European Consensus Recommendations for direct Cholangioscopy and Pancreatoscopy Using a Modified Delphi Process

Aims Direct cholangioscopy and pancreatoscopy have become widely implemented techniques in the diagnostic and therapeutic algorithm of pancreaticobiliary disorders. Currently, no widely accepted guidelines exist. This study aimed to generate general and indication-specific European consensus recommendations on cholangioscopy and pancreatoscopy.

Methods Supported by the available literature evidence, statements were formulated and grouped into the following categories: 1) pre-procedural considerations, 2) general technical aspects, 3) biliopancreatic stones, 4) biliary strictures, and 5) other indications. The evidence level of each statement was determined using the GRADE methodology. European cholangioscopy experts were invited to participate in a modified Delphi process. When no 80% consensus was reached, the statement was modified based on expert feedback and subjected to a second Delphi round. Statements were rejected if no consensus was reached after the second Delphi round.

Results Thirty-four cholangioscopy experts throughout Europe completed the Delphi process. Forty (97.5%) of 41 generated statements were accepted, of which 39 (95.1%) were in the first Delphi round. Supported by moderate-to-high level evidence, 100% consensus was reached on the need for prophylactic antibiotics and NSAIDs before cholangioscopy. Despite low to very low level of evidence, expert consensus was reached on several aspects related to training and technique (e.g. the need for sphincterotomy and guidewires, handling of the elevator and the steering wheels, and methods of irrigation during the procedure). No consensus was achieved on the use of simethicone during cholangioscopy. Specific recommendations for biliopancreatic stones covered the position of cholangioscopy in the therapeutic algorithm of biliopancreatic stones and the optimal technique of lithotripsy. With regard to biliary strictures, consensus definitions to differentiate ‘unexplained biliary strictures’ from ‘indeterminate biliary strictures’ were generated. Other recommendations concerned the position of cholangioscopy in the therapeutic algorithm of unexplained biliary strictures and primary sclerosing cholangitis, the value of standardized visual evaluation criteria, the minimal number of targeted biopsies and the preferred specimen fixation medium. The remaining consensus recommendations related to the use of cholangioscopy a) for selective guidewire placement, b) for retrieval of internally migrated biliary or pancreatic stents, c) to identify the bleeding source in haemobilia and d) to perform diagnostic pancreatoscopy.

Conclusions Using a modified Delphi process within a large group of European experts, we developed general and indication-specific consensus recommendations for cholangioscopy and pancreatoscopy to guide clinical practice.