Cholangioscopy using a new type of cholangioscope for the diagnosis of biliary tract disease: a case series

• Introduction
• Case series
• Patients
• Methods
• Outcomes
• Results
• Discussion
• References

We present an initial report regarding the clinical usefulness of peroral cholangioscopy, using a new type of cholangioscope, the Polyscope. Peroral cholangioscopy was performed in four patients with strictures after orthotopic liver transplantation (OLT) which were suspected of being ischemic biliary lesions, in three with indeterminate biliary strictures, in three with suspected retained bile duct stones, and in two for evaluation of the intraductal spread of adenomatous tissue after an ampullectomy. In all cases peroral cholangioscopy was performed successfully without complications. On the basis of direct viewing and/or tissue sampling a correct diagnosis was reached in all cases: in all patients who underwent OLT the strictures were not ischemic; the indeterminate strictures were all benign; and, in patients with suspected stones, complete clearance was confirmed. Intraductal spread was confirmed in one patient and excluded in the other. In our experience, peroral cholangioscopy using a Polyscope is a safe and effective method for diagnosing bile duct lesions.

Introduction

Peroral cholangioscopy has been developed over the past three decades to enable direct endoscopic observation of bile duct lesions that are difficult to evaluate by endoscopic retrograde cholangiography (ERC), and to guide tissue sampling. Previous limitations of cholangioscopy included limited image resolution, fragile and cumbersome cholangioscopes, the need for two endoscopists to perform the cholangioscopic examinations, inadequate small-caliber accessories, and the absence of data demonstrating clinical benefit [1] [2] [3] [4].

The new generation of cholangioscopes have overcome these problems, and recently presented data have shown the clinical benefit of cholangioscopy in the assessment of indeterminate intraductal lesions, visually guided stone therapy, targeted tissue sampling for diagnosing neoplasms, and the evaluation of intraductal spread of tumors [3] [4] [5] [6] [7].

We present an initial report regarding the clinical usefulness of peroral cholangioscopy using a new type of cholangioscope, the Polyscope, for diagnosing biliary tract disease.

Case series

Patients

Between January 2010 and December 2010, 12 consecutive patients (8 men; median age 61.5 years) referred for peroral cholangioscopy for biliary tract disease were included in the study. Written informed consent was obtained from all patients and the study protocol was approved by our institutional review board.

Methods

A Polyscope (Polyscope system; Polydiagnost, Pfaffenhofen, Germany) was used for peroral cholangioscopy. The Polyscope system ([Fig. 1a]) consists of a detachable flexible endoscope system available in 8 Fr (185 cm length) with separate optical, working/irrigation (1.2 mm), illumination, and steering channels ([Fig. 1b]), with a deflection section 10 cm in length and with a deflection of 180° ([Fig. 1c]). Due to this separation, dealing with a breakdown such as laser-related damage to the working channel or the distal scope tip is confined to the disposable insertion catheter alone. Coupled in the optical channel, hermetically closed by a piece of diamond glass, the optical system never comes into contact with the patient. The reusable optical system consists of a 0.55-mm-diameter optical fiber with 10 000 pixels and an angle of view of 70°. The Endognost LS 200 Xenon Endoscopic Light Source (Polydiagnost) was used as light source.

The Polyscope was introduced into the bile duct over the wire through the accessory channel of a duodenoscope (TJF 160 or TFJ 180; Olympus America Inc., Center Valley, Pennsylvania, USA) ([Fig. 2]). The bile duct was irrigated with saline solution through an accessory channel during endoscopic biliary examination using an irrigation pump (Endognost IP200PD-IP-0100; Polydiagnost), and all endoscopic images were recorded using a digital video system ([Video 1]). Before or after the cholangioscopy, an endoscopic sphincterotomy was performed in all patients for therapeutic purposes. After inspection by peroral cholangioscopy, biopsies from the lesions were attempted using ultrathin biopsy forceps (PD-TI-0101 and PD-TI-0100; Polydiagnost) 220 cm in length and 1 mm in diameter, as needed. After the procedures, a diagnosis was reached on the basis of both the visual appearance and the histology of the samples obtained during the cholangioscopy (in those cases where they were available). All endoscopies were performed with the patients under deep sedation.

Outcomes

The outcome data collected included patient demographics and clinical data, technical success rate, complication rate, and cholangioscopic findings. The accuracy of the cholangioscopic diagnosis was determined by comparing the peroral cholangioscopy results with the final surgical pathological diagnosis (when surgery was performed) or with the results of the clinical follow-ups (clinical and/or imaging studies).

Results

The demographic and clinical data of the patients included in the study are presented in [Table 1].

A total of 16 peroral cholangioscopies were performed in 12 patients: four with strictures after orthotopic liver transplantation (OLT) which were suspected to be ischemic biliary lesions, three with indeterminate biliary strictures (2 suspected malignancies), three with suspected retained bile duct stones after lithotripsy, and two in whom evaluation of the intraductal spread of adenomatous tissue after an ampullectomy was required.

All the peroral cholangioscopies were performed successfully, and there was no procedure-related morbidity or mortality. For the 16 procedures in this series, the mean (± SD) total procedure time (ERCP plus Polyscope) was 59 ± 12.5 minutes and the mean total Polyscope time was 18.4 ± 6.5 minutes.

Tissue sampling was attempted in eight cases and was successful in four; the failures were due to inability to pass the forceps through the Polyscope. Notably, all the patients in whom the sampling attempts failed were post-OLT patients. In all the cases in which the biopsies were taken successfully, the specimens were found to be adequate for histological evaluation.

