Spyglass, ¿es real y útil en nuestro medio? / Does the Spyglass Cholangioscope Exist in our Midst? And is it Useful?

A pesar de contar en la actualidad con duodenoscopios y equipos de fluoroscopia y radiología de gran calidad, en muchas ocasiones la visualización endoscópica directa del árbol biliar y pancreático es requerida para definir mejor el diagnóstico y tratamiento de la patología del paciente. La experiencia inicial con la colangioscopia peroral fue muy promisoria, sin embargo, el entusiasmo declinó rápidamente con la aparición de nuevas técnicas de imagenología, pero principalmente por la extrema fragilidad y los altos costos de los colangioscopios. La colangioscopia a pesar de que es considerada como una técnica emergente, en los últimos años y apoyándose en los grandes avances tecnológicos en materia de equipos endoscópicos, ha sufrido una serie de modificaciones gracias al desarrollo de instrumental más resistente y de menor diámetro, costo, entre otros factores; lo que ha permitido que sea cada día más utilizada, permitiendo posicionarse como una herramienta muy útil para el diagnóstico y tratamiento de diferentes patologías pancreáticas y biliares como colangiocarcinoma, litos gigantes, estenosis o pólipos de pequeño tamaño, entre otros. En el presente artículo se busca realizar una breve revisión sobre el tema y presentar los nuevos equipos y sus ventajas. También se pretende resaltar la gran utilidad del procedimiento en ciertos grupos de pacientes y su real aplicación en Colombia, donde hace más de un año se cuenta con la tecnología y los procedimientos se ha realizado con éxito.

Despite today’s high quality duodenoscopes, fluoroscopy equipment and x-ray equipment, a direct endoscopic view of the biliary tree and the pancreas is often required for the best diagnosis and treatment of a patient’s pathology. Initial experience with peroral cholangioscopy was very promising, but the enthusiasm for this technique quickly declined due to the extreme fragility and high cost of cholangioscopes and also because of the advent of new imaging techniques. As the result of recent technological advances in endoscopic equipment, cholangioscopy has undergone a number of changes that include development of stronger instruments that are smaller in diameter and which cost less than earlier versions. Consequently, despite the fact that his is still considered to be an emerging technique, peroral cholangioscopy is increasingly being used as a very useful tool for diagnosis and treatment of various pancreatic and biliary diseases including cholangiocarcinoma, giant calculi, stenoses and small polyps. This article briefly reviews the topic, introduces new equipment and the advantages thereof, and focuses on highlighting the usefulness of this method for certain groups of patients as it is actually being implemented in Colombia over the last year ago with success.

A Case of Intraductal Papillary Mucinous Neoplasm of the Pancreas with Pancreatoduodenal Fistula Diagnosed by Pancreatoscopy Using a Standard Upper Endoscope / 대한췌담도학회지

Intraductal papillary mucinous neoplasm of the pancreas (IPMN) is characterized by the production of mucin and marked dilatation of pancreatic duct. There are only several cases reports about fistula formation with adjacent organs in IPMN. A 61-year-old man was admitted due to jaundice and weight loss. CT scans showed that multiloculated cystic mass had replaced the body and tail of the pancreas. Interestingly, a fistula was found between cystic mass and duodenal bulb. With a diagnosis of malignant IPMN and pancreatoduodenal fistula, endoscopic forcep-biopsy was performed at the orifice of the fistula and pancreatic duct, through the fistula, under a fluoroscopic guidance. Pathologic examination showed only inflammatory cells. Direct peroral pancreatoscopy was performed through the pancreatoduodenal fistula using a standard upper endoscope with saline irrigation. Endoscopic forcep-biopsy was performed on the papillary tumor. Pathologic examination revealed intestinal type IPMN and radical total pancreatectomy was performed. Pathologic examination of the surgical specimen showed tubular adenocarcinoma arising from 15 cm sized intestinal type IPMN.

Biliary Tract & Pancreas; Usefulness of Intraductal Endoscopy for Pancreaticobiliary Disease / 대한소화기내시경학회지

