Single-step direct cholangioscopy by freehand intubation using standard endoscopes for diagnosis and therapy of biliary diseases

Abstract

Objectives: Commercially available 10F cholangioscope systems have limitations in examination of the biliary tree. Further, they are not readily available in all endoscopy units. Direct cholangioscopy (DC) using slim and ultraslim gastroscopes have been utilized to detect and treat bile duct (BD) diseases. It often requires initial duodenoscope introduction, followed by over-the-wire exchange to a gastroscope for BD intubation. We report a novel single-step DC technique using forward-viewing endoscopes without requiring tandem-scope exchange.

Methods: In patients with native papilla, a "J" maneuver, accomplished by retroflexing the endoscope in the second portion of the duodenum and withdrawing the retroflexed scope into the BD, was used to achieve free intubation. A variety of readily available standard endoscopes were used. For biliary-enteric anastomoses, balloon dilation, if necessary followed by enteroscope advancement, was utilized for BD visualization.

Results: A total of 18 patients underwent 22 DC procedures (8 male, 10 female, mean age 69 years). Direct intubation was successful in all procedures. Indications included BD stone (n=10), BD stricture or tumor (n=8). A native papilla was present in 13 patients and biliary-enteric anastomoses in 5; 8 patients had altered gastrointestinal anatomy. Sphincterotomy was required in 12/13 native papilla patients to facilitate DC. Free intubation of the BD was accomplished in 19 of 22 exams, and 3 facilitated by guidewire (over-the-wire in 2 and alongside a guidewire in 1). Overtube-assisted enteroscopy was used to reach the BD in four patients. The findings were stones (n=6), strictures or tumors (n=7), abnormal mucosa (n=5), a dilated duct confirming stone clearance without stricture (n=3), and retained stent (n=1). Interventions were biopsy (n=8), stone extraction (n=5), electrohydraulic lithotripsy (n=3), chromoendoscopy (n=2), narrow-band imaging (n=2), through the scope stricture dilation (n=2), and argon-plasma coagulation of biliary tumor (n=1). Complications were cholangitis managed with intavenous antibiotics (n=1).

Conclusions: Single-step DC can be achieved without using tandem-scope exchange, and may be clinically useful for diagnostic and therapeutic purposes in managing select biliary tract diseases.