Recommendations for the Clinical Practice concerning the Use of Cholangiopancreatoscopy: Proceedings from a Consensus Meeting

Abstract

After a consensus meeting including experts from all over the country (more than 6 years of experience, at least 50 procedures and their center perform more than 30 procedures/year), several recommendations were issued. Main recommendations: (1) Single-operator digital cholangioscopy is indicated in cases of undetermined biliary strictures (UBSs) in which visual inspection, with or without histology, may change the patient's approach. (Strong recommendation, moderate quality of evidence). (2) In a cholangioscopy for a stricture of unclear etiology, the optical assessment aspects should be recorded in a standardized report and, according to the endoscopist's visual impression, suggest a malignant or benign etiology. (Strong recommendation, high quality of evidence). (3) When using cholangioscopy regardless of the visual impression, biopsies of the stenosis should be taken (ideally in a number equal to or greater than 6 fragments). (Strong recommendation, moderate quality of evidence). (4) Cholangioscopy with biopsies has a high diagnostic accuracy in the evaluation of UBSs, with a technical success >98% and visual diagnosis with sensitivity/specificity >95%. However, it must be considered that the sensitivity of histological diagnosis is lower (around 70%). (Strong recommendation, high quality of evidence). (5) The single-operator cholangioscopy (SOC)-assisted lithotripsy is a safe procedure associated with high rates of success. (Strong recommendation, high quality of evidence). (6) SOC-assisted lithotripsy should be reserved for selected cases in which conventional techniques for the treatment of difficult biliary stones have failed. However, SOC-assisted lithotripsy should be used early in the treatment algorithm to avoid repeated procedures. (Strong recommendation, moderate quality of evidence). (7) Pancreatoscopy can allow the diagnosis of lesions suggestive of malignancy in the pancreatic duct of patients with intraductal papillary mucinous neoplasm of the main duct with high sensitivity and specificity. The groups of patients who benefit most from its use are those with a diffusely dilated duct with a diameter greater than 10 mm, and in whom sectional imaging methods and endoscopic ultrasound do not reveal focal lesions. (Weak recommendation, low quality of evidence). (8) The use of intraductal lithotripsy guided by pancreatoscopy in patients with lithiasis in the main pancreatic duct should be reserved for patients with pain and lithiasis greater than 5 mm that cannot be removed using conventional techniques. Patients with an excessively distal location in the tail or head may cause increased technical difficulty. (Low recommendation, low quality of evidence).

Keywords: Biliary stricture; Cholangioscopy; Colangioscopia; Consenso; Consensus meeting; Difficult biliary stone; Estenose biliar; Litíase biliar complicada; Pancreatoscopia; Pancreatoscopy.

Fig. 1.

Summary of the role of digital cholangioscopy in the diagnosis of biliary strictures of undetermined etiology. Adapted from Angsuwatcharakon et al. [31]. ERCP, endoscopic retrograde cholangiopancreatography; FNA, fine-needle aspiration; FNB, fine-needle biopsy.

Fig. 2.

Proposed approach for the management of difficult biliary stones. CBD, common bile duct; EST, endoscopic sphincterotomy; EHL, electrohydraulic lithotripsy; LL, laser lithotripsy; ERCP, endoscopic retrograde cholangiopancreatography.