Diagnostic utility of peroral cholangioscopy for various bile-duct lesions

Tissue yield and diagnostic efficacy of fluoroscopic and cholangioscopic techniques to assess indeterminate biliary strictures

BACKGROUND & AIMS

Evaluation of indeterminate biliary strictures typically involves collection and analysis of tissue or cells. Single-operator, peroral, cholangioscopic techniques have been developed that allow for a biopsy sample to be obtained from a specific area of the visualized stricture. We investigated whether standard fluoroscopic-guided and cholangioscopic-directed (SpyGlass Direct Visualization System; Boston Scientific, Natick, MA) biopsy collection provide adequate tissue for histologic assessment.

METHODS

We examined 110 consecutive bile duct specimens collected from 89 patients with indeterminate biliary strictures at a single institution using fluoroscopy or cholangioscopy (from October 2007 to March 2010). Because of the small nature of the intraductal biopsy fragments, special procedures were followed in the pathology laboratory to maximize the amount of tissue for histopathology analysis.

RESULTS

Only 4 specimens (3.6%) had insufficient material for a diagnosis. More tissue was obtained from standard fluoroscopic-guided than cholangioscopic-directed biopsies (more biopsy fragments, P = .018; larger total biopsy size, P = .001). Fluoroscopy-guided biopsies assessed indeterminate biliary strictures with 76% sensitivity and 88% accuracy; these values were 57% and 78%, respectively, for cholangioscopic-directed biopsies. Each procedure had 100% specificity.

CONCLUSIONS

Analysis of bile duct biopsies is important in management of patients with indeterminate biliary strictures. Use of a special handling protocol for these small biopsies could reduce the number of cases with insufficient material for diagnosis. Increasing the sample size (either by using larger biopsy forceps or obtaining more biopsy bites) could improve the sensitivity of the SpyGlass technique. As endoscopists and pathologists gain more experience in collecting and handling small biopsies, the diagnostic efficacy of intraductal biopsies will continue to improve.

Current management of cholangiocarcinoma

Cholangiocarcinoma is the second most common primary hepatobiliary malignancy after hepatocellular carcinoma and remains among the most difficult management problems faced by surgeons. Curative surgery is achieved in only 25% to 30% of patients. Local tumor extent, such as portal vein invasion and hepatic lobar atrophy, does not preclude resection. Long-term survival has been seen only in patients who underwent extensive liver resections, suggesting that bile-duct excision alone is less effective. The majority of patients have unresectable disease, with 20% to 30% incidence of distant metastasis at presentation. Unresectable patients should be referred for nonsurgical biliary decompression, and in potential curative resection candidates the use of biliary stents should be reduced. Liver transplantation provides the option of wide resection margins, expanding the indication of surgical intervention for selected patients who otherwise are not surgical candidates due to lack of functional hepatic reserve.

Evaluating the feasibility of direct peroral cholangioscopy training with an endoscopic simulator

INTRODUCTION

Direct peroral cholangioscopy (DPOCS) was reported to present clinical potential, and creating a target-specific training program for biliary endoscopists who lack experience with DPOCS is an important task.

METHODS

This prospective and observational study used five male domestic pigs. Optimal procedures were decided after pilot tests using an in vivo live porcine model. A total of three ERCP men were enrolled into the training program. The objective parameters, including the rate of success and complications, and the length of the procedure, were recorded for each participant.

RESULTS

In the training program, all the trainees successfully performed DPOCS and biopsies without significant complications. Close observation, free discussions, and the sharing of experiences helped shorten the total procedure time from 37.3 to 18.5 min.

CONCLUSIONS

This training program is a feasible approach to help biliary endoscopists acquire the experience for DPOCS with the ultrathin endoscope.

Management of perihilar cholangiocarcinoma in the era of multimodal therapy

Perihilar cholangiocarcinoma (CCA) is the second most common primary malignant tumor of the liver. In the USA, there are approximately 3000 cases of CCA diagnosed annually, with approximately 50-70% of these tumors arising at the hilar plate of the biliary tree. Risk factors include advanced age, male gender, primary sclerosing cholangitis, choledochal cysts, cholelithiasis, parasitic infection, inflammatory bowel disease, cirrhosis and chronic pancreatitis. Patients typically present with jaundice, abdominal pain, pruritus and weight loss. The mainstays of treatment include surgery, chemotherapy, radiation therapy and photodynamic therapy. Specific preoperative interventions for patients with perihilar CCA include endoscopic retrograde cholangiopancreatography, percutanteous transhepatic cholangiography and portal vein embolization. Surgical resection offers the only chance for curative therapy in perihilar CCA. R0 resection is of utmost importance and has been linked to improved survival. Major hepatic resection is needed to achieve both longitudinal and radial margins negative for tumor. Fractionated stereotactic body radiotherapy has shown promising results in CCA. Perihilar CCA typically presents with advanced disease, and many patients receive systemic therapy; however, the response to current regimens is limited. Orthotopic liver transplantation offers complete resection of locally advanced tumors in select patient groups.

Clinical utility of single-operator cholangiopancreatoscopy using a SpyGlass probe through an endoscopic retrograde cholangiopancreatography catheter

BACKGROUND AND AIM

A single-operator cholangiopancreatoscopy was developed to overcome a problem in conventional peroral cholangiopancreatoscopy. The aim of this pilot study was to clarify the clinical utility of single-operator cholangiopancreatoscopy using a SpyGlass probe through an endoscopic retrograde cholangiopancreatography (ERCP) catheter.

METHODS

Patients undergoing ERCP with a SpyGlass probe passed through a catheter were included in this study. The SpyGlass probe was inserted into the catheter following successful cannulation, and cholangiopancreatoscopy was performed by a single operator. We retrospectively analyzed the successful visualization rate of this technique.

RESULTS

Fifteen patients were included in this study. SpyGlass cholangiopancreatoscopy was technically successful in all patients. Successful visualization was obtained in nine patients (60%). The median SpyGlass procedure time was 10 min. Cholangiopancreatoscopic diagnoses were as follows: bile duct carcinoma in three patients; intraductal papillary mucinous adenoma in two; and intraductal pancreatic stone, benign biliary stricture, gallbladder cholesterolosis, and gallbladder carcinoma in one each. There were no cases of post-ERCP pancreatitis.

CONCLUSIONS

While the low rate of successful visualization must be improved, single-operator cholangiopancreatoscopy using a SpyGlass probe through an ERCP catheter is a safe and effective procedure.

