Intraductal biliopancreatic imaging: European Society of Gastrointestinal Endoscopy (ESGE) technology review

This technology review expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) on the available techniques for intraductal biliopancreatic imaging.

The three cholangioscopy techniques are described: the “dual-operator” and “ single-operator” mother-baby approaches using dedicated instruments, and the “direct” technique using currently available ultrathin gastroscopes.

The mother-baby method is standardized and reproducible, while direct cholangioscopy is technically demanding and its safety requires further evaluation.

As well as direct visualization of the bile ducts, cholangioscopy has the further advantage of allowing targeted biopsy.

Image quality is still suboptimal for single-operator cholangioscopy, while the other techniques have achieved adequately detailed imaging.

The costs of mother-baby cholangioscopy are high and its application in clinical practice should be restricted to selected cases (i.e. indeterminate biliary strictures/intraluminal lesions, difficult biliary stones) and to the setting of tertiary care centers.

Peroral pancreatoscopy may find an indication in situations where other imaging modalities (mainly EUS) are inconclusive (i.e. delineation of main duct intraductal papillary mucinous neoplasia extension, sampling of indeterminate main pancreatic duct strictures)

Intraductal ultrasonography (IDUS) has a poorer performance than EUS in the staging of pancreatic malignancies and can increase the risk of pancreatitis. A promising indication for IDUS could be the evaluation of indeterminate biliary strictures and ampullary tumors.

Probe-based confocal laser endomicroscopy (pCLE) of the bile ducts is a difficult and expensive technique. Appropriate training needs to be established, since interpretation of images is challenging. pCLE can be an important diagnostic tool in the setting of indeterminate biliary strictures.

