Balloon-assisted insertion of a cholangioscope into the common bile duct: a novel technique

A snare-assisted peroral direct choledochoscopy and pancreatoscopy using an ultra-slim upper endoscope: A case series study

OBJECTIVE

To evaluate the feasibility, effectiveness and safety of a new snare-assisted peroral direct choledochoscopy/pancreatoscopy (PDCPS) technique.

METHODS

From November 2014 through December 2016, 20 consecutive patients with indications for PDCPS were enrolled in this observational study. Endoscopic retrograde cholangiography was initially performed using a conventional duodenoscope, and endoscopic papillary balloon dilation was performed. Next, an ultra-slim endoscope was inserted to perform the PDCPS; a snare tightened around the end of the scope's bending section facilitated its entry into the common bile duct (CBD). The primary endpoint was the overall success rate of the PDCPS procedure (successful biliary intubation and visualization of the area of interest) and the time for biliary intubation with the ultra-slim upper endoscope.

RESULTS

Participants (11 men and 9 women; mean age, 72.2 years [range, 41-93 years]) had CBD adenoma (n=1), large CBD stones after failed extraction/lithotripsy treatment (n=13), CBD strictures (n=4), pancreatic duct tumor (n=1) or pancreatic duct dilation (n=1). The success rate was 95%. The mean intubation time was 18min (range, 4-57min). No adverse events were reported.

CONCLUSIONS

A snare-assisted PDCPS technique appears to be technically feasible, effective and safe for both diagnostic and therapeutic applications.

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-baby 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.

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.

Direct peroral cholangioscopy using an ultra-slim upper endoscope for the treatment of retained bile duct stones

OBJECTIVES

Intracorporeal lithotripsy must be used under direct visual control with an additional endoscope in order to ensure safety and precise targeting during the removal of difficult-to-extract bile duct stones using conventional methods. The currently available "mother-baby" scope system has several disadvantages. We evaluated the feasibility and efficacy of direct peroral cholangioscopy (POC) using an ultra-slim upper endoscope for electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) for the treatment of difficult-to-extract bile duct stones.

METHODS

A total of 18 patients who were unsuccessfully treated for common bile duct (CBD) stones using conventional endoscopy, including mechanical lithotripsy (ML), underwent EHL or LL under intraductal balloon-guided direct POC using an ultra-slim upper endoscope. The balloon catheter was used to maintain access while an ultra-slim upper endoscope was advanced directly into the bile duct. EHL or LL was performed until it became possible to capture the fragmented stones in a basket. Endoscopic removal of stone fragments by duodenoscopy was attempted in the same session.

RESULTS

The overall success rate of bile duct clearance by lithotripsy under direct POC by a single endoscopist was 88.9% (16 of 18). Stone fragmentation under direct POC was successfully performed in nine patients using EHL and in seven patients using LL. The average number of treatment sessions required to complete stone removal was 1.6. ML was performed to complete stone removal in 5 of 18 (27.8%) patients. Procedure-related complications were not observed.

CONCLUSIONS

Lithotripsy with EHL or LL under direct POC involving the use of an ultra-slim endoscope by a single endoscopist seems to be an effective and safe treatment for select patients with difficult-to-extract CBD stones.

Transnasal endoscopic retrograde chalangiopancreatography using an ultrathin endoscope: A prospective comparison with a routine oral procedure

AIM: To investigate if transnasal endoscopic retrograde cholangiopancreatography (n-ERCP) using an ultrathin forward-viewing scope may overcome the disadvantages of conventional oral ERCP (o-ERCP) related to the large-caliber side-viewing duodenoscope.

METHODS: The study involved 50 patients in whom 25 cases each were assigned to the o-ERCP and n-ERCP groups. We compared the requirements of esophagogastroduodenoscopy (EGD) prior to ERCP, rates and times required for successful cannulation into the pancreatobiliary ducts, incidence of post-procedure hyperamylasemia, cardiovascular parameters during the procedure, the dose of a sedative drug, and successful rates of endoscopic naso-biliary drainage (ENBD).

RESULTS: Screening gastrointestinal observations were easily performed by the forward-viewing scope and thus no prior EGD was required in the n-ERCP group. There was no significant difference in the rates or times for cannulation, or incidence of hyperamylasemia between the groups. However, the cannulation was relatively difficult in n-ERCP when the scope appeared U-shape under fluoroscopy. Increments of blood pressure and the amount of a sedative drug were significantly lower in the n-ERCP group. ENBD was successfully performed succeeding to the n-ERCP in which mouth-to-nose transfer of the drainage tube was not required.

CONCLUSION: n-ERCP is likely a well-tolerable method with less cardiovascular stress and no need of prior EGD or mouth-to-nose transfer of the ENBD tube. However, a deliberate application is needed since its performance is difficult in some cases and is not feasible for some endoscopic treatments such as stenting.