In all patients, a correct diagnosis was reached with or without histological confirmation. In the four OLT patients, the suspected ischemic biliary lesion was ruled out by the cholangioscopy, which detected convergence of the folds and showed that the white mucosa was confined to the anastomotic segment, which was therefore regarded as a cicatricial stricture ([Fig. 3a], [Video 2]). In the three patients with suspected residual stones, the direct-view cholangioscopy first showed the residual stones ([Fig. 3b]), requiring further stone lithotripsy and extraction, and then confirmed their clearance. In the three patients with indeterminate strictures, the cholangioscopy enabled malignancy to be excluded, as was confirmed by follow-up (2 patients) and surgery (1 patient). Of the two patients who underwent ampullectomy, the follow-up cholangioscopy excluded intraductal recurrence in one. In the second patient intraductal tissue was excluded by peroral cholangioscopy at the time of the ampullectomy, but 3 months later, prompted by abnormal liver enzymes with bile duct dilatation, a second peroral cholangioscopy was performed and adenomatous tissue extending proximally into the bile duct was recorded ([Fig. 3c], [Video 3]) and was confirmed by tissue sampling.

Ultimately, the cholangioscopy changed the previous diagnosis in all four of the OLT patients (100 %), in two of the three patients with indeterminate strictures (67 %), and in one of the two patients followed up for ampullectomy (50 %).

Discussion

We report the first prospective evaluation of a new cholangioscope, the Polyscope system, in the biliary tract.

A Polyscope is a single-operator multilumen cholangioscopic catheter with a very thin outer diameter of 8 Fr and a working channel of 3.5 Fr. The steering component has a Luer-Lok mechanism for deflection of the steerable tip of the catheter, which can also be rotated. The tip deflection is approximately 180°, resulting in easy access into the biliary tract. Furthermore, the small caliber and flexibility of the Polyscope meant that it was unnecessary to perform a endoscopic sphincterotomy first in order to reach the bile duct. Indeed, in our series, the Polyscope was able to achieve bile duct cannulation without a previous endoscopic sphincterotomy. Thanks to its very small diameter, the Polyscope was also able to pass through all the strictures without any previous dilation.

In our series tissue sampling was attempted in eight cases and was successful in four; in four post-OLT patients we were unable to pass the forceps through the working channel. One explanation of this could be that the acute angle of the duodenoscope under postsurgical conditions caused the working channel inside the Polyscope to collapse.

Nevertheless, all the peroral cholangioscopy diagnoses, even when not supported by histology, provided an accurate final diagnosis in 100 % of cases. The optical resolution of the Polyscope – approximately 10 000 pixels – results in excellent picture quality. As recently shown in other fields of endoscopy, the newest optical advanced techniques can provide better accuracy than histological findings. A high-quality direct view alone might be able to provide high diagnostic accuracy even when not supported by histology [2].

In summary, in our experience, peroral cholangioscopy using a Polyscope is a safe and effective technique for diagnosing bile duct lesions.

Competing interests: None.

• References

• 1 Terheggen G, Neuhaus H. New options of cholangioscopy. Gastroenterol Clin North Am 2010; 39: 827-844
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• 5 Kawakami H, Kuwatani M, Etoh K et al. Endoscopic retrograde cholangiography versus peroral cholangioscopy to evaluate intraepithelial tumor spread in biliary cancer. Endoscopy 2009; 41: 959-964
  Thieme ConnectPubMedSearch in Google Scholar
• 6 Itoi T, Osanai M, Igarashi Y et al. Diagnostic peroral video cholangioscopy is an accurate diagnostic tool for patients with bile duct lesions. Clin Gastroenterol Hepatol 2010; 8: 934-938
  CrossrefPubMedSearch in Google Scholar
• 7 Draganov PV, Lin T, Chauhan S et al. Prospective evaluation of the clinical utility of ERCP-guided cholangiopancreatoscopy with a new direct visualization system. Gastrointest Endosc 2011; 73: 971-979
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Corresponding author

• References

• 1 Terheggen G, Neuhaus H. New options of cholangioscopy. Gastroenterol Clin North Am 2010; 39: 827-844
  CrossrefPubMedSearch in Google Scholar
• 2 Itoi T, Neuhaus H, Chen YK. Diagnostic value of image-enhanced video cholangiopancreatoscopy. Gastrointest Endosc Clin N Am 2009; 19: 557-566
  CrossrefPubMedSearch in Google Scholar
• 3 Petersen BT. Cholangioscopy for special applications: primary sclerosing cholangitis, liver transplant, and selective duct access. Gastrointest Endosc Clin N Am 2009; 19: 579-586
  CrossrefPubMedSearch in Google Scholar
• 4 Chathadi KV, Chen YK. New kid on the block: development of a partially disposable system for cholangioscopy. Gastrointest Endosc Clin N Am 2009; 19: 545-555
  CrossrefPubMedSearch in Google Scholar
• 5 Kawakami H, Kuwatani M, Etoh K et al. Endoscopic retrograde cholangiography versus peroral cholangioscopy to evaluate intraepithelial tumor spread in biliary cancer. Endoscopy 2009; 41: 959-964
  Thieme ConnectPubMedSearch in Google Scholar
• 6 Itoi T, Osanai M, Igarashi Y et al. Diagnostic peroral video cholangioscopy is an accurate diagnostic tool for patients with bile duct lesions. Clin Gastroenterol Hepatol 2010; 8: 934-938
  CrossrefPubMedSearch in Google Scholar
• 7 Draganov PV, Lin T, Chauhan S et al. Prospective evaluation of the clinical utility of ERCP-guided cholangiopancreatoscopy with a new direct visualization system. Gastrointest Endosc 2011; 73: 971-979
  CrossrefPubMedSearch in Google Scholar