• References

• 1 Takekoshi T, Takagi K. Retrograde pancreatocholangioscopy [in Japanese with English abstract]. Gastroenterol Endosc 1975; 17: 678-683
• 2 Dumonceau JM, Hassan C, Riphaus A et al. European Society of Gastrointestinal Endoscopy (ESGE) Guideline Development Policy. Endoscopy 2012; 44: 626-629
• 3 Itoi T, Osanai M, Igarashi Y et al. Diagnostic peroral video cholangioscopy is an accurate diagnostic tool for patients with bile duct lesions. Clin Gastroenterol Hepatol 2010; 8: 934-938
• 4 Ueki T, Mizuno M, Ota S et al. Carbon dioxide insufflation is useful for obtaining clear images of the bile duct during peroral cholangioscopy (with video). Gastrointest Endosc 2010; 71: 1046-1051
• 5 Doi S, Yasuda I, Nakashima M et al. Carbon dioxide insufflation vs. conventional saline irrigation for peroral video cholangioscopy. Endoscopy 2011; 43: 1070-1075
• 6 Siddique I, Galati J, Ankoma-Sey V et al. The role of choledochoscopy in the diagnosis and management of biliary tract diseases. Gastrointest Endosc 1999; 50: 67-73
• 7 Fukuda Y, Tsuyuguchi T, Sakai Y et al. Diagnostic utility of peroral cholangioscopy for various bile-duct lesions. Gastrointest Endosc 2005; 62: 374-382
• 8 Nishikawa T, Tsuyuguchi T, Sakai Y et al. Comparison of the diagnostic accuracy of peroral video-cholangioscopic visual findings and cholangioscopy-guided forceps biopsy findings for indeterminate biliary lesions: a prospective study. Gastrointest Endosc 2013; 77: 219-226
• 9 Osanai M, Itoi T, Igarashi Y et al. Peroral video cholangioscopy to evaluate indeterminate bile duct lesions and preoperative mucosal cancerous extension: a prospective multicenter study. Endoscopy 2013; 45: 635-642
• 10 Itoi T, Sofuni A, Itokawa F et al. Evaluation of peroral videocholangioscopy using narrow-band imaging for diagnosis of intraductal papillary neoplasm of the bile duct. Dig Endosc 2009; 21: 103-S107
• 11 Parsi MA, Jang S, Sanaka M et al. Diagnostic and therapeutic cholangiopancreatoscopy: performance of a new digital cholangioscope. Gastrointest Endosc 2014; 79: 936-942
• 12 Arya N, Nelles SE, Haber GB et al. Electrohydraulic lithotripsy in 111 patients: a safe and effective therapy for difficult bile duct stones. Am J Gastroenterol 2004; 99: 2330-2334
• 13 Piraka C, Shah RJ, Awadallah NS et al. Transpapillary cholangioscopy-directed lithotripsy in patients with difficult bile duct stones. Clin Gastroenterol Hepatol 2007; 5: 1333-1338
• 14 Swahn F, Edlund G, Enochsson L et al. Ten years of Swedish experience with intraductal electrohydraulic lithotripsy and laser lithotripsy for the treatment of difficult bile duct stones: an effective and safe option for octogenarians. Surg Endosc 2010; 24: 1011-1016
• 15 Tsuyuguchi T, Sakai Y, Sugiyama H et al. Long-term follow-up after peroral cholangioscopy-directed lithotripsy in patients with difficult bile duct stones, including Mirizzi syndrome: an analysis of risk factors predicting stone recurrence. Surg Endosc 2011; 25: 2179-2185
• 16 Jakobs R, Pereira-Lima JC, Schuch AW et al. Endoscopic laser lithotripsy for complicated bile duct stones: is cholangioscopic guidance necessary?. Arq Gastroenterol 2007; 44: 137-140
• 17 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
• 18 Igarashi Y, Okano N, Ito K et al. Effectiveness of peroral cholangioscopy and narrow band imaging for endoscopically diagnosing the bile duct cancer. Dig Endosc 2009; 21: 101-S102
• 19 Parsi MA, Stevens T, Collins J et al. Utility of a prototype peroral video cholangioscopy system with narrow-band imaging for evaluation of biliary disorders (with videos). Gastrointest Endosc 2011; 74: 1148-1151
• 20 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
• 21 Chen YK, Pleskow DK. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study (with video). Gastrointest Endosc 2007; 65: 832-841
• 22 Draganov PV, Chauhan S, Wagh MS et al. Diagnostic accuracy of conventional and cholangioscopy-guided sampling of indeterminate biliary lesions at the time of ERCP: a prospective, long-term follow-up study. Gastrointest Endosc 2012; 75: 347-353
• 23 Hartman DJ, Slivka A, Giusto DA et al. Tissue yield and diagnostic efficacy of fluoroscopic and cholangioscopic techniques to assess indeterminate biliary strictures. Clin Gastroenterol Hepatol 2012; 10: 1042-1046