Endoscopic management of benign biliary strictures

Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management in most situations when a benign biliary stricture is suspected. Although management principles are similar in all subgroups, the anticipated response rates, need for ancillary medical and endoscopic approaches, and use of less proven strategies vary between differing causes. Exclusion of malignancy should always be a focus of management. Newer endoscopic techniques such as endoscopic ultrasound, cholangioscopy, confocal endomicroscopy, and metal biliary stenting are increasingly complementing traditional ERCP techniques in achieving long-term sustained stricture resolution. Surgery remains a definitive management alternative when a prolonged trial of endoscopic therapy does not achieve treatment goals.

Focal intrahepatic strictures: a review of diagnosis and management

INTRODUCTION

Focal intrahepatic strictures are becoming more common owing to more prevalent and accurate cross-sectional imaging. However, data relating to their management are lacking. The purpose of the present review was to synthesize the current evidence regarding these lesions and to formulate a strategy for diagnosis and management.

METHODS

A literature search of relevant terms was performed using Medline. References of papers were subsequently searched to obtain older literature.

RESULTS

Focal intrahepatic strictures involve segmental hepatic ducts and/or left and right main hepatic ducts during their intrahepatic course. Most patients are asymptomatic while the minority present with vague abdominal pain or recurrent sepsis and only rarely with jaundice. Investigations used to distinguish benign from malignant aetiologies include blood tests (CEA, Ca19.9), imaging studies [ultrasonography (US), computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and fluorodeoxyglucose-positron emission tomography (FDG-PET)], endoscopic modalities [endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic ultrasound (EUS)/cholangioscopy] and tissue sampling (brush cytology/biopsy).

CONCLUSIONS

A focal intrahepatic stricture requires thorough investigation to exclude malignancy even in patients with a history of biliary surgery, hepatolithiasis or parasitic infection. If during the investigative process a diagnosis or suspicion of malignancy is demonstrated then surgical resection should be performed. If all diagnostic modalities suggest a benign aetiology, then cholangioscopy with targeted biopsies should be performed.

Endoscopic retrograde cholangioscopy and advanced biliary imaging

Developments in endoscopic retrograde cholangioscopy provide multiple new advanced methods of biliary imaging. Cholangioscopy provides direct visualization of epithelium with white light as well as advanced modalities, such as narrow band imaging and autofluorescence. In vivo histologic images can be achieved with confocal endomicroscopy. Cross-sectional imaging is also possible with intraductal ultrasonography and optical coherence tomography. This article describes these advanced imaging techniques, which can be used together to assist in the diagnosis of biliary strictures and lesions.

Diagnostic and therapeutic utility of single-operator peroral cholangioscopy for indeterminate biliary lesions and bile duct stones

BACKGROUND AND AIM

We aimed to evaluate the diagnostic utility of single-operator peroral cholangioscopy (SOC) for indeterminate biliary lesions and its usefulness in electrohydraulic lithotripsy (EHL) of biliary stones not amenable to conventional endoscopic therapy.

PATIENTS AND METHODS

All patients undergoing SpyGlass SOC in four UK tertiary centres between 2008 and 2010 were retrospectively enrolled. Patients were followed up until death or the last clinic visit until May 2011. The operating characteristics of SOC for detecting malignant lesions and the stone clearance rate after SOC-guided EHL were calculated.

RESULTS

A total of 165 patients underwent 179 SOC procedures. Sixty-six percent were referred for indeterminate biliary strictures, 13% for filling defects and 21% for SOC-guided EHL. Cannulation with the SOC system was successful in 95% but visualization was inadequate in 13%. Primary sclerosing cholangitis was a risk factor for failed cannulation and conscious sedation (vs. general anaesthesia) for inadequate visualization (P<0.05). The accuracy of SOC for diagnosing malignant lesions was 87%. SOC-guided biopsies were adequate in 72%. Obtaining at least four versus less than four biopsy specimens resulted more often in adequate samples (90 vs. 64%, P=0.037). Complete stone clearance could be achieved in 73% of patients. The adverse event rate was 9.6%. Cholangitis was the most common event (56%, one fatal).

CONCLUSION

SOC is useful for the differential diagnosis of indeterminate biliary lesions and the treatment of 'difficult' biliary stones. The adequacy of SOC-guided biopsies is related to the number of specimens obtained. Primary sclerosing cholangitis is related to failed cannulation with the SOC system, whereas general anaesthesia is related to adequate visualization.

[Klatskin tumors: rational diagnostics and staging]

Klatskin tumors continue to be a challenge for diagnostic assessment and staging due to their longitudinal tumor growth along the perihilar bile ducts. Therefore the rate of non-resectable tumors remains relatively stable despite modern imaging and endoscopic techniques. This article reviews the current diagnostic methods for preoperative staging and the significance for predicting resectability.

Single-operator cholangioscopy in patients requiring evaluation of bile duct disease or therapy of biliary stones (with videos)

BACKGROUND

The feasibility of single-operator cholangioscopy (SOC) for biliary diagnostic and therapeutic procedures was previously reported.

OBJECTIVE

To confirm the utility of SOC in more widespread clinical use.

DESIGN

Prospective clinical cohort study.

SETTING

Fifteen endoscopy referral centers in the United States and Europe.

PATIENTS

Two hundred ninety-seven patients requiring evaluation of bile duct disease or biliary stone therapy.

INTERVENTIONS

SOC examination and, as indicated, SOC-directed stone therapy or forceps biopsy.

MAIN OUTCOME MEASUREMENTS

Procedural success defined as ability to (1) visualize target lesions and, if indicated, collect biopsy specimens adequate for histological evaluation or (2) visualize biliary stones and initiate fragmentation and removal.

RESULTS

The overall procedure success rate was 89% (95% CI, 84%-92%). Adequate tissue for histological examination was secured in 88% of 140 patients who underwent biopsy. Overall sensitivity in diagnosing malignancy was 78% for SOC visual impression and 49% for SOC-directed biopsy. Sensitivity was higher (84% and 66%, respectively) for intrinsic bile duct malignancies. Diagnostic SOC procedures altered clinical management in 64% of patients. Procedure success was achieved in 92% of 66 patients with stones and complete stone clearance during the study SOC session in 71%. The incidence of serious procedure-related adverse events was 7.5% for diagnostic SOC and 6.1% for SOC-directed stone therapy.

LIMITATIONS

The study was observational in design with no control group.

CONCLUSIONS

Evaluation of bile duct disease and biliary stone therapy can be safely performed with a high success rate by using the SOC system.

