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Cholangioscopy

Cholangioscopy. Deepak Agrawal MD University Texas Southwestern Parkland Hospital. No conflicts of interest. Normal Biliary anatomy. Right hepatic duct. Left hepatic duct. Imaging of bile ducts. Cholangio graphy. Cholangio scopy. - Direct visualization. - Radiographic visualization.

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Cholangioscopy

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  1. Cholangioscopy • Deepak Agrawal MD • University Texas Southwestern • Parkland Hospital

  2. No conflicts of interest

  3. Normal Biliary anatomy Right hepatic duct Left hepatic duct

  4. Imaging of bile ducts Cholangiography Cholangioscopy - Direct visualization • - Radiographic visualization

  5. Imaging of bile ducts Cholangiography Cholangioscopy < --- > Colonoscopy • < --- > Barium enema

  6. Imaging of bile ducts Cholangiography Cholangioscopy

  7. Cholangiography

  8. Stones Stricture

  9. Advantages • Simple • No additional endoscope • Does the job in most cases

  10. Disadvantages • Large stones (requiring Electrohydraulic lithotripsy) ERCP methods of removing stones

  11. Disadvantages • Large stones (requiring Electrohydraulic lithotripsy)

  12. Disadvantages • Large stones (requiring Electrohydraulic lithotripsy) • Characterizing strictures

  13. Bile duct strictures: benign or malignant Clin Gastroenterol Hepatol 2006; 4:219-225 Gastrointestinal Endoscopy 62: 374-382, 2005

  14. Bile duct strictures: brush cytology Sensitivity 30 – 40 %

  15. Bile duct strictures: fluoro guided biopsies Sensitivity 37 – 65 %

  16. Its important to visualize the stricture • Cholangioscopy Cholangio = bile duct Scopy= to see

  17. Bile duct strictures: benign or malignant

  18. Bile duct strictures: benign or malignant Benign Malignant Benign

  19. Cholangioscopy Two types 1. Percutaneous 2. Peroral

  20. Percutaneous cholangioscopy T-tube Transhepatic

  21. Percutaneous cholangioscopy Limitations - Intrahepatics should be dilated - Potential for injury to vessels - Have to wait for the tract to mature - Uncomfortable for the patient

  22. Peroral Cholangioscopy Techniques 1. Mother daughter endoscope 2. Direct cholangioscopy

  23. Peroral Cholangioscopy Techniques 1. Mother daughter endoscope • Two operator system • Single operator system (Spyglass)

  24. Peroral cholangioscopy Two operator system Mother scope

  25. Peroral cholangioscopy Two operator system Daughter scope Mother scope

  26. Peroral Cholangioscopy Two operator system Daughter scope Mother scope

  27. Peroral Cholangioscopy Two operator system Daughter scope Mother scope Lithotripsy probe

  28. Peroral Cholangioscopy Two operator system • Requires two endoscopists • Set up two towers • Time consuming • Small caliber of the working channel Limitations

  29. Peroral Cholangioscopy Two operator system • Fiberoptic “baby” endoscope Limitations - Fragile - high repair costs - Poor picture quality

  30. Peroral Cholangioscopy Two operator system • Intraductal lithotripsy of large bile duct stones Main Use

  31. Peroral Cholangioscopy Single operator system “Spyglass”

  32. Peroral Cholangioscopy Single operator system “Spyglass” 4 lumen catheter Optical probe

  33. Peroral Cholangioscopy Single operator system “Spyglass” 4 lumen catheter biopsy forceps optical probe

  34. Peroral Cholangioscopy Single operator system “Spyglass” EHL of large bile duct stone

  35. Peroral Cholangioscopy Single operator system “Spyglass” Benign biliary stricture

  36. Peroral Cholangioscopy Single operator system “Spyglass” biopsy forceps Malignant biliary stricture

  37. Peroral Cholangioscopy Single operator system “Spyglass” • Easier to perform • Better images • Larger biopsies • Better suction and irrigation Advantages

  38. Peroral Cholangioscopy Single operator system “Spyglass” • Images still not great • Expensive • Limited accessories • No narrow band imaging Limitations

  39. Peroral Cholangioscopy Two types 1. Mother-daughter - Two operator system - Single operator system 2. Direct cholangioscopy

  40. Direct cholangioscopy

  41. Regular scope Ultrathin scope 4.9 9mm 5.5

  42. Peroral cholangioscopy Technical problems Forward viewing Side viewing Bile duct endoscope duodenum

  43. Peroral cholangioscopy • Wire guided • Balloon assisted

  44. Peroral cholangioscopy Wire guided ERCPscope Ultrathin endoscope over wire Wire in bile duct

  45. Video of wire guided peroral cholangioscopy

  46. Direct cholangioscopy Recurrent bile duct stones

  47. Peroral cholangioscopy Balloon assisted

  48. Peroral cholangioscopy Balloon assisted Ultrathin endoscope over balloon catheter 4Fr balloon over wire ERCP scope removed Wire in bile duct

  49. Balloon assisted peroral cholangioscopy 4 Fr Stiffening wire Detachable proximal end

  50. “Spy glass” Direct cholangioscopy New technique and limited data • Has been around longer

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