• 24 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
• 25 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 2012; 27: 1569-1572
• 26 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
• 27 Dumonceau J-M. Sampling at ERCP for cyto- and histopathologicical examination. Gastrointest Endosc Clin N Am 2012; 22: 461-477
• 28 Sethi A, Widmer J, Shah NL et al. Interobserver agreement for evaluation of imaging with single operator choledochoscopy: what are we looking at?. Dig Liver Dis 2014; 46: 518-522
• 29 Mou S, Waxman I, Chennat J. Peroral cholangioscopy in Roux-en-Y hepaticojejunostomy anatomy by using the SpyGlass Direct Visualization System (with video). Gastrointest Endosc 2010; 72: 458-460
• 30 Navaneethan U, Venkatesh PGK, Al MohajerM et al. Successful diagnosis and management of biliary cast syndrome in a liver transplant patient using single operator cholangioscopy. JOP 2011; 12: 461-463
• 31 Maydeo A, Kwek BEA, Bhandari S et al. Single-operator cholangioscopy-guided laser lithotripsy in patients with difficult biliary and pancreatic ductal stones (with videos). Gastrointest Endosc 2011; 74: 1308-1314
• 32 Madhoun MF, Wani S, Hong S et al. Endoscopic papillary large balloon dilation reduces the need for mechanical lithotripsy in patients with large bile duct stones: a systematic review and meta-analysis. Diagn Ther Endosc 2014; 2014: 309618
• 33 Dumonceau JM, Delhaye M, Tringali A et al. Endoscopic treatment of chronic pancreatitis: European Society of Gastrointest Endosc (ESGE) Clinical Guideline. Endoscopy 2012; 44: 784-800
• 34 Wright H, Sharma S, Gurakar A et al. Management of biliary stricture guided by the Spyglass Direct Visualization System in a liver transplant recipient: an innovative approach. Gastrointest Endosc 2008; 67: 1201-1203
• 35 Barkay O, Bucksot L, Sherman S. Endoscopic transpapillary gallbladder drainage with the SpyGlass cholangiopancreatoscopy system. Gastrointest Endosc 2009; 70: 1039-1040
• 36 Ransibrahmanakul K, Hasyagar C, Prindiville T. Removal of bile duct foreign body by using spyglass and spybite. Clin Gastroenterol Hepatol 2010; 8: e9
• 37 Kantsevoy SV, Frolova EA, Thuluvath PJ. Successful removal of the proximally migrated pancreatic winged stent by using the SpyGlass visualization system. Gastrointest Endosc 2010; 72: 454-455
• 38 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
• 39 Pohl J. Direct cholangioscopy with standard ultraslim endoscopes for electrohydraulic lithotripsy of an incarcerated large bile duct stone. Video Journal and Encyclopedia of GI Endoscopy 2013. DOI: 10.1016/S2212–0971(13)70200–0
• 40 Parsi MA, Stevens T, Vargo JJ. Diagnostic and therapeutic direct peroral cholangioscopy using an intraductal anchoring balloon. World J Gastroenterol 2012; 18: 3992-3996
• 41 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
• 42 Meves V, Ell C, Pohl J. Efficacy and safety of direct transnasal cholangioscopy with standard ultraslim endoscopes: results of a large cohort study. Gastrointest Endosc 2014; 79: 88-94
• 43 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
• 44 Pohl J, Ell C. Direct transnasal cholangioscopy with ultraslim endoscopes: a one-step intraductal balloon-guided approach. Gastrointest Endosc 2011; 74: 309-316
• 45 Pohl J, Meves VC, Mayer G et al. Prospective randomized comparison of short-access mother-baby cholangioscopy versus direct cholangioscopy with ultraslim gastroscopes. Gastrointest Endosc 2013; 78: 609-616
• 46 Moon J, Ko B, Choi H et al. Direct peroral cholangioscopy using an ultra-slim upper endoscope for the treatment of retained bile duct stones. Am J Gastroenterol 2009;
• 47 Pohl J, Ell C. Direct cholangioscopy: new horizons for complex intraductal treatments under direct high-resolution visualization. Gastroenterology 2013; 144: 270-271
• 48 Brauer BC, Fukami N, Chen YK. Direct cholangioscopy with narrow-band imaging, chromoendoscopy, and argon plasma coagulation of intraductal papillary mucinous neoplasm of the bile duct (with videos). Gastrointest Endosc 2008; 67: 574-576
• 49 Park DH, Park BW, Lee HS et al. Peroral direct cholangioscopic argon plasma coagulation by using an ultraslim upper endoscope for recurrent hepatoma with intraductal nodular tumor growth (with videos). Gastrointest Endosc 2007; 66: 201-203
