Nonsurgical cholangioscopy: The present state

H Neuhaus; M Classen

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SPECIAL ARTICLE

Year : 1995 | Volume : 1 | Issue : 2 | Page : 75-80

Nonsurgical cholangioscopy: The present state

H Neuhaus, M Classen
From The II. Medizinische Klinik and Poliklinik, Klinikumrechts der Isar der Technischen Universitat Munchen. Prof. Dr med. Meinhard Classen II. Med. Klinik der TU Munchen, Klinikum rechts der Isar. Ismaninger Sir. 22, D - 81675 Munchen, Germany

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How to cite this article:
Neuhaus H, Classen M. Nonsurgical cholangioscopy: The present state. Saudi J Gastroenterol 1995;1:75-80

How to cite this URL:
Neuhaus H, Classen M. Nonsurgical cholangioscopy: The present state. Saudi J Gastroenterol [serial online] 1995 [cited 2020 Dec 3];1:75-80. Available from: https://www.saudijgastro.com/text.asp?1995/1/2/75/34044

Introduction

Ultrasonography, CT-scan, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) are well-established diagnostic procedures for biliary tract diseases. These indirect imaging methods clearly demonstrate bile duct lesions but they may fail in differentiation of strictures or polyps. About 15 years ago, peroral and percutaneous cholangioscopy were introduced as complementary methods which allow a direct visualization of the biliary system with target biopsies of pathological findings ^{[1],[2],[3],[4]} . Since then, endoscopes and accessorial equipment have been continuously improved and facilitate not only a less invasive diagnostic approach but also offer a variety of therapeutic interventions for difficult stenoses or bile duct stones. These procedures are complementary to intraoperative or postoperative T-tube tract choledochoscopy developed for residual stones.

Technique

Peroral cholangioscopy (POCS)

Retrograde transpapillary cholangioscopy can be safely achieved by the use of a mother-baby scope after endoscopic sphincterotomy (EST). The technique requires an adequate approach to the papilla. The procedure should be carried out by two skillful endoscopists. The conventional baby- cholangioscope has an outer diameter of 4.5 mm and 1.7 mm instrumentation channel so that target biopsies or introduction of guide-wires or probes for lithotripsy are possible. A recentlydeveloped 3.4 mm miniscope (prototype CHF B 34; Olympus, Tokyo) can be inserted through a conventional therapeutic duodenoscope so that a change to the stiffer motherscope is not required ^[5] . This sophisticated instrument can be angulated in two directions and has a 1.2 mm channel. Intracorporeal lithotripsy using laser systems or electrohydraulic generators with probes < 3 FG is therefore possible. In contrast to electrohydraulic lithotripsy (EHL) the bile ducts can be continuously flushed beside the ultra-thin laser fiber so that a nasobiliary probe is not needed. The cholangioscopes for the peroral approach are fragile and must be carefully handled.

Percutaneous cholangioscopy (PTCS)

PTCS is usually performed according to the techniques initially described by Takada and Nimura ^[3],[4] . Following PTC, a drainage catheter is inserted into the bile ducts through the right lateral chest wall or the anterior abdominal wall. The cutaneobiliary fistula is sequentially dilated every second day by replacing catheters of progressively increasing diameters. Cholangioscopy can be carried out without using sheaths at the earliest 7 to 8 days after the initial procedure through a 14 to 18 FG sinus tract ^[6],[7] . The smallest steerable cholangioscopes which provide an instrumentation channel of 1.0-1.2 mm have an outer diameter of 3.1-3.7 mm ^[5],[8] . These instruments are suitable for target brush cytology, biopsy, electrocoagulation and stone extraction with baskets. Lithotripsy can be carried out mechanically or by electrohydraulic or laser systems. After establishment of the sinus tract, the percutaneous endoscopic approach is much easier than the peroral access due to the better maneuverability of the directly inserted short cholangioscopes. The sinus tract can be preserved by leaving plastic prosthesis in situ which can be closed with a stop-cock at the skin level ^[7],[9] . After definitive removal of these drainage catheters, the fistula closes spontaneously within 1-2 days.

Results

Diagnostic Indications

In contrast to percutaneous cholangioscopy only a few series with a limited number of patients on the peroral approach for diagnostic indications have been reported ^[10] . This may be due to technical difficulties or the limited availability of the equipment. In particular, the efficacy of biopsy studies with 3 FG forceps for 3.4-3.7 mm miniscopes is yet to be determined. According to a recent study in patients with malignant or benign biliary stenoses, peroral cholangioscopy with a 4.5 mm babyscope yielded additional diagnostic information in 20 to 27 cases ^[11] . Diagnostic improvement is expected from recently developed electronic (video) cholangioscopes which provide a higher resolution and more brightness of the image.

