienced a case of IPMN of the bile duct penetrating into two neighboring organs of the stom-ach and duodenum presenting with abdominal pain and jaundice. Endoscopy showed thick mucin extruding from two openings of the fistulas. Endoscopic suction of thick mucin using direct peroral cholangioscopy with ultra-slim endoscope through choledochoduodenal fis-tula was very difficult and ineffective because of very thick mucin and next endoscopic suction through the stent after prior insertion of biliary metal stent into cho-ledochogastric fistula also failed. Pathologic specimen obtained from the proximal portion of the choledocho-gastric fistula near left intrahepatic bile duct through the metal stent showed a low grade adenoma. The pa-tient declined the surgical treatment due to her old age and her abdominal pain with jaundice was improved af-ter percutaneous transhepatic biliary drainage with the irrigation of N-acetylcysteine three times daily for 10 d.     

Narrow band imaging cholangioscopy in hilar cholangiocarcinoma

Per oral cholangioscopy has been developed as a diagnostic modality for evaluation of bile duct lesions. Per oral cholangioscope with narrow band imaging (NBI) system can provide good quality images of bile duct lesions. There is limited data on per oral cholangioscopy using NBI in biliary tract diseases. We report our experience of NBI cholangioscopy in hilar strictures.     

"Mother-Baby" Biliary Endoscopy: The University of Chicago Experience

Objectives : The "mother-baby" technique of peroral cholangioscopy is a relatively recent development in biliary endoscopy and permits direct visualization of the biliary tree. This paper presents the experience of one institution with this new technique. Methods : We used the Olympus mother-baby endoscopy system at the University of Chicago and at one of its affiliated hospitals to examine and treat selected lesions in the biliary tree that had eluded successful diagnosis or treatment by standard means. In addition, we used the baby endoscope alone through surgically created percutaneous tracts to treat selected patients with retained stones. Results : From July 1990 to June 1993, peroral cholangioscopy was performed 18 times in 12 patients at the University of Chicago and affiliated hospitals. The baby endoscope was successfully passed into the bile duct in 15 of 18 cases (83.3%). Additionally, the baby endoscope alone was used through a T-tube or cholecystostomy tract 10 times in six patients. Complications occurred in two patients and were minor; there were no fatalities. With refinement of technique, successful passage of the baby endoscope was accomplished in 100% of patients undergoing peroral cholangioscopy. Conclusions : Direct visualization of the biliary tree with the ability to sample (brush, biopsy) or treat (basket removal, electrohydraulic or laser lithotripsy) lesions significantly aided in the care of all patients in whom the baby endoscope was successfully passed by providing the correct diagnosis and, when appropriate, by allowing definitive treatment of lesions. The eventual role of this technique in the current cost-conscious climate is unclear, but at present it should be limited to selected referral centers.     

Technical tips for peroral transluminal cholangioscopy using novel single‐operator cholangioscope (with videos)

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold‐standard modality for diagnosis and therapy of bilio‐pancreatic disease. In particular, peroral cholangiography (POCS) is a useful modality not only for diagnosing biliary disease, but also for therapeutic procedures such as electrohydraulic lithotripsy. The SPY‐DS single‐operator cholangioscope has recently become available, and offers favorable visualization, a wide view, suction function and a larger accessory working channel. However, if the duodenoscope cannot be advanced into the ampulla of Vater for reasons such as surgical anatomy, POCS cannot be performed. On the other hand, percutaneous transhepatic cholangiodrainage (PTCD) has been developed as an alternative endoscopic ultrasound‐guided approach to the biliary tract. Peroral transluminal cholangioscopy (PTLC) using SPY‐DS is a novel approach. Because transluminal interventional procedures under endoscopic ultrasound guidance have recently been developed, our technique may have clinical impact for selected cases.     