• 50 Lee YN, Moon JH, Choi HJ et al. Direct biliary drainage using transnasal endoscopy for patients with severe-to-moderate acute cholangitis. J Gastroenterol Hepatol 2013; 28: 739-743
• 51 Waxman I, Chennat J, Konda V. Peroral direct cholangioscopic-guided selective intrahepatic duct stent placement with an ultraslim endoscope. Gastrointest Endosc 2010; 71: 875-878
• 52 Demaerel P, Gevers A-M, De Bruecker Y et al. Stroke caused by cerebral air embolism during endoscopy. Gastrointest Endosc 2003; 57: 134-135
• 53 Efthymiou M, Raftopoulos S, Antonio ChirinosJ et al. Air embolism complicated by left hemiparesis after direct cholangioscopy with an intraductal balloon anchoring system. Gastrointest Endosc 2012; 75: 221-223
• 54 Finsterer J, Stöllberger C, Bastovansky A. Cardiac and cerebral air embolism from endoscopic retrograde cholangio-pancreatography. Eur J Gastroenterol Hepatol 2010; 22: 1157-1162
• 55 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
• 56 Kodama T, Sato H, Horii Y et al. Pancreatoscopy for the next generation: development of the peroral electronic pancreatoscope system. Gastrointest Endosc 1999; 49: 366-371
• 57 Kodama T, Tatsumi Y, Sato H et al. Initial experience with a new peroral electronic pancreatoscope with an accessory channel. Gastrointest Endosc 2004; 59: 895-900
• 58 Brauer BC, Chen YK, Ringold DA et al. Peroral pancreatoscopy via the minor papilla for diagnosis and therapy of pancreatic diseases. Gastrointest Endosc 2013; 78: 545-549
• 59 Yamao K, Ohashi K, Nakamura T et al. Efficacy of peroral pancreatoscopy in the diagnosis of pancreatic diseases. Gastrointest Endosc 2003; 57: 205-209
• 60 Kodama T, Koshitani T, Sato H et al. Electronic pancreatoscopy for the diagnosis of pancreatic diseases. Am J Gastroenterol 2002; 97: 617-622
• 61 Cheon Y, Moon J, Choi H et al. Direct peroral pancreatoscopy with an ultraslim endoscope for the evaluation of intraductal papillary mucinous neoplasms. Endoscopy 2012; 43: E390-E391
• 62 Prachayakul V, Aswakul P, Kachintorn U. Overtube-assisted direct peroral pancreatoscopy using an ultraslim gastroscope in a patient suspected of having an intraductal papillary mucinous neoplasm. Endoscopy 2011; 43: E279-E280
• 63 Sung K-F, Chu Y-Y, Liu N-J et al. Direct peroral cholangioscopy and pancreatoscopy for diagnosis of a pancreatobiliary fistula caused by an intraductal papillary mucinous neoplasm of the pancreas: a case report. Dig Endosc 2011; 23: 247-250
• 64 Tanaka M, Fernandez-del Castillo C, Adsay V et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012; 12: 183-197
• 65 Arnelo U, Siiki A, Swahn F et al. Single-operator pancreatoscopy is helpful in the evaluation of suspected intraductal papillary mucinous neoplasms (IPMN). Pancreatology 2014; 14: 510-514
• 66 Hara T, Yamaguchi T, Ishihara T et al. Diagnosis and patient management of intraductal papillary-mucinous tumor of the pancreas by using peroral pancreatoscopy and intraductal ultrasonography. Gastroenterology 2002; 122: 34-43
• 67 Miura T, Igarashi Y, Okano N et al. Endoscopic diagnosis of intraductal papillary-mucinous neoplasm of the pancreas by means of peroral pancreatoscopy using a small-diameter videoscope and narrow-band imaging. Dig Endosc 2010; 22: 119-123
• 68 Mukai H, Yasuda K, Nakajima M. Differential diagnosis of mucin-producing tumors of the pancreas by intraductal ultrasonography and peroral pancreatoscopy. Endoscopy 1998; 30: A99-A102
• 69 Nagayoshi Y, Aso T, Ohtsuka T et al. Peroral pancreatoscopy using the SpyGlass system for the assessment of intraductal papillary mucinous neoplasm of the pancreas. J Hepatobiliary Pancreat Sci 2014; 410-417
• 70 Yasuda K, Sakata M, Ueda M et al. The use of pancreatoscopy in the diagnosis of intraductal papillary mucinous tumor lesions of the pancreas. Clin Gastroeneterol Hepatol 2005; 3: 53-S57
• 71 Kaneko T, Nakao A, Nomoto S et al. Intraoperative pancreatoscopy with the ultrathin pancreatoscope for mucin-producing tumors of the pancreas. Arch Surg 1998; 133: 263-267
• 72 Yelamali A, Mansard MJ, Dama R et al. Intraoperative pancreatoscopy with narrow band imaging: a novel method for assessment of resection margins in case of intraductal papillary mucinous neoplasm. Surg Endosc 2012; 26: 3682-3685