In contrast to the peroral route, PTCS achieves excellent visualization of bile duct lesions even above ductal strictures. Although Nimura never observed pathological vessels in benign lesions, target biopsies are frequently required to differentiate abnormal findings ^[6] . The sensitivity for malignant stenoses is 76-81% ^[7],[12] [Figure - 1]. In a large series of PTCS, correct results for bile duct carcinoma were obtained in 101 of 111 patients (sensitivity, 96%) ^[12] . Therefore PTCS is obviously the most reliable nonsurgical diagnostic procedure for bile duct cancer which is difficult to detect with noninvasive methods. Apart from histological studies, diagnostic PTCS together with superselective cholangiography can evaluate the intrahepatic extension of biliary tumors. Nimura, one of the pioneers in this field, strongly advocates routine percutaneous cholangioscopy for preoperative staging of proximal bile duct carcinoma ^[12] . The determination of the variations of each segmental duct and the tumor-involved hepatic segments allows a precisely-designed segmentectomy which can minimize the risk of postoperative hepatic failure. This strategy may explain the excellent surgical results for bile duct carcinoma of the same group. In 69.7% of 55 patients, curative resection was achieved with a 6.4 % operative mortality rate and a 37.8% fiveyear survival rate ^[13] .

Diagnosis of biliary parasites can be usually achieved by ERCP. Endoscopic papillotomy allows removal of echinococcus cysts obstructing the biliary tree ^[14] . In selected cases, cholangioscopy can be used as a complementary procedure for detection of minor lesions or intrahepatic findings not amenable to ERCP. In addition, this method is helpful for differentiation of postoperative strictures or recurrence of parasites after biliary surgery for treatment of E. multilocularis [Figure - 2].

Therapeutic Indications

Intracorporeal lithotripsy of bile duct stones not amenable to ERCP and mechanical lithotripsy is the most important therapeutic indication for peroral cholangioscopy (POCS). This technique provides for electrohydraulic lithotripsy and conventional laser lithotripsy since delivery of pulses to the bile duct wall may result in bleeding and perforation. In contrast to extracorporeal shockwave lithotripsy, POCS and intracorporeal stone disintegration usually achieve complete bile duct clearance within a single treatment session. In a recent trial, peroral cholangioscopic elecltrohydraulic lithotripsy succeeded in 64 of 65 patients ^[15] . Laser lithotripsy seems to be comparably effective but more time consuming [Figure - 3]. On the other hand, the induced fragments are much smaller and the procedure can be carried out with miniscopes without need for the motherscope ^[5],[16] .

PTCS and intracorporeal lithotripsy of difficult bile duct stones offer an alternative to surgery when less invasive transpapillary maneuvers fail or prove to be impossible due to an inaccessible papilla or large stones above a biliary stricture. Depending on the size of the cholangioscopes extrahepatic as well as intrahepatic stones can be approached and disintegrated by electrohydraulic lithotripsy or laser under excellent direct visual control. The fragments can be easily flushed into the small bowel through the papilla or a biliodigestive anastomosis. According to two recent trials, percutaneous cholangioscopic electrohydraulic lithotripsy and laser lithotripsy seem to be comparably effective with success rates of 93% and 96%, respectively ^[16],[17] .

A new "smart" laser provides an automatic stone recognition system which allows lithotripsy even under a limited direct visual control or under fluoroscopy ^[18] . This flashlamp excited rhodamine 6G laser has a wave length of 594 m (Telemit Electronic, Munchen, Germany). The system provides an automatic cut-out upon tissue contact. The laser energy is transmitted via a 200 µm flexible quartz fiber. The laser light which is backscattered by a surface in the first hundreds of nanoseconds of the pulse is conducted back through the fiber, decoupled by a beam splitter and analyzed. Previous studies demonstrated that tissue and ureter stones can be differentiated using this method. If, therefore, the intensity of the reflected laser beam is below a threshold value which indicates that the fiber is not in contact with a concrement, the pulse is immediately interrupted with the aid of a polarizer by rotating the plane of polarization by 90^° . Up to this moment, less than 10% of the total power of the laser pulse has been emitted and tissue damage is thus safely avoided. First clinical results of lithotripsy under fluoroscopy or cholangioscopy with miniscopes are promising ^[19],[20] .

Complications

Peroral cholangioscopy is very safe after EPT provided that electrohydraulic lithotripsy is not performed under a limited visual control. The risks of percutaneous cholangioscopy are predominately related to the placement of the transhepatic catheter and subsequent dilatation procedures ^[7] . The creation of a firm sinus tract is obviously safer than the establishment of a large-bore cutaneobiliary fistula within a single session ^[15]. In the majority of the patients, measures for drainage are required for therapeutic reasons so that the complications cannot be related strictly to endoscopy and are rarely mentioned in reports on cholangioscopy.

Conclusions

Peroral cholangioscopy is still a sophisticated method for differential diagnosis of bile duct lesions or treatment of difficult stones. Further improvement of the endoscope system and the accessory equipment is desirable since the transpapillary approach promises a rapid and safe visualization of the biliary tree.

Percutaneous transhepatic cholangioscopy yields important diagnostic information including histological examinations in patients with undetermined cholangiographic findings. Due to an exact mapping of the intraductal extension of malignant lesions cholangioscopy can improve the preoperative staging of biliary tumors. Percutaneous cholangioscopic lithotripsy offers a highly effective and safe alternative to surgery in patients with difficult extrahepatic and intrahepatic ductal stones which are not amenable to routine endoscopy. In contrast to electrohydraulic lithotripsy, a new laser with automatic stone recognition does not require a precise direct visual control for stone targeting and is therefore appropriate for ultrathin endoscopes or for fluoroscopic targeting.

References

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