Update of cholangioscopy and biliary strictures

Cholangioscopy remains another modality in the investigation of biliary strictures. At cholangioscopy, the “tumour vessel” sign is considered a specific sign for malignancy. Through its ability to not only visualise mucosa, but to take targeted biopsies, it has a greater accuracy, sensitivity and specificity for malignant strictures than endoscopic retrograde cholangiopancreatography guided cytopathological acquisition. Cholangioscopy however, is time consuming and costly, requires greater technical expertise, and should be reserved for the investigation of undifferentiated strictures after standard investigations have failed.

Role of single-operator peroral cholangioscopy in the diagnosis of indeterminate biliary lesions: a single-center, prospective study

BACKGROUND

Currently available techniques to diagnose indeterminate biliary lesions have many limitations.

OBJECTIVE

To assess the accuracy of single-operator peroral cholangioscopy by using the SpyGlass system to differentiate malignant from benign disease in patients with indeterminate biliary lesions.

DESIGN

Prospective, single-arm, single-center study.

SETTING

Tertiary referral center.

PATIENTS

Thirty-six patients with indeterminate biliary strictures and filling defects who had inconclusive results on previous biliary ductal tissue sampling.

INTERVENTIONS

SpyGlass cholangioscopy with cholangioscopically guided intraductal biopsies.

MAIN OUTCOME MEASUREMENTS

Accuracy of SpyGlass visual impression and SpyBite biopsies for differentiating malignant from benign ductal lesions.

RESULTS

Thirty-six patients (22 men, mean age 48.3 years [range 27-68 years]) with indeterminate stricture and/or filling defects underwent SpyGlass cholangioscopy. Of the 22 patients with a final diagnosis of malignant lesion, cholangioscopic impression was malignant in 21 patients (95%) and benign in 1 patient (5%). Of the 14 patients with a final diagnosis of benign disease, including the 3 patients with common bile duct stones and no stricture, cholangioscopic impression was malignant in 3 patients (21%) and benign in 11 patients (79%). The overall accuracy of SpyGlass visual impression for differentiating malignant from benign ductal lesions was 89% (32/36). The accuracy of SpyBite biopsies for differentiating malignant from benign ductal lesions that were inconclusive on ERCP-guided brushing or biopsy was 82% (27/33) in an intent-to-treat analysis.

LIMITATIONS

No randomized comparison with alternative diagnostic modalities for the nature of biliary strictures.

CONCLUSIONS

SpyGlass cholangioscopy with SpyBite biopsies has a high accuracy with regard to confirming or excluding malignancy in patients with indeterminate biliary lesions.

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.

Endoscopic diagnosis of extrahepatic bile duct carcinoma: Advances and current limitations

The accurate diagnosis of extrahepatic bile duct carcinoma is difficult, even now. When ultrasonography (US) shows dilatation of the bile duct, magnetic resonance cholangiopancreatography followed by endoscopic US (EUS) is the next step. When US or EUS shows localized bile duct wall thickening, endoscopic retrograde cholangiopancreatography should be conducted with intraductal US (IDUS) and forceps biopsy. Fluorescence in situ hybridization increases the sensitivity of brush cytology with similar specificity. In patients with papillary type bile duct carcinoma, three biopsies are sufficient. In patients with nodular or infiltrating-type bile duct carcinoma, multiple biopsies are warranted, and IDUS can compensate for the limitations of biopsies. In preoperative staging, the combination of dynamic multi-detector low computed tomography (MDCT) and IDUS is useful for evaluating vascular invasion and cancer depth infiltration. However, assessment of lymph nodes metastases is difficult. In resectable cases, assessment of longitudinal cancer spread is important. The combination of IDUS and MDCT is useful for revealing submucosal cancer extension, which is common in hilar cholangiocarcinoma. To estimate the mucosal extension, which is common in extrahepatic bile duct carcinoma, the combination of IDUS and cholangioscopy is required. The utility of current peroral cholangioscopy is limited by the maneuverability of the “baby scope”. A new baby scope (10 Fr), called “SpyGlass” has potential, if the image quality can be improved. Since extrahepatic bile duct carcinoma is common in the Far East, many researchers in Japan and Korea contributed these studies, especially, in the evaluation of longitudinal cancer extension.

Current status of direct peroral cholangioscopy

Recently, several endoscopists have reported the usefulness of direct peroral video cholangioscopy for the diagnosis and therapy of bile duct lesions. Although ultra-slim pediatric or Tran nasal video endoscopes are usually used for the direct peroral video cholangioscopy, direct scope insertion without pretreatment and any assistant is considerably difficult. Based on the previous literatures, intraductal balloon catheter-assisted scope insertion might be relatively reliable method. To overcome the issue on the scope insertion, recently prototype cholangioscope that has short bending section and anchoring balloon catheter for scope replacement and insertion has been developed. In the near future, we could establish the direct peroral cholangioscopy using new developed technology.

Per-oral cholangioscopy

Direct endoscopic views of bile duct have been described in literature since the 1970s. Since then rapid strides have been made with the advent of technologically advanced systems with better image quality and maneuverability. The single operator semi-disposable per-oral cholangioscope and other novel methods such as the cholangioscopy access balloon are likely to revolutionize this field. Even though cholangioscopy is currently used primarily for characterization of indeterminate strictures and management of large bile duct stones, the diagnostic and therapeutic indications are likely to expand in future. The following is an overview of the currently available per-oral cholangioscopy equipments, indications for use and future directions.

Surgical strategy for bile duct cancer: Advances and current limitations

The aim of this review is to describe recent advances and topics in the surgical management of bile duct cancer. Radical resection with a microscopically negative margin (R0) is the only way to cure cholangiocarcinoma and is associated with marked survival advantages compared to margin-positive resections. Complete resection of the tumor is the surgeon’s ultimate aim, and several advances in the surgical treatment for bile duct cancer have been made within the last two decades. Multidetector row computed tomography has emerged as an indispensable diagnostic modality for the precise preoperative evaluation of bile duct cancer, in terms of both longitudinal and vertical tumor invasion. Many meticulous operative procedures have been established, especially extended hepatectomy for hilar cholangiocarcinoma, to achieve a negative resection margin, which is the only prognostic factor under the control of the surgeon. A complete caudate lobectomy and resection of the inferior part of Couinaud’s segment IV coupled with right or left hemihepatectomy has become the standard surgical procedure for hilar cholangiocarcinoma, and pylorus-preserving pancreaticoduodenectomy is the first choice for distal bile duct cancer. Limited resection for middle bile duct cancer is indicated for only strictly selected cases. Preoperative treatments including biliary drainage and portal vein embolization are also indicated for only selected patients, especially jaundiced patients anticipating major hepatectomy. Liver transplantation seems ideal for complete resection of bile duct cancer, but the high recurrence rate and decreased patient survival after liver transplant preclude it from being considered standard treatment. Adjuvant chemotherapy and radiotherapy have a potentially crucial role in prolonging survival and controlling local recurrence, but no definite regimen has been established to date. Further evidence is needed to fully define the role of liver transplantation and adjuvant chemo-radiotherapy.