• 73 Uehara H, Nakaizumi A, Tatsuta M et al. Diagnosis of carcinoma in situ of the pancreas by peroral pancreatoscopy and pancreatoscopic cytology. Cancer 1997; 79: 454-461
• 74 Yamaguchi T, Shirai Y, Ishihara T et al. Pancreatic juice cytology in the diagnosis of intraductal papillary mucinous neoplasm of the pancreas: significance of sampling by peroral pancreatoscopy. Cancer 2005; 104: 2830-2836
• 75 Attwell AR, Brauer BC, Chen YK et al. Endoscopic retrograde cholangiopancreatography with per oral pancreatoscopy for calcific chronic pancreatitis using endoscope and catheter-based pancreatoscopes: a 10-year single-center experience. Pancreas 2014; 43: 268-274
• 76 Yamaguchi T, Hara T, Tsuyuguchi T et al. Peroral pancreatoscopy in the diagnosis of mucin-producing tumors of the pancreas. Gastrointest Endosc 2000; 52: 67-73
• 77 Frossard JL, Dumonceau JM. The role of EUS in the biliary system. In: VM ShamiVM, Kahaleh M, eds Endoscopic ultrasound. New York: Humana Press; 2010: 371-390
• 78 Moon JH, Cho YD, Cha S-W et al. The detection of bile duct stones in suspected biliary pancreatitis: comparison of MRCP, ERCP, and intraductal US. Am J Gastroenterol 2005; 100: 1051-1057
• 79 Endo T, Ito K, Fujita N et al. Intraductal ultrasonography in the diagnosis of bile duct stones: when and whom?. Dig Endosc 2011; 23: 173-175
• 80 Kim HS, Moon JH, Choi HJ et al. The role of intraductal US in the management of idiopathic recurrent pancreatitis without a definite cause on ERCP. Gastrointest Endosc 2011; 73: 1148-1154
• 81 Das A, Isenberg G, Wong RC et al. Wire-guided intraductal US: an adjunct to ERCP in the management of bile duct stones. Gastrointest Endosc 2001; 54: 31-36
• 82 Tamada K, Ohashi A, Tomiyama T et al. Comparison of intraductal ultrasonography with percutaneous transhepatic cholangioscopy for the identification of residual bile duct stones during lithotripsy. J Gastroenterol Hepatol 2001; 16: 100-103
• 83 Catanzaro A, Pfau P, Isenberg GA et al. Clinical utility of intraductal US for evaluation of choledocholithiasis. Gastrointest Endosc 2003; 57: 648-652
• 84 Tsuchiya S, Tsuyuguchi T, Sakai Y et al. Clinical utility of intraductal US to decrease early recurrence rate of common bile duct stones after endoscopic papillotomy. J Gastroenterol Hepatol 2008; 23: 1590-1595
• 85 Meister T. Intraductal ultrasound substantiates diagnostics of bile duct strictures of uncertain etiology. World J Gastroenterol 2013; 19: 874
• 86 Vazquez-Sequeiros E, Baron TH, Clain JE et al. Evaluation of indeterminate bile duct strictures by intraductal US. Gastrointest Endosc 2002; 56: 372-379
• 87 Menzel J, Poremba C, Dietl KH et al. Preoperative diagnosis of bile duct strictures--comparison of intraductal ultrasonography with conventional endosonography. Scand J Gastroenterol 2000; 35: 77-82
• 88 Domagk D, Wessling J, Conrad B et al. Which imaging modalities should be used for biliary strictures of unknown aetiology?. Gut 2007; 56: 1032
• 89 Heinzow HS, Kammerer S, Rammes C et al. Comparative analysis of ERCP, IDUS, EUS and CT in predicting malignant bile duct strictures. World J Gastroenterol 2014; 20: 10495-10503
• 90 Tamada K, Tomiyama T, Wada S et al. Endoscopic transpapillary bile duct biopsy with the combination of intraductal ultrasonography in the diagnosis of biliary strictures. Gut 2002; 50: 326-331
• 91 Jong HoM. The usefulness of IDUS-guided transpapillary bile duct biopsy for the diagnosis of malignant biliary strictures. Endoscopy 2011; 43
• 92 Tamada K, Ido K, Ueno N et al. Assessment of hepatic artery invasion by bile duct cancer using intraductal ultrasonography. Endoscopy 1995; 27: 579-583
• 93 Inui K, Miyoshi H, Yoshino J. Bile duct cancers: what can EUS offer? Intraductal US, 3D-IDUS? FNA – is it possible? . Endoscopy 2006; 38: 47-S49
• 94 Tamada K, Ido K, Ueno N et al. Preoperative staging of extrahepatic bile duct cancer with intraductal ultrasonography. Am J Gastroenterol 1995; 90: 239-246
• 95 Gleeson F, Rajan E, Levy M et al. EUS-guided FNA of regional lymph nodes in patients with unresectable hilar cholangiocarcinoma. Gastrointest Endosc 2008; 67: 438-443