Peroral direct cholangioscopy for diagnosis and treatment]

Peroral direct cholangioscopy (PDCS) is endoscopic method for diagnosis in the common bile duct (CBD) utilizing an ultra-slim upper endoscope. Clinical utility and problem of this method were investigated in ten patients who had stenosis or obstruction in the CBD with stones or a tumor. Scope shaft had to become the form of a U loop by counterclockwise rotation, to advance the scope in the direction of intrahepatic bile duct. As for one case, although the scope was formed alpha loop without U loop, direct observation of total CBC was possible. Large working channel of the endoscope could take adequate tissue sample by large biopsy forceps. Electrohydraulic lithotripsy and stone extraction with a basket could be accomplished easily and safely by direct visualization with a clear image. Pneumobilia was noted in all cases with insertion of PDCS. Although the abdominal pain and pyrexia with regard to PDCS did not occur, transient leukocytosis was noted.     

CLINICAL EVALUATION OF PERORAL CHOLANGIOSCOPY FOR BILIARY DISEASE USING NARROW BAND IMAGING

Regarding peroral cholangioscopy (POCS) for biliary disease, due to the recent appearance of a video cholangioscope that can obtain high‐quality images, it is possible to observe subtle changes of the biliary mucosa. In addition to the conventional observation method using POCS, the biliary mucosa with also observed with narrow band imaging (NBI) in one case of chronic cholangitis and four cases of extra hepatic bile duct tumor (three surgical cases). In the conventional observation method, the vessels in the surface layer of the biliary mucosa could be observed more clearly using NBI. In one case in which a tumor was observed, the irregularity of the biliary mucosa became clear on NBI, and the vessels inside a papillary tumor could also be easily observed. In another case of bile duct tumor, the conventional observation method showed a region in the proximity of the tumor where the vessels could not be seen clearly, but they could be seen clearly on NBI. In all of the cases, the bile juice was seen as red on NBI, which disturbed the observation. With POCS using NBI, it was possible to observe the vessels and irregularities in the surface layer of the biliary mucosa more clearly than with conventional observation methods.     

Laser lithotripsy of difficult bile duct stones under direct visual control.

Biliary laser lithotripsy was performed under direct visual control in 35 consecutive patients not amenable to routine endoscopy. The patients had 1-50 (median 1) bile duct stones with the greatest diameter of the largest stone being 9-42 mm (median 20 mm). Conventional endoscopic treatment had failed because of an inaccessible papilla (16 patients), biliary strictures (seven patients), and impaction or large size of calculi (12 patients). Twelve patients, depending on their anatomical condition, underwent peroral cholangioscopy by means of a mother-babyscope system. Percutaneous cholangioscopy was initially carried out in 23 patients, 7-20 days (median 10 days) after creation of a transhepatic fistula. Pulsed dye laser (32 patients) or alexandrite laser (three patients) lithotripsy was applied under an appropriate direct visual control in all cases. Complete stone disintegration succeeded in 33 of 35 patients. All resultant fragments passed the papilla within a mean number of 1.3 treatment sessions. Peroral cholangioscopic lithotripsy failed in two cases. One patient successfully underwent percutaneous laser treatment and the other patient was referred to surgery. Fever, temporary haemobilia, or a subcapsular liver haematoma were seen in a total of eight patients during establishment of the cutaneobiliary fistula. A 95 year old patient who had been admitted with septic cholangitis died because of cardiorespiratory failure 5 days after bile duct clearance. It is concluded that laser lithotripsy performed under a direct visual control is an effective and safe procedure for the non-surgical treatment of difficult bile duct stones. Ductal clearance can usually be achieved in a single treatment session when the papilla and the stones are accessible by the peroral route. Percutaneous cholangioscopic lithotripsy is more time consuming but highly effective even in patients with a difficult anatomy, bile duct strictures, or intrahepatic calculi. This approach should be limited, however, to cases not amenable to retrograde procedures because the creation of the cutaneobiliary fistula is not without risks.