Biliary interventions using single-operator cholangioscopy

Feasibility of gallbladder lesion visualization using a novel ultrafine peroral cholangioscopy: A preliminary investigation

BACKGROUND

Endoscopic visualization of gallbladder lesions by the traditional peroral cholangioscopy (POCS) during the endoscopic retrograde cholangiopancreatography process is challenging. In the present study, we evaluated the feasibility of a newly designed POCS with an ultrafine outer diameter that facilitates gallbladder visualization.

METHODS

The novel POCS was designed and manufactured with an outer diameter of 7 French and achieved extremely high performance. The feasibility of this novel POCS for gallbladder observation was assessed in our center between April 2022 and January 2023. The primary outcome was technical success.

RESULTS

A total of 16 patients (64.6 ± 18.1 years, 9 males) who underwent novel ultrafine POCS inspection for gallbladder visualization were included. Technical success was achieved in 14 of 16 cases (87.5%); the main reasons for the two unsuccessful inspections were the presence of cystic duct strictures. A total of 1 adverse event occurred, for an overall rate of 6.3%, and there were no serious adverse events during the follow-up.

CONCLUSIONS

The results suggest that endoscopic visualization of the gallbladder using the novel ultrafine POCS is feasible. The device is expected to provide a new direction for the management of gallbladder disorders in the future.

Evaluation of the effectiveness and safety of single-operator cholangiopancreatoscopy with the SpyGlass™ system

BACKGROUND AND STUDY AIMS

The single-operator cholangiopancreatoscopy (SOCP) with the SpyGlass™ system is a endoscopy technique whose use has grown exponentially in recent years. The aims of this study were to evaluate the efficacy and safety of SOCP with SpyGlass™ and determine the factors related to the onset of adverse events (AEs).

PATIENTS AND METHODS

Retrospective study at a single tertiary institution with inclusion of all consecutive patients undergoing SOCP with SpyGlass™ from February-2009 to December-2021. No exclusion criteria were considered. A descriptive statistical analysis was performed. The factors associated with the existence of AE were analyzed using Chi-square and Student's t-test.

RESULTS

A total of 95 cases were included. The most common indications were biliary strictures (BS) evaluation (66.3%) or treatment of difficult common bile duct stones (27.4%). Technical and clinical success was attained in 98.9%. Single-session stone clearance was obtained in 84%. The AE rate was 7.4%. To detect malignancy in BS, optical diagnosis presents a sensitivity and specificity of 100% and 91.2%, respectively; while histology results were 36.4% and 100% respectively. A previous endoscopic sphincterotomy was associated with a lower rate of AEs (2.4% vs 41.7%; p<0.001).

CONCLUSIONS

SOCP with SpyGlass™ is a safe and effective technique to diagnose and treat pancreatobiliary pathology. The presence of sphincterotomy performed prior to the procedure could improve the technique's safety.

Cholangioscopy-guided lithotripsy in the treatment of difficult bile ducts stones - Bulgarian and Egyptian experience

Introduction: Up to 10% of bile duct stones are deemed 'difficult' because they cannot be extracted using standard endoscopic techniques. In these situations, cholangioscopy allows for stone fragmentation under direct visual control.

Role of Cholangioscopy in a Patient With Hepatolithiasis and Caroli Disease

Caroli disease is an infrequent congenital pathology that is part of the spectrum of fibrocystic diseases, characterized mainly by malformation of bile ducts. These patients often have stones and cholangitis, which respond poorly to conventional endoscopic retrograde cholangiopancreatography. To date, there is little evidence on the usefulness of cholangioscopy in this disease, so we describe the experience of performing cholangioscopy in a patient with hepatolithiasis and Caroli disease.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Optimization Study of the Hemodynamics of Saline Flushing in Endoscopic Imaging of Chronic Total Occlusions (CTOs)

PURPOSE

In this study, in vitro experiments and computational fluid dynamic (CFD) simulations are used to expand the understand of the physics of saline flushing of a blocked artery to enable optical imaging. This process involves saline injection, mixing with blood, and advection of the mixture away from the region of interest to provide a clear optical path for imaging.