• 96 Tamada K, Nagai H, Yasuda Y et al. Transpapillary intraductal US prior to biliary drainage in the assessment of longitudinal spread of extrahepatic bile duct carcinoma. Gastrointest Endosc 2001; 53: 300-307
• 97 Inui K, Yoshino J, Okushima K et al. Intraductal EUS. Gastrointest Endosc 2002; 56: 58-S62
• 98 Noda Y, Fujita N, Kobayashi G et al. Prospective study of intraductal ultrasonography before biliary drainage (IDUS-BD), transpapillary biopsy (TPB) and peroral cholangioscopy (POCS) in assessment of the longitudinal extent of bile duct cancer. Gastrointest Endosc 2008; 67: AB156-AB157
• 99 Cellier C, Cuillerier E, Palazzo L et al. Intraductal papillary and mucinous tumors of the pancreas: accuracy of preoperative computed tomography, endoscopic retrograde pancreatography and endoscopic ultrasonography, and long-term outcome in a large surgical series. Gastrointest Endosc 1998; 47: 42-49
• 100 Cheon YK, Cho YD, Jeon SR et al. Pancreatic resection guided by preoperative intraductal ultrasonography for intraductal papillary mucinous neoplasm. Am J Gastroenterol 2010; 105: 1963-1969
• 101 Kobayashi G, Fujita N, Noda Y et al. Lateral spread along the main pancreatic duct in branch-duct intraductal papillary-mucinous neoplasms of the pancreas: usefulness of intraductal ultrasonography for its evaluation. Dig Endosc 2011; 23: 62-68
• 102 Paini M, Crippa S, Scopelliti F et al. Extent of surgery and implications of transection margin status after resection of IPMNs. Gastroenterol Res Pract 2014; 2014: 1-10
• 103 Heinzow HS, Lenz P, Lallier S et al. Ampulla of Vater tumors: impact of intraductal ultrasound and transpapillary endoscopic biopsies on diagnostic accuracy and therapy. Acta Gastroenterol Belg 2011; 74: 509-515
• 104 Meister T, Heinzow H, Heinecke A et al. Post-ERCP pancreatitis in 2364 ERCP procedures: is intraductal ultrasonography another risk factor?. Endoscopy 2011; 43: 331-336
• 105 Furukawa T, Oohashi K, Yamao K et al. Intraductal ultrasonography of the pancreas: development and clinical potential. Endoscopy 1997; 29: 561-569
• 106 Committee AT. Confocal laser endomicroscopy. Gastrointest Endosc 2014; 80: 928-938
• 107 Loeser CS, Robert ME, Mennone A et al. Confocal endomicroscopic examination of malignant biliary strictures and histologic correlation with lymphatics. J Clin Gastroenterol 2011; 45: 246-252
• 108 Meining A, Chen YK, Pleskow D et al. Direct visualization of indeterminate pancreaticobiliary strictures with probe-based confocal laser endomicroscopy: a multicenter experience. Gastrointest Endosc 2011; 74: 961-968
• 109 Meining A, Shah R, Slivka A et al. Classification of probe-based confocal laser endomicroscopy findings in pancreaticobiliary strictures. Endoscopy 2012; 44: 251-257
• 110 Caillol F, Filoche B, Gaidhane M et al. Refined probe-based confocal laser endomicroscopy classification for biliary strictures: the Paris Classification. Dig Dis Sci 2013; 58: 1784-9
• 111 Slivka A, Gan I, Jamidar P et al. Validation of the diagnostic accuracy of probe-based confocal laser endomicroscopy for the characterization of indeterminate biliary strictures: results of a prospective multicenter international study. Gastrointest Endosc 2015; 81: 282-290
• 112 Caillol F, Bories E, Autret A et al. Evaluation of pCLE in the bile duct: final results of EMID study: pCLE: impact in the management of bile duct strictures. Surg Endosc 2014; Dec 10 [Epub ahead of print]
• 113 Kahaleh M, Turner BG, Bezak K et al. Probe-based confocal laser endomicroscopy in the pancreatic duct provides direct visualization of ductal structures and aids in clinical management. Dig Liver Dis 2015; 47: 202-204
• 114 Talreja JP, Sethi A, Jamidar PA et al. Interpretation of probe-based confocal laser endomicroscopy of indeterminate biliary strictures: is there any interobserver agreement?. Dig Dis Sci 2012; 57: 3299-3302
• 115 Talreja JP, Turner BG, Gress FG et al. Pre- and post-training session evaluation for interobserver agreement and diagnostic accuracy of probe-based confocal laser endomicroscopy for biliary strictures. Dig Endosc 2014; 26: 577-580
• 116 Wallace MB, Meining A, Canto MI et al. The safety of intravenous fluorescein for confocal laser endomicroscopy in the gastrointestinal tract. Aliment Pharmacol Ther 2010; 31: 548-552