ERCP with cholangiopancreatoscopy may be associated with higher rates of complications than ERCP alone: a single-center experience

BACKGROUND

Comparative data regarding complications associated with ERCP alone or when performed with cholangiopancreatoscopy (CP) are lacking.

OBJECTIVE

To determine whether ERCP complications are more frequent when concomitant CP is performed.

DESIGN

A retrospective query of a prospectively maintained database of ERCP, CP, and complications.

MAIN OUTCOME MEASUREMENTS

Consensus criteria complications and additional adverse events (AEs), including unplanned medical evaluation, cardiopulmonary/sedation events, and others.

SETTING

Academic, tertiary referral center.

RESULTS

A total of 4214 ERCPs were performed (337 sphincter of Oddi manometry cases excluded) during the study period, of which 3475 ERCPs and 402 ERCPs with CP were analyzed. There were 28 of 402 AEs (7.0%) in the ERCP with CP group and 101 of 3475 (2.9%) in the ERCP-only group (odds ratio [OR], 2.50; 95% CI, 1.56-3.89). Subgroup analysis revealed a significantly higher rate of cholangitis in the CP group versus ERCP group (1.0% vs 0.2%; OR, 4.98; 95% CI, 1.06-19.67) and similar rates of pancreatitis (2.2% vs 1.3%; OR, 1.75; 95% CI, 0.74-3.65) and perforation (1.0% vs 0.3%; OR, 3.16; 95% CI, 0.73-10.75).

LIMITATIONS

Retrospective review of a complications database that relies on physician self-reporting.

CONCLUSIONS

AEs from CP may be more than double those of ERCP alone (when sphincter of Oddi manometry cases are excluded). CP appears to be associated with a significantly higher rate of cholangitis, possibly because of intermittent intraductal irrigation required during the procedure.

Biliary, pancreatic, and hepatic imaging for the general surgeon

Technologic advancements have allowed imaging modalities to become more useful in the diagnosis of hepatobiliary and pancreatic disorders. Computed tomography scanners now use multidetector row technology with contrast-delayed imaging for quicker and more accurate imaging. Magnetic resonance imaging with cholangiopancreatography can more clearly delineate liver lesions and the biliary and pancreatic ducts, and can diagnose pathologic conditions early in their course. Newer technologies, such as single-operator cholangioscopy and endoscopic ultrasonography, have sometimes shown superiority to traditional modalities. This article addresses the literature regarding available imaging techniques in the diagnosis and treatment of common surgical hepatobiliary and pancreatic diseases.

Peroral cholangioscopy in the new millennium

Peroral cholangioscopy was first described in 1970s and has recently gained popularity. Peroral cholangioscopy is appealing to therapeutic endoscopists because a direct intraluminal view of the biliary duct system offers possibilities for diagnosis and interventions beyond that which other imaging or endoscopic modalities can provide. As the image quality of cholangioscopies improves, so too does their diagnostic capability, and as their durability and maneuverability increases, so too does their potential use for therapeutic applications. This editorial is intended to provide a brief review of recent developments in peroral cholangioscopy and current indications for its use.

Role of EUS for preoperative evaluation of cholangiocarcinoma: a large single-center experience

BACKGROUND

Accurate preoperative diagnosis and staging of cholangiocarcinoma (CCA) remain difficult.

OBJECTIVE

To evaluate the utility of EUS in the diagnosis and preoperative evaluation of CCA.

DESIGN

Observational study of prospectively collected data.

SETTING

Single tertiary referral hospital in Indianapolis, Indiana.

PATIENTS

Consecutive patients with CCA from January 2003 through October 2009.

INTERVENTIONS

EUS and EUS-guided FNA (EUS-FNA).

MAIN OUTCOME MEASUREMENTS

Sensitivity of EUS for the detection of a tumor and prediction of unresectability compared with CT and magnetic resonance imaging (MRI); sensitivity of EUS-FNA to provide tissue diagnosis, by using surgical pathology as a reference standard.

RESULTS

A total of 228 patients with biliary strictures undergoing EUS were identified. Of these, 81 (mean age 70 years, 45 men) had CCA. Fifty-one patients (63%) had distal and 30 (37%) had proximal CCA. For those with available imaging, tumor detection was superior with EUS compared with triphasic CT (76 of 81 [94%] vs 23 of 75 [30%], respectively; P < .001). MRI identified the tumor in 11 of 26 patients (42%; P = .07 vs EUS). EUS identified CCA in all 51 (100%) distal and 25 (83%) of 30 proximal tumors (P < .01). EUS-FNA (median, 5 passes; range, 1-12 passes) was performed in 74 patients (91%). The overall sensitivity of EUS-FNA for the diagnosis of CCA was 73% (95% confidence interval, 62%-82%) and was significantly higher in distal compared with proximal CCA (81% vs 59%, respectively; P = .04). Fifteen tumors were definitely unresectable. EUS correctly identified unresectability in 8 of 15 and correctly identified the 38 of 39 patients with resectable tumors (53% sensitivity and 97% specificity for unresectability). CT and/or MRI failed to detect unresectability in 6 of these 8 patients.

LIMITATION

Single-center study.

CONCLUSION

EUS and EUS-FNA are sensitive for the diagnosis of CCA and very specific in predicting unresectability. The sensitivity of EUS-FNA is significantly higher in distal than in proximal CCA.

New options of cholangioscopy

In the evaluation of biliary diseases, cholangioscopy is considered as complementary procedure to radiographic imaging. Direct visualization of the bile duct is the premier advantage of cholangioscopy over indirect imaging techniques. However, cholangioscopy has not gained wide acceptance because of several technical limitations such as scope fragility, impaired steerability, limited irrigation, and suction capabilities, as well as the need for two experienced endoscopists. Recent innovations such as the implementation of electronic video cholangioscopes and the development of single-operator systems facilitate the procedure, and promise to increase the diagnostic and therapeutic yield of cholangioscopy.

Diagnostic peroral video cholangioscopy is an accurate diagnostic tool for patients with bile duct lesions

BACKGROUND & AIMS

We evaluated the diagnostic ability of a newly developed peroral video cholangioscopy (PVCS) in patients with pancreaticobiliary disorders.

