Evaluation of direct peroral cholangioscopy by freehand intubation for diagnosis and therapy of biliary diseases / 中华消化内镜杂志

Objective To evaluate the feasibility and safety of direct peroral cholangioscopy (DPCS) by freehand intubation using routine straight-view endoscope for diagnosis and therapy of biliary diseases.Methods Patients with unexplained choledochal stenosis and choledocholithiasis underwent standard ERCP.Native papilla was dilated using endoscopic papillary large balloon dilation (EPLBD)according to the size of papilla and the diameter of common bile duct.DPCS was performed using routine straight-view endoscope,and biopsy or laser lithotripsy was performed according to imaging of DPCS.General data of patients,procedure of ERCP,diagnosis of DPCS,and complications were recorded.Serum amylase after 2 hours and 24 hours,total bilirubin,direct bilirubin,leukocyte count,neutrophilic granulocyte percentage,and C-reactive protein were measured.Results A total of 15 patients underwent DPCS,including 5 cases of huge common bile duct stones and 10 cases of common bile duct stricture.The diameter of common bile duct ranged from 1.5 cm to 2.5 cm.Single EPLBD was required in 3 cases,endoscopic sphincteropapillotomy and EPLBD was required in 12 cases to facilitate DPCS.DPCS was successfully completed in 14 cases,including 11 cases in distal common bile duct,3 cases in proximal common bile duct.Among the 14 cases,4 cases used ordinary gastroscope,and 10 cases used ultrathin gastroscope.Laser lithotripsy was successfully completed in 4 choledocholithiasis patients.DPCS was successfully completed in 9 patients of common bile duct stenosis.The reasons of stenosis included 5 calculi,2 normal,1 scar and 2 adenoma.There were 1 case of cholangitis and 4 cases of hyperamylasemia after operation.No procedure related death occurred.Conclusion Freehand DPCS using ordinary gastroscope or ultrathin gastroscope is feasible and safe,and may be clinically useful for diagnosis and therapy of unexplained choledocholithiasis and common bile duct stenosis.

A Case of Direct Peroral Cholangioscopy-Guided Intraductal Radiofrequency Ablation for Malignancy Biliary Obstruction via Choledochoduodenostomy Orifice / 대한췌담도학회지

BAlthough intraductal radiofrequency ablation (RFA) has been reported to be a feasible treatment of malignancy biliary obstruction in unresectable cholangiocarcinoma, endoscopic retrograde cholangiopancreatography (ERCP)-guided intraductal RFA has a disadvantage that cannot be directly visualize the biliary tract using the fluoroscopic image. On the other hand, direct peroral cholangioscopy-guided intraductal RFA is easy to insert catheter and apply treatment by visualizing the bile duct lesions. We present a case of direct peroral cholangioscopy-guided intraductal RFA without biliary stent in 67-year-old woman patient with cholangiocarcinoma for treatment of malignancy biliary obstruction. In the past, she underwent choledochoduodenostomy for intrahepatic stones. She underwent direct peroral cholangioscopy-guided intraductal RFA via choledochoduodenostomy orifice, and biliary patency was preserved for 90days without additional treatment such as biliary stent and severe complication. Direct peroral cholangioscopy-guided intraductal RFA is expected to be able to reduce the complications of the procedure by ensuring the bile duct lesions. Prospective studies with long term follow up are warranted.

Early Bile Duct Cancer Detected by Direct Peroral Cholangioscopy with Narrow-Band Imaging after Bile Duct Stone Removal

Cholangioscopy not only enables the direct visualization of the biliary tree, but also allows for forceps biopsy to diagnosis early cholangiocarcinoma. Recently, some reports have suggested the clinical usefulness of direct peroral cholangioscopy (POC) using an ultra-slim endoscope with a standard endoscopic unit by a single operator. Enhanced endoscopy, such as narrow band imaging (NBI), can be helpful for detecting early neoplasia in the gastrointestinal tract and is easily applicable during direct POC. A 63-year-old woman with acute cholangitis had persistent bile duct dilation on the left hepatic duct after common bile duct stone removal and clinical improvement. We performed direct POC with NBI using an ultra-slim upper endoscope to examine the strictured segment. NBI examination showed an irregular surface and polypoid structure with tumor vessels. Target biopsy under direct endoscopic visualization was performed, and adenocarcinoma was documented. The patient underwent an extended left hepatectomy, and the resected specimen showed early bile duct cancer confined to the ductal mucosa.