A multicenter study on the role of direct retrograde cholangioscopy in patients with inconclusive endoscopic retrograde cholangiography
submitted 19 June 2013
accepted after revision 30 October 2013
18 December 2013 (online)
Background and study aims: Direct retrograde cholangioscopy (DRC) may improve the diagnostic and therapeutic yield of endoscopic retrograde cholangiography (ERC) but safety, feasibility, and outcome are unknown.
Patients and methods: All consecutive patients who underwent DRC at three tertiary endoscopy centers for inconclusive findings at ERC were included in this retrospective analysis. Ultraslim endoscopes (FujiFilm EG 530NP; Olympus GIF XP180; GIF N180) were used by the peroral route for intubating all accessible bile ducts. Success rate, usefulness in diagnosis and therapy, and safety of DRC were assessed in terms of technical and clinical parameters and therapeutic vs. diagnostic indication.
Results: DRC was performed in 130 cases (89 patients). CO2 insufflation and an anchoring balloon were used in 66.9 % and 97.7 % of cases, respectively. Intubation of the papilla was successful in 115 of 130 (88.5 %) cases, and the aim of the DRC investigation was accomplished in 105 cases (80.8 %). DRC-guided biopsies were taken in 53 cases (40.8 %), and a therapeutic intervention was performed in 32 cases (24.6 %). The initial diagnosis was revised by DRC in 18 of 69 patients (26.1 %) with indeterminate biliary stricture. Complications were observed in 10 cases (7.7 %), including cholangitis (n = 2; 1.5 %), bleeding (n = 2; 1.5 %), and pain, hypoxia, bradyarrhythmia, air embolism, and perforation of an intrahepatic and an extrahepatic bile duct (1 each; 0.8 %). There was no mortality associated with DRC.
Conclusions: DRC was successfully performed for the diagnosis and treatment of biliary disease that had eluded diagnosis with conventional ERC. DRC impacted on clinical decision making. The complication rate was low and similar to other cholangioscopy techniques.
- 1 Pohl J, Ell C. Direct transnasal cholangioscopy with ultraslim endoscopes: a one-step intraductal balloon-guided approach. Gastrointest Endosc 2011; 74: 309-316
- 2 Albert JG, Friedrich-Rust M, Elhendawy M et al. Peroral cholangioscopy for diagnosis and therapy of biliary tract disease using an ultra-slim gastroscope. Endoscopy 2011; 43: 1004-1009
- 3 Larghi A, Waxman I. Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study. Gastrointest Endosc 2006; 63: 853-857
- 4 Moon JH, Ko BM, Choi HJ et al. Intraductal balloon-guided direct peroral cholangioscopy with an ultraslim upper endoscope (with videos). Gastrointest Endosc 2009; 70: 297-302
- 5 Moon JH, Ko BM, Choi HJ et al. Direct peroral cholangioscopy using an ultra-slim upper endoscope for the treatment of retained bile duct stones. Am J Gastroenterol 2009; 104: 2729-2733
- 6 Tsou Y, Lin C, Tang J et al. Direct peroral cholangioscopy using an ultraslim endoscope and overtube balloon-assisted technique: a case series. Endoscopy 2010; 42: 681-684
- 7 Choi HJ, Moon JH, Ko BM et al. Clinical feasibility of direct peroral cholangioscopy-guided photodynamic therapy for inoperable cholangiocarcinoma performed by using an ultra-slim upper endoscope (with videos). Gastrointest Endosc 2011; 73: 808-813
- 8 Brauer BC, Chen YK, Shah RJ. Single-step direct cholangioscopy by freehand intubation using standard endoscopes for diagnosis and therapy of biliary diseases. Am J Gastroenterol 2012; 107: 1030-1035
- 9 Lee YN, Moon JH, Choi HJ et al. Direct peroral cholangioscopy using an ultraslim upper endoscope for management of residual stones after mechanical lithotripsy for retained common bile duct stones. Endoscopy 2012; 44: 819-824
- 10 Mori A, Tatebe H, Ohashi N et al. Balloon-assisted insertion of a cholangioscope into the common bile duct: a novel technique. Endoscopy 2008; 40 (Suppl. 02) E106-107
- 11 Choi HJ, Moon JH, Ko BM et al. Overtube-balloon-assisted direct peroral cholangioscopy by using an ultra-slim upper endoscope (with videos). Gastrointest Endosc 2009; 69: 935-940
- 12 Waxman I, Dillon T, Chmura K et al. Feasibility of a novel system for intraductal balloon-anchored direct peroral cholangioscopy and endotherapy with an ultraslim endoscope (with videos). Gastrointest Endosc 2010; 72: 1052-1056
- 13 Doi S, Yasuda I, Nakashima M et al. Carbon dioxide insufflation vs. conventional saline irrigation for peroral video cholangioscopy. Endoscopy 2011; 43: 1070-1075
- 14 Draganov PV, Lin T, Chauhan S et al. Prospective evaluation of the clinical utility of ERCP-guided cholangiopancreatoscopy with a new direct visualization system. Gastrointest Endosc 2011; 73: 971-979
- 15 Ramchandani M, Reddy DN, Gupta R et al. Role of single-operator peroral cholangioscopy in the diagnosis of indeterminate biliary lesions: a single-center, prospective study. Gastrointest Endosc 2011; 74: 511-519
- 16 Manta R, Frazzoni M, Conigliaro R et al. SpyGlass single-operator peroral cholangioscopy in the evaluation of indeterminate biliary lesions: a single-center, prospective, cohort study. Surg Endosc 2013; 27: 1569-1572
- 17 Chen YK, Parsi MA, Binmoeller KF et al. Single-operator cholangioscopy in patients requiring evaluation of bile duct disease or therapy of biliary stones (with videos). Gastrointest Endosc 2011; 74: 805-814
- 18 Kalaitzakis E, Webster GJ, Oppong KW et al. Diagnostic and therapeutic utility of single-operator peroral cholangioscopy for indeterminate biliary lesions and bile duct stones. Eur J Gastroenterol Hepatol 2012; 24: 656-664
- 19 Sethi A, Chen YK, Austin GL et al. ERCP with cholangiopancreatoscopy may be associated with higher rates of complications than ERCP alone: a single-center experience. Gastrointest Endosc 2011; 73: 251-256