BACKGROUND/AIMS: The aim of this study was to evaluate the usefulness of intraductal endoscopy in pancreaticobiliary tract disease by means of percutaneous cholangioscopy(PCS), peroral cholangioscopy(POCS) and peroral pancteatoscopy(POPS). METHODS: PCS was performed in 33 patients, including 24 patients with biliary tract stones, and 8 patients with malignant biliary tract disease, and one with villous adenoma of common bile duct(CBD), POCS was performed in 5 patients, including two with cholangiocarcinoma, two with icteric hepatoma and one with benign stenosis of bile duct. POPS performed in 6 patients, ineluding 3 patients with chronic pancreatitis, two with pancreatic cancer and one with mucinous ductal ectasia. RESULTS: 1. Complete removal of the stones was achieved in 22 of 24 patie~nts(91.7%). 2. Accuracy rate of forceps biopsy in PCS was achieved 13 fo 14 patients(92.9%). 3. Success rate of therapeutic PCS was 100%. 4. Accuracy rate of forceps biopsy in POCS was achieved 3 of 5 patients(60%). 5. Diagnostic gain of POPS was achieved 5 of 6 patients(83.3%). 6. There was no serious complications with only mild complications in 3 patients, including mild bleeding in 2 patients and cholangitis in only one. CONCLUSIONS: Intraductal endoscopy of biliary tract, including PCS and POCS were useful diagnostic and therapeutic methods with advantages of direct visualization of intraductal disease and POPS using ultrathin pancreatoscope could provide direct assessment of the pancreatic duct.

Two Cases of Mucinous Ductal Ectasia of the Pancreas which Showed Characteristic Pancreatoscopic Findings / 대한소화기내시경학회지

We report two cases of mucinous ductal ectasia of the pancreas which showed characteristic pancreatoscopic findings. They also showed characteristic duodenoscopic findings such as patulous ampullary orifice and mucus leakage from the papilla, and underlying pathology was hyperplasia in one case and adenoma in the other case, The insertions of pancreatoscope into the main pancreatic duct were easy without previous sphincterotomy and whitish frog egg-like mucosa was noted in one case and finger-like papillary projection was noted in the other case.

Clinical Usefulness of Ultrathin - caliber Pancreatoscopy on Diagnosis of Various Pancreatic Diaeases / 대한소화기내시경학회지

Although ERCP has been widely used to diagnose and occasionally treat chronic pancreatitis, it is not always easy to differentiate between malignancy and benign disease by ERCP alone. So peroral pancreatoscopy(PPS) using mother and baby type scopes was developed and several types of peroral pancreatoscopes with various diameters have been used at several institutes. To assess the clinical usefulness of ultrathin-caliber pancreatoscopy on diagnosis of various pancreatic diseases, we performed peroral pancreatoscopy with PF 8P (Olympus, external diameter: 0.8 mm) in 12 cases(6 cases of chronic pancreatitis, 5 cases of pancreatic tumor, and 1 case of mucinous ductal ectasia) of pancreatic diseases. The pancreatoscope was successfully inserted into main pancreatic duct in 11 cases and permitted satisfactory endoscopic observation. The endoscopic findings of chronic pancreatitis were smooth stenosis, protein plug, and stones in pancreatic duct. Peroral pancreatoscopic findings of pancreatic cancer were characteristically seen as stenosis with irregular mucosal protrusion. In the mucin-producing tumor cases, the lesions were generally not clearly visualized due to the presence of copious amount of mucin. We conclude that pancreatoscopy is a valuable alternative or supplementary procedure to diagnostic imaging method of arriving at a more definite diagnosis in difficult cases. But several limitations, such as poor visual field, absence of biopsy channel and controllable tip, and poor durability of endoscope will be overcomed to serve as essential diagnosic tool for pancratic diseases.

One Case of Mucinous Ductal Ectasia Diagnosed with Ultrathin Pancreatoscopy / 대한소화기내시경학회지

Mucinous ductal ectasia(MDE) is a newly described entity of mucinous neoplasm of pancreas with characteristic endoscopic and pancreatographic findings. It is charaeterized by a patulous duodenal papilla extruding mucus and a pancreatogram showing dilatation with amorphous filling defects, communication of the mass with the pancreatic duct. MDE is intraductal lesion consisting of dilated "cystified" ducts lined by mucin-producing columnar cells. The lesion is usually located in the head or uncinate process. When the radiographic appearance of the ERCP cannot provide sufficient information for definite diagnosis, additional endoscopic visualization is desirable. With the advent of pancreatoscopy, an endoscopic procedure is now available that has proven to enhance diagnostic accuracy. The 0.8-mm ultrathin pancreatoscope allows macroscopic diagnosis under direct vision. Endoscopic sphincterotomy is not required, and insertion into the pancreatic duct is feasible in most cases with the aid of guidewires. Major indications are unclear filling defects on ERCP, strictures of uncertain origin, and duct cut-offs. A limitation of this procedure are the lack of angulation, insufficient illumination, fragility of endoscopic equipment, and nonspecific findings. In addition, biopsy while directly viewing the lesion is impossible at present. We experienced one case of MDE who presented with the symptom of weight loss. Ultrathin pancreatoscopy was useful for the direct visualization af pancreatic duct in the differential diagnosis of filling defects of main pancreatic duct.