Cholangioscopy has an increasingly important role in the diagnosis and treatment of biliary and pancreatic diseases. Initiative attempts were made during late 1970s, but due to the technical difficulties the procedure did not find a place in routine endoscopic practice (1,2). Over the past 20 years miniature scopes were designed which pass through the working channel of a standard ERCP scope to visualize the biliary tracts directly. Disadvantages of these traditional mother-daughter cholangioscopy systems are requirement of two experienced endoscopists, poor visualization and the absence of a meaningful working channel. Recent advances in technology made this challenging procedure more convenient. Spyglass® Direct Visualization System (Boston Scientific) is the latest system developed for the examination of biliary tract but one-time usability and high cost limits its utilization.
Direct peroral cholangioscopy (DPOC) offers a single-operator platform, digital image quality, and simultaneous irrigation and therapeutic capabilities. DPOC can be performed by (i) direct scope insertion, (ii) wire guided insertion, (iii) overtube-balloon assisted insertion, (iv) occlusion-balloon assisted insertion and (v) intraductal balloon catheter assisted insertion (3). In this presentation we aimed to show usability of ultraslim gastroscope for wire-guided cholangioscopy.
We present a case of a 64 years old man who presented with RUQ pain, jaundice and fever. Further evaluation revealed acute cholangitis with choledocolithiasis. ERCP was performed and multipl stone was extracted after sphincterotomy. 0.035 inch guidewire was placed into intrahepatic bile duct by ultraslim gastroscope. The ultraslim gastroscope was then introduced into the extrahepatic bile duct over the guidewire under the fluoroscopic guidance. Biliary tree was visualised until right and left main hepatic ducts are seen at their take-off from the bifurcation by ultraslim gastroscope. The ultraslim gastroscope was withdrawn from the bifurcation and cystic duct take-off was shown.
In the second case of a 61 year old male patient with acute cholangitis ERCP was performed. The examination revealed a biliary stone and after sfincterotomy stone was extracted successfully. A stricture in the distal common bile duct was noted during examination. Guidewire was then placed as previously described and ultraslim gastroscope was advanced over it through the papilla. The stricture was directly visualized and biopsied during cholangioscopy in which pathologic examination showed benign fibrotic tissue.
In conclusion, wire-guided peroral cholangioscopy by ultraslim gastroscope is feasible and appears to be a safe method for direct visualization of biliary tract. However, there are several published reports of increased risk of pneumobilia with air embolism and cholangitis (4-5).
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Cetin Karaca, MD, Istanbul University
Bulent Baran, MD, Istanbul University