Endoscopy 2009; 41(8): 730
DOI: 10.1055/s-0029-1214878
Letters to the editor

© Georg Thieme Verlag KG Stuttgart · New York

Effective device for peroral direct cholangioscopy: double-balloon enteroscope or ultra-slim gastroscope?

M.  Matsushita, M.  Shimatani, M.  Takaoka, K.  Okazaki
Further Information

Publication History

Publication Date:
10 August 2009 (online)

We read with interest the article by Muralikrishna et al. [1] on peroral direct cholangioscopy with a double-balloon enteroscope (DBE). Despite their multiple attempts after sphincterotomy, proximal biliary access failed in a patient with jaundice and fever. Because of the lack of an expensive mother–baby system, they performed peroral cholangioscopy with a diagnostic DBE. Despite their success in the dilated bile duct, we believe that their technique would be ineffective in a nondilated bile duct because of the large diameter of the enteroscope. Moreover, they described the use of an 8.5-mm Fujinon DBE with a 2.8-mm working channel, but the 8.5-mm diagnostic DBE (EN-450P5/20; Fujinon) has a 2.2-mm working channel, and a 9.4-mm therapeutic DBE (EN-450T5; Fujinon) has a 2.8-mm working channel. Both DBEs have a 200-cm working length.

DBE can visualize the entire small bowel via either a peroral and/or peranal approach, and provide high diagnostic yields and therapeutic capabilities [2] [3]. Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging and often unsuccessful in patients with altered gastrointestinal anatomy because of the necessary passage length and/or anastomosis angulation [4] [5] [6]. With the advent of the DBE technique, access to the papilla and ERCP in such patients is possible with accessories that are specialized and custom-made or very limited, because of the short accessory lengths. We have also applied a ”short” DBE (EC450-BI5; Fujinon), having a 2.8-mm working channel and a 152-cm working length, for diagnostic and therapeutic ERCP in such patients with a high success rate because all conventional accessories are available [5] [6].

Peroral and percutaneous transhepatic cholangioscopy, which are well-established nonsurgical procedures, permit direct visualization and biopsy of the bile duct [7]. Peroral cholangioscopy is performed by passing a small-caliber (3-mm) scope (the ”baby”), through the channel of a duodenoscope (the ”mother”), then advancing it into the bile duct. This procedure appears safer and faster than percutaneous cholangioscopy, but it remains expensive, time-consuming, and cumbersome, and requires two experienced endoscopists [7] [8]. The search for an easier and less awkward technique for direct cholangioscopy is still underway [7].

Successful peroral direct cholangioscopy with an ultra-slim gastroscope, originally designed for pediatric and transnasal use, has been reported for management of biliary diseases [7] [8] [9]. The technique is less cumbersome, and offers real advantages, being done by a single endoscopist without the need of additional equipment or setup. The 5.9-mm (GIF-XP160; Olympus) [7] [9] or the 4.9-mm (GIF-N180; Olympus) [8] gastroscope having a 2.0-mm working channel was used. With the assistance of a guide wire [7] [9] or a balloon catheter [8], it was possible to advance the gastroscope through the post-sphincterotomy papilla into the bile duct. We therefore believe that peroral direct cholangioscopy with an ultra-slim gastroscope would be an effective alternative even in a nondilated bile duct.

Competing interests: None

References

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  • 5 Matsushita M, Shimatani M, Takaoka M. et al . ”Short“ double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy.  Am J Gastroenterol. 2008;  103 3218-3219
  • 6 Shimatani M, Matsushita M, Takaoka M. et al . ”Short” double balloon enteroscope for endoscopic retrograde cholangiopancreatography with conventional sphincterotomy and metallic stent placement after Billroth II gastrectomy.  Endoscopy. 2009;  41 E19-E20
  • 7 Larghi A, Waxman I. Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study.  Gastrointest Endosc. 2006;  63 853-857
  • 8 Beretta P, Cucino C, Caputo V. Endoscopic diagnosis of adenocarcinoma of the common bile duct using an ultra-slim upper endoscope.  Am J Gastroenterol. 2008;  103 2956-2957
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M. MatsushitaMD 

Third Department of Internal Medicine
Kansai Medical University

2-3-1 Shinmachi, Hirakata
Osaka 573-1191
Japan

Fax: +81-72-8042061

Email: matsumit@hirakata.kmu.ac.jp

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