Endoscopy 2022; 54(05): E234-E235
DOI: 10.1055/a-1494-2854
E-Videos

Intraoperative digital single-operator cholangioscopy – extra-anatomical biliary access and insights into severe sclerosing cholangitis in a pediatric patient

1   Department and Outpatientsʼ Department of Internal Medicine I, University Hospital Regensburg, Germany
,
Stefan M. Brunner
2   Department of Surgery, University Hospital Regensburg, Germany
,
Birgit Knoppke
3   University Children’s Hospital Regensburg (KUNO), Regensburg, Germany
,
Hans J. Schlitt
2   Department of Surgery, University Hospital Regensburg, Germany
,
Arne Kandulski
1   Department and Outpatientsʼ Department of Internal Medicine I, University Hospital Regensburg, Germany
› Author Affiliations
 

A 3-year-old boy with Downʼs syndrome, born prematurely with atrial septal defect type II and stenosis of the pulmonary artery, presented with hepatopathy and fibrosis. Magnetic resonance imaging (MRI) showed diffuse dilations of the biliary system, with large cystic changes suspicious for Caroli syndrome ([Fig. 1]). Endoscopic retrograde cholangiography (ERC) presented signs of secondary sclerosing cholangitis of the right liver lobe with missing contrast enhancement of the left biliary system ([Fig. 2]). Because there was no communication of the left liver lobe with the central biliary system, the patient underwent surgery to drain the left liver lobe by peripheral hepaticojejunostomy. Access to the biliary system was gained by the open biliary system of segment II and intraoperative cholangioscopy was performed using the newly developed, short digital system (SpyGlass Discover; Boston Scientific Corp., Marlborough, Massachusetts, USA) ([Video 1], [Fig. 3]). Intraoperative cholangioscopy revealed cystic dilated bile ducts, partly filled with biliary casts in accordance with the MRI imaging ([Fig. 4]). These findings further supported the diagnosis of systemic sclerosis due to severe postnatal respiratory insufficiency and circulatory problems.

Zoom Image
Fig. 1 Magnetic resonance imaging scan presenting cystic dilation of the biliary tract system.
Zoom Image
Fig. 2 Endoscopic retrograde cholangiography showing signs of secondary sclerosing cholangitis in the right biliary system.

Video 1 Intraoperative cholangioscopy in a 3-year-old boy with severe sclerosing cholangitis.


Quality:
Zoom Image
Fig. 3 Biliary access of the SpyGlass Discover catheter via liver segment II.
Zoom Image
Fig. 4 Biliary casts in a cystic dilated segment confirming the diagnosis of secondary sclerosing cholangitis.

Intraoperative cholangioscopy enables direct visualization of the biliary tract and is evaluated for stone clearance during cholecystectomy [1] [2]. Single-operator cholangioscopy has developed as a standardized procedure during ERCP for indeterminate strictures and complex biliary stones [3] [4]. Intraoperative access to the biliary system with the digital, single-operator cholangioscope (SpyGlass DS II system) is technically easy to achieve, but the length of the scope limits intraoperative maneuvers. A short system has been approved for percutaneous and intraoperative biliary interventions (SpyGlass Discover) that facilitates intraoperative cholangioscopy with its short scope length (65 cm) and angulation up to 270°.

We present the technical feasibility of access to any part of the biliary system, even from peripheral segments in pediatric anatomy. The insights provided by the biliary system open new horizons, bringing surgeons and endoscopists even closer.

Endoscopy_UCTN_Code_TTT_1AR_2AJ


#

Competing interests

Arne Kandulski receives honoraria for presentations and scientific advisories for Boston Scientific Corp. All other authors have no financial or other conflicts to declare.


Corresponding author

Philipp Dobsch, MD
Department and Outpatientsʼ Department of Internal Medicine I
University Hospital Regensburg
Franz-Josef-Strauß-Allee 11
93053 Regensburg
Germany   

Publication History

Publication Date:
08 June 2021 (online)

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Magnetic resonance imaging scan presenting cystic dilation of the biliary tract system.
Zoom Image
Fig. 2 Endoscopic retrograde cholangiography showing signs of secondary sclerosing cholangitis in the right biliary system.
Zoom Image
Fig. 3 Biliary access of the SpyGlass Discover catheter via liver segment II.
Zoom Image
Fig. 4 Biliary casts in a cystic dilated segment confirming the diagnosis of secondary sclerosing cholangitis.