METHODS

We retrospectively evaluated data from 144 patients with pancreaticobiliary disorders, collected from 5 tertiary referral centers. Endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilation (EPBD) was performed before PVCS. We performed 2 types of PVCS, using a conventional therapeutic duodenoscope. If tissue samples were needed, cholangioscopy-assisted biopsy or fluoroscopy-guided biopsy was performed.

RESULTS

PVCS was advanced into the bile duct in all cases after patients received EST (n = 134 cases), EPBD (n = 2), a combination of EST and EPBD (n = 1), or without treatment of the major papilla (n = 7). Biopsy samples were collected successfully from 112 of 120 cases in which endoscopists considered tissue sampling necessary. Endoscopic retrograde cholangiopancreatography (ERCP)/biopsy correctly identified 83 of 96 malignant lesions and 19 of 24 benign lesions (accuracy = 85.0%; sensitivity = 86.5%; specificity = 79.2%; positive predictive value = 94.3%; negative predictive value = 59.4%). Endoscopic retrograde cholangiopancreatography (ERCP)/biopsy plus PVCS correctly identified 95 of 96 malignant lesions and 23 of 24 benign lesions (accuracy = 98.3%; sensitivity = 99.0%; specificity = 95.8%; positive predictive value = 99.0%; negative predictive value = 95.8%). Procedure-related complications included pancreatitis (4 cases, 2.8%) and cholangitis (6 cases, 4.3%).

CONCLUSIONS

PVCS is an accurate diagnostic tool for patients with pancreaticobiliary disorders; resolution was well-defined when combined with biopsy analysis. Prospective multicenter clinical trials should evaluate the clinical utility of PVCS in diagnosis of biliary tract diseases.

Endoscopic retrograde cholangiopancreatography in the diagnosis and management of cholangiocarcinoma

Cholangiocarcinomas (CCAs) are rare malignancies that arise from the biliary epithelium. Intrahepatic CCAs usually present as mass lesions that are asymptomatic or cause nonspecific systemic symptoms such as fatigue, fever, and weight loss. Hilar and extrahepatic tumors most commonly present with jaundice, though cholangitis also can be seen. Tumor markers such as carbohydrate antigen 19-9 and carcinoembryonic antigen have been used to diagnose CCA, but these are nonspecific and may be elevated in infection, inflammation, or any obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) has been used for the diagnosis and management of CCA for many years. This article summarizes the data regarding the application of ERCP in the diagnosis and management of CCA.

Carbon dioxide insufflation is useful for obtaining clear images of the bile duct during peroral cholangioscopy (with video)

BACKGROUND

Peroral cholangioscopy (POCS) is useful for the diagnosis of various bile duct lesions. However, it is often difficult to obtain clear images because of bile or biliary sludge in the bile duct, even after vigorous irrigation of the bile duct with saline solution. Therefore, this study investigated whether inflation with carbon dioxide (CO(2)) yields clearer images of the bile duct than conventional saline solution irrigation during POCS.

OBJECTIVE

To evaluate the clinical utility and safety of CO(2) insufflation into the bile duct to obtain clear images in POCS observations by comparing this method with conventional saline solution irrigation.

SETTING

A single center.

DESIGN

Case-control study.

PATIENTS

Nineteen patients with suspected biliary diseases.

INTERVENTIONS

CO(2) insufflation into the bile duct during POCS.

MAIN OUTCOME MEASUREMENTS

The quality and safety of this method.

RESULT

The quality of the images of the bile duct lumen with CO(2) insufflation (10 patients) was significantly superior to those with saline solution irrigation (9 patients) in both clarity (P < .05) and color (P < .05). In particular, extremely clear images could be obtained from the middle part of common bile duct to the right and left hepatic duct. No serious POCS-related complications occurred. There was no significant change in the venous partial pressure of the CO(2) level during the procedure.

LIMITATIONS

The number of patients examined was small.

CONCLUSIONS

CO(2) insufflation is useful for obtaining clear images of the bile duct during POCS, which makes it possible to determine the qualitative diagnosis and the extent of various bile duct lesions.

An appraisal of anatomical and limited hepatectomy for regional hepatolithiasis

Aim. Determination of first line treatment with limited hepatectomy or Anatomical hepatectomy provides better clinical outcome. Methods. Immediate and long-term outcomes of 106 patients who underwent partial hepatectomy for RH at our institution from January 2001 to February 2005 were analyzed retrospectively. Clinical end-points included time to recovery of hepatic function, residual stones, infection of the liver remnant, bile leakage, recurrent stones, morbidity, and mortality. Results. LH was performed in 59 patients and AH in 47 patients as first-line treatment. The time of hepatic function recovery was not statistically different between the two groups (P > .05). However, Patients in AH group suffered from less residual stones (P < .05), less infection of the raw surface of liver remnant (P < .05), and less bile leakage (P < .05), with a median follow-up of 40.3 ± 0.8 months (range 3–48), and AH group suffered a less recurrent stone rate (P < .05). No difference in morbidity, and mortality rates between the two groups. Conclusion. AH is a safe and effective treatment for RH, with a fair rate of surgical complications, it should be considered as first-line treatment of RH.

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.

The successful use of peroral cholangioscopy for the diagnosis and treatment of the biliary tract lesions and giant bile duct stones in a 76-year-old man

We encountered a case in whom peroral cholangioscopy was useful for the diagnosis and treatment of irregular biliary tract mucosa and giant bile duct stones. Peroral cholangioscopy seems to improve the diagnosis of biliary tract diseases and allow internal treatment. The proper diagnosis of biliary tract diseases may be further confirmed by the concomitant use of narrow band imaging and this endoscopic technology.

Cholangiopancreatoscopy for targeted biopsies of the bile and pancreatic ducts

Establishing a tissue diagnosis in patients with suspected pancreaticobiliary malignancies remains challenging. Endoscopic retrograde cholangiopancreatography (ERCP)-based sampling methods have been reviewed in a previous issue of this journal but, unfortunately, the diagnostic yield continues to be inadequate in a significant minority of patients. The availability and image quality of cholangioscopy and pancreatoscopy have advanced in the last few years and our ability to make a diagnosis on imaging alone is improving. However, a definitive diagnosis requires tissue; cholangiopancreatoscopy allows targeted biopsies of the epithelium of the biliary and pancreatic ducts. This article reviews the evidence that cholangioscopy- and pancreatoscopy-guided biopsies improves diagnostic yield over ERCP-based tissue sampling techniques.

Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990-2009

Several advances in diagnosis, treatment and palliation of cholangiocarcinoma (CC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. CC is a relatively rare tumor and the main risk factors are: chronic inflammation, genetic predisposition and congenital abnormalities of the biliary tree. While the incidence of intra-hepatic CC is increasing, the incidence of extra-hepatic CC is trending down. The only curative treatment for CC is surgical resection with negative margins. Liver transplantation has been proposed only for selected patients with hilar CC that cannot be resected who have no metastatic disease after a period of neoadjuvant chemo-radiation therapy. Magnetic resonance imaging/magnetic resonance cholangiopancreatography, positron emission tomography scan, endoscopic ultrasound and computed tomography scans are the most frequently used modalities for diagnosis and tumor staging. Adjuvant therapy, palliative chemotherapy and radiotherapy have been relatively ineffective for inoperable CC. For most of these patients biliary stenting provides effective palliation. Photodynamic therapy is an emerging palliative treatment that seems to provide pain relief, improve biliary patency and increase survival. The clinical utility of other emerging therapies such as transarterial chemoembolization, hepatic arterial chemoinfusion and high intensity intraductal ultrasound needs further study.

Intraductal balloon-guided direct peroral cholangioscopy with an ultraslim upper endoscope (with videos)

BACKGROUND

Peroral cholangioscopy (POC) provides direct visualization of the bile duct and facilitates diagnostic procedures and therapeutic intervention. The currently available mother-baby endoscope system is not widely used because of several limitations. Although direct cholangioscopy with an ultraslim upper endoscope with a guidewire has been reported, success is not always guaranteed.

OBJECTIVE

To evaluate the feasibility and success rate of direct POC using an ultraslim endoscope with an intraductal balloon to maintain access compared with the guidewire method.

DESIGN

Prospective, observational clinical feasibility study.

SETTING

Tertiary referral center.

MAIN OUTCOME MEASUREMENTS

We compared overall procedure success rates and complications. A successful procedure was defined as one in which the endoscope was advanced into the bifurcation or stenotic segment of the biliary system.

PATIENTS AND METHODS

Twenty-nine patients with biliary disease underwent direct POC. All patients had previously undergone an endoscopic sphincterotomy or papillary balloon dilation with a large balloon. Eleven patients underwent wire-guided direct POC. Intraductal balloon-guided direct POC was performed in 21 patients. The balloon catheter was used to maintain access while an ultraslim upper endoscope was advanced over the balloon catheter, through the ampulla of Vater, and directly into the bile duct.

RESULTS

Wire-guided direct POC was successful in 5 of 11 (45.5%) patients. In contrast, the success rate of intraductal balloon-guided direct POC was 95.2% (20/21 patients, P < .05). Forceps biopsies under direct visualization of the intraductal lesion and therapeutic intervention, including laser lithotripsy or electrohydraulic lithotripsy, were performed successfully. Procedure-related complications were not observed.

LIMITATIONS

A small number of patients and no comparison with conventional cholangioscopy.

CONCLUSIONS

Intraductal balloon-guided direct POC with an ultraslim upper endoscope allows the direct visual examination and therapeutic intervention of bile ducts in patients with biliary disease. Further development of the endoscopic apparatus and specialized accessories are expected to facilitate this procedure.

Evaluation of peroral videocholangioscopy using narrow-band imaging for diagnosis of intraductal papillary neoplasm of the bile duct

BACKGROUND

It is very important for intraductal papillary neoplasm of the bile duct (IPNB) to determine the extension of the neoplasms because of substantial differences in the approach to treatment strategy. Peroral videocholangioscopy (PVCS) has been developed as a new diagnostic tool for high resolution imaging of biliary disorders. Recently, narrow-band imaging (NBI) has made it possible to emphasize the imaging of certain features, such as mucosal structures and capillary vessels. The aim of this study is to evaluate the clinical usefulness of PVCS using NBI for the diagnosis of IPNB.

PATIENTS AND METHODS

Four patients (3 men and 1 woman) were eligible for this study as they were scheduled for PVCS for evaluation of IPNB between August 2005 and September 2008 at Tokyo Medical University Hospital. We evaluated endoscopic imaging of white light imaging (WLI) and NBI for IPNB lesions, and ability of removing mucin in the bile duct by PVCS. The quality of the visualization was evaluated. : (i) poor, (ii) fair, and (iii) excellent, compared to WLI and the feasibility of irrigation: (i) poor, (ii) fair, and (iii) excellent, compared to those in patients with non-mucin-producing biliary tract diseases.

RESULTS

After sufficient removal of mucin by balloon catheter, conventional cholangioscopy could detect the papillary lesion, and revealed the range of tumor spread in all cases. Interestingly, another papillary lesion far from the main tumor was detected only by PVCS. In the ability to detect the fine mucosal structure, NBI was predisposed to be better than conventional imaging while only one case was "poor" by NBI observation because we could not eliminate the influence of bile.

CONCLUSION

Our results presented here suggest that the depiction ability of the margin of lesions by NBI observation is superior to conventional observation if abundant mucin can be removed sufficiently. Although further cases should be accumulated, choledochoscopy using NBI may be helpful for the observation of fine mucosal structures, resulting in diagnosis of tumor spread in patients with IPNB.

Diagnostic videocholangioscopy using narrow-band imaging and recanalization by rendezvous technique for difficult benign biliary stricture

A 51-year-old man was hospitalized because of close examination for liver dysfunction. drip infusion cholangiography-computed tomography (DIC-CT) revealed a stricture located at the middle bile duct but normal biliary scintigraphy. Endoscopic retrograde cholangiopancreatography (ERCP) showed obstruction of bile duct. Although we tried to pass the stricture using several kinds of guidewire under direct vision of peroral cholangioscopy, recanalization could not be achieved. Then percutaneous transhepatic biliary drainage (PTBD) was conducted. Cholangioscopy using narrow band imaging showed no tumor vessel or irregular mucosa. The biopsy specimens obtained from both distal and proximal sides of stricture showed no malignancy. Eventually, a rendezvous technique was tried using guidewire under percutaneous transhepatic cholangioscopy (PTCS) direct vision. Fortunately, since a guidewire could advance into a tiny hole at the center of a scar and an endoscopic nasobiliary drainage (ENBD) tube could be placed across the biliary stricture. One week after placement of ENBD tube, a 10 Fr plastic stent was inserted and the PTBD tube was removed without procedure-related complication. Eight months later, the stent was removed and the chief complaint disappeared without liver dysfunction.

Long-term prognosis of patients with endoscopically treated postoperative bile duct stricture and bile duct stricture due to chronic pancreatitis

AIM

To compare the outcome of endoscopic therapy for postoperative benign bile duct stricture and benign bile duct stricture due to chronic pancreatitis, including long-term prognosis.

