Peroral cholangioscopy for the evaluation of bile duct stricture in hepatocellular carcinoma on a preoperative examination / Journal of Rural Medicine

Objective: Bile duct tumor thrombosis in hepatocellular carcinoma (HCC) is a relatively rare event with a poor prognosis. Furthermore, bile duct tumor thrombus in HCC may be misdiagnosed when only imaging modalities are used. The efficiency of peroral cholangioscopy (POCS) in evaluating bile duct lesions has been reported.Patients: We present three cases of HCC with bile duct strictures in which POCS was performed as a preoperative evaluation.Results: In these three cases, diagnosing whether the lesion was a bile duct tumor thrombus on CT and endoscopic retrograde cholangiopancreatography was difficult. We performed POCS in three cases and were able to diagnose the presence of bile duct tumor thrombus of HCC, including differentiation from extrinsic compression of the bile duct.Conclusion: POCS for HCC with bile duct features is useful for the preoperative diagnosis of bile duct tumor thrombus, especially in cases where the surgical procedure depends on the presence of bile duct tumor thrombus.

Evaluation of a China-made disposable peroral cholangioscope in an animal experiment / 中华消化内镜杂志

Objective:To evaluate the efficacy and safety of a China-made disposable peroral cholangioscope in animal cholangioscopy.Methods:Six healthy Bama minipigs underwent the domestic disposable peroral cholangioscopy after anesthesia. The operation performance and image quality of the products were evaluated, and intraoperative and postoperative complications were recorded.Results:All 6 animals received the domestic disposable peroral cholangioscopy. The cholangioscope showed good operating performance and could smoothly enter the biliary tract through the duodenoscope. The water injection, suction and instrument channels were unobstructed. The cholangioscopic image was clear, the color resolution was good, and there was no image distortion. The lumen and the mucosal surface could be accurately assessed. During the examination, there was no operative injuries such as bleeding, perforation, or adverse events such as respiratory depression or cardiac arrest. All pigs survived the operation with no adverse reaction.Conclusion:The China-made disposable peroral cholangioscope is safe, with good operability and high-quality image.

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.

Advanced Imaging Technology in Biliary Tract Diseases:Narrow-Band Imaging of the Bile Duct

Newly introduced direct peroral cholangioscopy and the development of video choledochoscopes have enabled more defined observation of bile duct mucosal lesions with clearer images. Narrow-band imaging (NBI) is a unique endoscopic imaging technology that provides enhanced endoscopic images of surface mucosal structures and its superficial microvessels. Advanced cholangioscopy and NBI are expected to be useful for precise evaluation and correct diagnosis of biliary tract diseases. However, the diagnostic value of advanced bile duct imaging with cholangioscopy requires further evaluation.

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.

A Case of Suspected Intrahepatic Bile Duct Perforation after Direct Peroral Cholangioscopy / 대한췌담도학회지

Direct peroral cholangioscopy (POC) which permits direct visualization of the biliary tree has recently gained widespread clinical use for diagnosis and treatment of various pancreatobiliary diseases. But, there is currently little reliable data on evaluating the complications of POC. POC is associated with complications such as pancreatitis, cholangitis, hemorrhage, rarely air embolism, and ductal perforation. The incidence of complication during POC is 2.9-12%. However, pneumoperitoneum due to intrahepatic bile duct perforation after POC has not yet been reported in Korea. We report a case of pneumoperitoneum after POC which has been successfully managed with endoscopic nasobiliary drainage and antibiotics.

The Role of Direct Peroral Cholangioscopy Using an Ultraslim Endoscope for Biliary Lesions: Indications, Limitations, and Complications

Advantages of direct peroral cholangioscopy (POC) using an ultraslim endoscope include use of conventional endoscopy equipment, operation by a single endoscopist, and superior image quality of the biliary tree with easy application of enhanced endoscopy and a large working channel. The major diagnostic indications of this system are an evaluation of biliary strictures, filling defects, or unclear findings on cholangiogram or other imaging studies. Therapeutic application using a direct POC system can be broadened by a larger working channel. However, direct POC is difficult to apply in patients with a narrow diameter bile duct, far distal common bile duct lesion, or failed anchoring of the scope with accessories. An air embolism is a rare complication of direct POC but can be a fatal problem. Cholangitis can also occur during or after the procedure. Use of a CO2 system instead of room air during the POC procedure and administration of antibiotics before and after the procedure are strongly recommended. Continuous development of specialized endoscopes and accessories is expected to facilitate the diagnostic and therapeutic roles of direct POC.

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.