METHODS

CFD simulations are used as a rapid turn-around tool for the evolutionary design process of an endovascular catheter that combines imaging forward-viewing element with saline flushing lumens.

RESULTS

A novel design and control technique is developed that provides the method to regulate the pressure in a blocked artery during saline flushing, so only small deviations from physiological pressure values are exerted on the damaged artery wall at any time, minimizing risk of rupture. In vitro experiments demonstrate the optical clearing process in phantoms simulating chronic total occlusions (CTOs) in coronary arteries with an opaque blood surrogate being removed by saline flushing. With the CFD compared by the experiments, parametric analyses of artery diameter and curvature, and flushing lumen diameter size were conducted to understand their impact on flushing times and pressures. Different plaque morphologies were studied to explore the feasibility of saline flushing in different CTO conditions.

CONCLUSIONS

A new catheter design is demonstrated to safely and effectively produce saline flushing, leading to a clear optical imaging field, and an improved technique is outlined that overcomes some practical challenges and limitations commonly encountered in angioscopy.

Diagnosis of Biliary Strictures Using Probe-Based Confocal Laser Endomicroscopy under the Direct View of Peroral Cholangioscopy: Results of a Prospective Study (with Video)

Background

The accurate diagnosis of biliary strictures remains problematic. The aim of the present study was to prospectively evaluate the clinical utility of probe-based confocal laser endomicroscopy (pCLE) under the direct view of peroral cholangioscopy (POCS) for the diagnosis of biliary strictures.

Methods

Consecutive patients with biliary strictures were included. We investigated sensitivity, specificity, and accuracy to diagnose malignancy for (1) ERCP alone, (2) POCS, (3) pCLE under the direct view of POCS, and (4) tissue sampling under the direct view of POCS.

Results

A total of 30 patients (17 with malignant lesions) were prospectively enrolled. (1) ERCP alone showed 88.2% sensitivity, 46.2% specificity, and 70% (95% confidence interval (CI), 52.1%–83.3%) accuracy. (2) POCS showed 100% sensitivity, 76.9% specificity, and 90% (95% CI, 74.4%–96.5%) accuracy. (3) pCLE under the direct view of POCS showed 94.1% sensitivity, 92.3% specificity, and 93.3% (95% CI, 78.7%–98.8%) accuracy. (4) Tissue sampling under the direct view of POCS showed 82.4% sensitivity, 100% specificity, and 90% (95% CI, 74.4%–96.5%) accuracy.

Conclusions

pCLE under the direct view of POCS provided highly accurate and sensitive characterization of biliary strictures and showed the potential for more diagnostic reliability and reduction of delays in diagnosis. This trial was registered at UMIN (registration number: UMIN000033801).

Cholangioscopy-assisted guidewire placement in a malignant biliary stricture: A case report

BACKGROUND

Cholangioscopy has been described in case reports and series to facilitate guidewire placement in difficult benign biliary strictures. Specifically, it has been infrequently used in difficult benign anastomotic liver transplant biliary strictures to visualize the stricture orifice for guidewire placement. Here we describe a case of guidewire placement through a difficult malignant biliary stricture using single operator cholangioscopy.

CASE SUMMARY

A 74-year-old female presented with jaundice and weight loss. Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) by other endoscopists demonstrated pancreatic adenocarcinoma with a dilated cystic duct (CD) and proximal common bile duct (CBD). The associated distal CBD stricture was dilated and stented with a plastic stent. However she subsequently developed cholangitis, prompting referral for a repeat ERCP. The stent was found to have migrated distally to the confluence of the dilated CD and CBD stricture. Despite using multiple hydrophilic guidewires, the stricture could not be traversed due to preferential wire passage into the dilated CD. SpyGlass DS (Boston Scientific Corp, Marlborough, MA, United States) was then used to visualize the orifices of the CD and CBD stenosis, enabling the guidewire to be placed directly through the stricture into the proximal CBD. A WallFlex covered metal stent (Boston Scientific Corp, Marlborough, MA, United States) was successfully placed, resulting in resolution of her cholangitis.

CONCLUSION

To our knowledge, this is one of the first cases to describe successful cholangioscopic guidewire placement for malignant biliary strictures.