METHODS

The subjects were 20 patients with postoperative benign bile duct stricture and 13 patients with bile duct stricture due to chronic pancreatitis who were 2 years or more after initial therapy. The patients underwent transpapillary drainage with tube exchange every 3 to 6 months until being free from the tube. Successful therapy was defined as a stent-free condition without hepatic disorder.

RESULTS

Endoscopic therapy was successful in 90% (18/20) of the patients with postoperative bile duct stricture. The stent was removed (stent free) in 100% (20/20) of the patients, but jaundice resolved in only 10% (2/20) of patients while biliary enzymes kept increasing. Restructure occurred in 5% (1/20) of the patients, but after repeat treatment the stent could be removed. In patients with bile duct stricture due to chronic pancreatitis the therapy was successful in only 7.7% (1/13) of the patients; the stent was retained in 92.3% (12/13) of the patients during a long period. Severe acute pancreatitis occurred in 3.0% (1/33) of the patients as an accidental symptom attributable to endoscopic retrograde cholangiopancreatography (ERCP); however, it remitted after conservative treatment.

CONCLUSION

Our results further confirm the usefulness of endoscopic therapy for postoperative benign bile duct strictures and good long-term prognosis of the patients.

Cholangioscopy: where are we now?

PURPOSE OF REVIEW

The purpose of this review is to provide an update on current technologies and clinical indications for cholangioscopy. The review also focuses on techniques, challenges and limitations of available devices.

RECENT FINDINGS

Recent technological advances such as the introduction into clinical practice of video cholangioscopes as well as a single-operator semidisposable per oral cholangioscope are described. Novel clinical applications of cholangioscopy are also discussed.

SUMMARY

The past several years have witnessed the emergence of new technologies, including video and semidisposable cholangioscopes, which have increased the availability and utilization of cholangioscopes. Although the most common indications for this technique remain investigation of indeterminate cholangiographic findings and management of large bile duct stones, technological advances in the devices and available accessories will invariably lead to expanded indications in the future.

Risk of pancreatitis after endoscopic retrograde cholangiopancreatography and endoscopic biliary drainage

BACKGROUND

Pancreatitis is the most common and serious complication to occur after endoscopic retrograde cholangiopancreatography (ERCP). It is often associated with additional diagnostic modalities and/or treatment of obstructive jaundice. The aim of this study was to determine the risk of post-ERCP pancreatitis associated with pancreaticobiliary examination and endoscopic biliary drainage (EBD).

METHODS

A total of 740 consecutive ERCP procedures performed in 477 patients were analysed for the occurrence of pancreatitis. These included 470 EBD procedures and 167 procedures to further evaluate the pancreaticobiliary tract using brush cytology and/or biopsy, intraductal ultrasound and/or peroral cholangioscopy or peroral pancreatoscopy. The occurrence of post-ERCP pancreatitis was analysed retrospectively.

RESULTS

The overall incidence of post-ERCP pancreatitis was 3.9% (29 of 740 procedures). The risk factors for post-ERCP pancreatitis were: being female (6.5%; odds ratio [OR] 2.5, P= 0.02); first EBD procedure without endoscopic sphincterotomy (ES) (6.9%; OR 3.0, P= 0.003), and performing additional diagnostic procedures on the pancreatobiliary duct (9.6%; OR 4.6, P < 0.0001). Pancreatitis after subsequent draining procedures was rare (0.4%; OR for first-time drainage 16.6, P= 0.0003). Furthermore, pancreatitis was not recognized in 59 patients who underwent ES. Seven patients with post-EBD pancreatitis were treated with additional ES.

CONCLUSIONS

Invasive diagnostic examinations of the pancreaticobiliary duct and first-time perampullary biliary drainage without ES were high-risk factors for post-ERCP pancreatitis. Endoscopic sphincterotomy may be of use to prevent post-EBD pancreatitis.

Overtube-balloon-assisted direct peroral cholangioscopy by using an ultra-slim upper endoscope (with videos)

BACKGROUND

The "mother-baby" endoscope system currently used for peroral cholangioscopy (POC) has several limitations. Endoscopic direct cholangioscopy when using an ultra-slim upper endoscope with a guidewire to maintain access has been reported, but appropriate accessories are required to increase the success rate. Herein, we describe a novel method, overtube-balloon-assisted endoscopy, for direct POC.

OBJECTIVE

To evaluate the feasibility and usefulness of direct POC when using an ultra-slim upper endoscope with an overtube balloon to maintain access.

SETTING

A single center.

DESIGN

Case series.

PATIENTS

Twelve patients with biliary disease.

INTERVENTIONS

Direct POC by using an ultra-slim upper endoscope and diagnostic and/or therapeutic procedures.

MAIN OUTCOME MEASUREMENTS

Success rate of this technique, diagnostic or therapeutic feasibility, and complications.

RESULTS

Overtube-balloon-assisted direct POC was performed successfully in 10 of 12 patients (83.3%). The procedure revealed 4 common bile duct (CBD) stones, 4 benign biliary strictures, 1 polypoid tumor, and 1 cholangiocarcinoma. Five patients underwent forceps biopsy under direct visualization of the intraductal lesion. Laser lithotripsy was successfully performed in 1 patient. No procedure-related complication occurred.

LIMITATIONS

A small number of patients and no comparison with conventional cholangioscopy.

CONCLUSIONS

The overtube balloon appears to be a useful accessory in direct POC when using an ultra-slim upper endoscope. However, further development of a slim overtube or other accessories is necessary to improve the success rate of direct POC.

Management of pancreaticobiliary disease using a new intra-ductal endoscope: The Texas experience

AIM: To evaluate a new single-operator mini-endoscope, Spyglass^®, for its performance, feasibility and safety in the management of pancreaticobiliary disease.

METHODS: In a multicenter retrospective analysis of patients undergoing intraductal endoscopy, we evaluated 128 patients (71 men, mean age 57.6 years). Indications were therapeutic (TX) in 72 (56%) and diagnostic (DX) in 56 (44%).