Two Cases of Direct Peroral Cholangioscopy Using an Ultra-Slim Upper Endoscope after Endoscopic correction of Endoscopic after Stone Removal / 대한소화기내시경학회지

Peroral cholagioscopy is a good procedure that permits direct visualization of the biliary tree and target biopsies of lesions. However, peroral cholangioscopy with a mother-baby system requires two experienced endoscopists, and the procedure remains time consuming and expensive and the apparatus is easily broken. Therefore, an easier technique to get direct visual examination of the biliary tree is needed. Direct peroral cholangioscopy (direct POC) with using an ultra-slim upper endoscope was performed in two patients after endoscopic stone removal for diagnosing their biliary stricture. One patient had wire-guided direct POC performed and the patient was diagnosed benign biliary stricture on the proximal CBD after forcep biopsy. Another patient had overtube-assisted direct POC performed and that patient was found to have a polypoid lesion at the bifurcation. Future advances in endoscope development, as well as specifically designed accessories, are expected to increase its clinical utility.

Clinical Application of Peroral Cholangioscopy in Biliary Diseases / 대한소화기내시경학회지

BACKGROUND: Peroral cholangioscopy (PCS) was usually conducted for a differential diagnosis in cases which were difficult to diagnose on a routine endoscopic retrograde cholangiogram (ERC) or during fragmentation of a large bile duct stone with electrohydraulic lithotripsy. This study was conducted to evaluate the clinical utility of a PCS in biliary diseases. METHOD: We retrospectively reviewed the clinical records of 31 patients in whom a PCS was performed to evaluate various biliary diseases from July 1991 to Aug. 1996. RESULT: A peroral cholangioscope was successfully inserted into the bile duct in 90.3% (28/31) of the patients. The underlying diseases included bile duct stones (11 cases), bile duct cancer (9 cases), benign bile duct strictures (2 cases), benign bile duct turnors (2 cases), biliary cystadenocarcinoma (2 cases), emboli of the HCC in the bile duct(1 case), and common bile duct polyposis (1 case). Most PCSs were performed for the differential diagnosis between benign and malignant bile duct strictures or obstructions (14 cases) and fragmentation of large bile duct stone with electrohydraulic lithotripsy (10 cases). Overall, the success rate was 78.6% (22/28) in achieving the purpose 88.9% (16/18) in diagnostic aim and 60.0% (6/10) in therapeutic aim. Complications from the PCS occurred in 4 cases (14.3%). Cholangitis and acute pancreatitis was found in 1 case and asymptomatic hyperamylasemia were discovered in 2 cases. CONCLUSION: PCS plays a major role in confirming difficult cases to diagnose using on ERC and fragment to remove large cornmon bile duct stones.

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.

Hepatocellular Carcinoma with Obstructive Jaundice Confirmed by Percutaneous Transhepatic Cholangioscopy (PTCS) and Peroral Cholangioscopy (POCS) / 대한소화기내시경학회지

Jaundice associated with hepatocellular carcinoma usually occurs in the later stages due to the advanced underlying liver cirrhosis or tumor infiltration of the liver parenchyme. In the rare cases, obstructive jaundice presents as the ininitial manifestation of hepatocellular carcinoma. The possible mechanisms of bile duct obstruction associated with hepatocellular carcinoma include extrinsic compression of bile duct by extensive tumor infiltration of the liver or enlarged lymph node, direct tumor invasion of the biliary duct system, and bile duct obstruction by tumor thrombus, necrotic debris, or blood clots. We experienced three cases with hepatocellular carcinoma in whom obstructive jaundice were caused by intraductal involvement of the tumor, which were confirmed by percutaneous transhepatic cholangioscopy(PTCS) and peroral cholangioscopy(POCS). PTCS and POCS finding showed multiple, irreguarly shaped, yellowish soft tissue(chicken fat) and blood clots and, round protruded mass in the ble duct. Biopsy specimens revealed pathologically hepatocelluar carcinoma.

Application of Peroral Cholangioscopy in Biliary Diseases / 대한소화기내시경학회지

Retrograde transpapillary cholangioscopy can be safely performed by use of a mother-baby-scope system after endoscopic sphincterotomy. Improved endoscopes are now available and may lead to a better acceptance of this technique. Cholangioscopy is complementary to cholangiography for differential diagnosis of various types of bile duct lesions. From march 1992 to September 1994, we performed 15 cases of peroral cholangioscopy for evaluation of bile duct lesions. Indications of peroral cholangioscopy were 6 cases of benign biliary diseases and 9 cases of malignant biliary diseases. In benign diseases, two cases of extrahepatic bile duct stones, 1 case of intrahepatic duct stone with stricture, 2 cases of benign elevated lesions of bile duct and 1 case of occluded expandable metallic stent were involved. In malignant diseases, 7 cases of primary bile duct cancer, 2 cases of hepatocellular carcinoma with bile duct invasion were involved. By use of peroral cholangioscopy with biopsy, differential diagnosis of bile duct lesion was possible. As a complication, severe abdominal pain and hypotension was developed in one case during the procedure and in another case, cholangitis was developed after the procedure. In conclusion, peroral cholangioscopy is a safe and useful procedure in various types of biliary diseases especially in the differential diagnosis of malignancy.