RESULTS: Peroral endoscopy was performed in 121 and percutaneous in seven. TX indications included CBD stones in 41, PD stones in six, and biliary strictures in 25. DX indications included abnormal LFT’s in 15, abnormal imaging in 38 and cholangiocarcinoma staging in three. Visualization of the stone(s) was considered good in 31, fair in six, and poor in four. Advancement of the electrohydraulic lithotripsy probe was not possible in three patients and proper targeting of the lesion was partial in four patients. A holmium laser was used successfully in three patients. Ductal clearance was achieved in 37 patients after one procedure and in four patients after two procedures. Diagnosis of biliary strictures was modified in 20/29 and confirmed to be malignant in 10/23. Of the modified patients, no diagnosis was available in 17. Spyglass^® demonstrated malignancy in 8/17 and non-malignancy in nine. Suspected pathology by imaging studies and abnormal LFT’s was modified in 43/63 (66%). Staging of cholangiocarcinoma demonstrated multicentric cholangiocarcinoma in 2/3. There was no morbidity associated with the use of Spyglass^®.

CONCLUSION: Spyglass Spyscope^® is a first generation, single operator miniature endoscope that can evaluate and treat various biliary and pancreatic tract diseases.

Endoscopic biliary plastic stenting and successful intentional stent retrieval in a benign biliary stricture with mural spherical calcification and porcelain gallbladder

We report a very rare case of benign biliary stricture with calcification and porcelain gallbladder, causing difficulty in differential diagnosis. A 64-year-old man was referred for further examination of jaundice. Computed tomography showed calcifications in the gallbladder wall and the common bile duct. Endoscopic retrograde cholangiopancreatography revealed narrowing and a filling defect in the distal common bile duct. Peroral cholangioscopy showed a protruded lesion and stricture, and pathological examinations revealed no evidence of malignancy. The stricture was resolved after temporary insertion of progressively larger of plastic stents. Patients with benign biliary stricture and/or porcelain gallbladder should be followed carefully, because malignancy can occur as a complication, although infrequent.

Endoscopic retrograde cholangiography in the diagnosis and treatment of mucobilia

OBJECTIVE

Some biliary neoplasms secrete copious mucin into bile ducts, yet the management of mucobilia is not well known. The objective of this study was to analyze 16 patients with copious mucin in the biliary tract stressing the diagnostic and therapeutic aspects of endoscopic retrograde cholangiography (ERC).

MATERIAL AND METHODS

Sixteen patients with mucobilia were found among 5635 cases of ERC from October 1999 to October 2006 in our institution. Diagnostic and therapeutic ERC as well as clinical features were retrospectively analyzed.

RESULTS

Mucin had a greater impact than the neoplasm itself on the cholangiogram and clinical presentation. ERC failed to show the tumors but a disproportionate or aneurysmal dilatation of the segmental or lobar duct correlated with the tumor-bearing duct was evident. Endoscopic managements included clearance of intraductal mucin and/or endoscopic nasobiliary drainage (ENBD). Three patients were excluded from outcome assessment because of non-specific symptoms or spontaneously subsiding jaundice. Among the 13 patients eligible for assessment, subjective improvement in symptoms and/or a decrease in jaundice along with subsiding cholangitis following ERC was observed in 5 of the 7 patients that underwent both clearance of intraductal mucin and ENBD (ENBD function was poor in all 7 patients), in 1 patient who underwent only clearance of intraductal mucin, and in 3 of the 5 patients who underwent only ENBD. The three patients with progressive jaundice, despite endoscopic management, had advanced disease.

CONCLUSIONS

ERC revealed the tumor-bearing duct but not the extent of the disease in most of the patients with mucobilia. When mucobilia is encountered during ERC, the management should include clearance of as much intraductal mucin as possible. ENBD is frequently obstructed by mucin and may be helpful only in selected cases.

Endoscopic biliopancreatic investigations and therapy

The management of most biliopancreatic diseases benefits from endoscopic treatment. Forty years after the first endoscopic cannulation of the ampulla of Vater, the overall effectiveness and safety of endoscopic retrograde cholangiopancreatography (ERCP) can be evaluated using the quality assurance programs that have recently been developed for gastrointestinal endoscopy, including ERCP. Such evaluation does not mean simply reporting therapeutic success and complication rates; rather, it involves a complex analysis of the entire gastrointestinal unit, of the medical practises, and of patient satisfaction. The overall quality of ERCP has been analysed and many quality deficits identified, even in referral centres. Training for such a specialised procedure is difficult and expensive. Competence in ERCP requires as many as 200 ERCP procedures. Quality assurance programs can help to improve the overall quality of endoscopic practise, including training of young endoscopists.

Diagnostic approaches for cholangiocarcinoma

Cholangiocarcinomas arise from the epithelial cells of the bile ducts and are associated with poor prognosis. Despite new diagnostic approaches, the definite diagnosis of this malignancy continues to be challenging. Cholangiocarcinomas often grow longitudinally along the bile duct rather than in a radial direction. Thus, large tumor masses are frequently absent and imaging techniques, including ultrasound, CT, and MRI have only limited sensitivity. Tissue collection during endoscopic (ERCP) and/or percutaneous transhepatic (PTC) procedures are usually used to confirm a definitive diagnosis of cholangiocarcinoma. However, forceps biopsy and brush cytology provide positive results for malignancy in about only 50% of patients. Percutaneous and peroral cholangioscopy using fiber-optic techniques were therefore developed for direct visualization of the biliary tree, yielding additional information about endoscopic appearance and tumor extension, as well as a guided biopsy acquistion. Finally, endoscopic ultrasonography (EUS) complements endoscopic and percutaneous approaches and may provide a tissue diagnosis of tumors in the biliary region through fine-needle aspiration. In the future, new techniques allowing for early detection, including molecular markers, should be developed to improve the diagnostic sensitivity in this increasing tumor entity.

Intraductal biliary and pancreatic endoscopy: An expanding scope of possibility

Intraductal endoscopy describes the use of an endoscope to directly visualize the biliary and pancreatic ducts. For many years, technological challenges have made performing these procedures difficult. The “mother-baby” system and other various miniscopes have been developed, but routine use has been hampered due to complex setup, scope fragility and the time consuming, technically demanding nature of the procedure. Recently, the SpyGlass peroral cholangiopancreatoscopy system has shown early success at providing diagnostic information and therapeutic options. The clinical utility of intraductal endoscopy is broad. It allows better differentiation between benign and malignant processes by allowing direct visualization and targeted sampling of tissue. Therapeutic interventions, such as electrohydraulic lithotripsy (EHL), laser lithotripsy, photodynamic therapy, and argon plasma coagulation (APC), may also be performed as part of intraductal endoscopy. Intraductal endoscopy significantly increases the diagnostic and therapeutic yield of standard endoscopic retrograde cholangiography (ERCP), and as technology progresses, it is likely that its utilization will only increase. In this review of intraductal endoscopy, we describe in detail the various endoscopic platforms and their diagnostic and clinical applications.