Direct transnasal cholangioscopy with standard ultra-slim endoscopes: new horizons for diagnostic and interventional cholangioscopy

Aims: Direct cholangioscopy using an ultra-slim endoscope is an attractive alternative to the conventional mother-baby endoscope system because it allows a single operator platform, high resolution image quality and advanced therapeutic interventions. However, biliary access is cumbersome and mostly affords previous placement of a guidewire by retrograde cholangiography.

Objective: To evaluate the feasibility of a novel one-step direct transnasal cholangioscopy (TNC) technique using an ultra-slim endoscope (EG 530 NP; Fujinon Inc., Saitama, Japan) with an intraductal balloon to maintain biliary access without previous placement of a guide-wire.

Design: Prospective, observational clinical feasibility study

Setting: Single tertiary referral center

Main Outcome Measurements: Overall procedure success rates and complications. A successful procedure was defined as one in which the endoscope was advanced into bifurcation or stenotic segment of the biliary system.

Patients and methods: 44 patients with biliary disease and previous sphincterotomy underwent 50 direct TNC procedures.

Results: TNC was successful in 39 out of 50 (78%) procedures (Table 1). In successfull cases the mean time from transnasal insertion to biliary access was 13,1±8,1 minutes. Mean total procedure time of TNC was 36±14,4 minutes. Endoscopic biopsies under direct visualization were performed for 16 intraductal lesions of unknown dignity and histological work-up showed 3 intraductal adenomas, 5 cholangiocarcinomas, 4 cases with inflammation and 8 cases with non-specific findings. Sixteen patients underwent therapeutic interventions including Argon plasma coagulation (n=5), laser lithotripsy (n=4) and stone extraction (n=7). Procedure-related cholangitis was observed in two cases.

Tab.1: Analysis of the maximum advancement of the ultra-s

Maximum insertion	Procedures N	Procedures %
Papilla of Vater (no cannulation of the CBD)	5	10
Distal common bile duct	4	8
Middle common bile duct	2	4
Hilum or site of intraductal stenosis	39	78
Total	50	100

Limitations: No comparison with conventional cholangioscopy

Abb.1: High resolution cholangioscopic image from ultra-s

Conclusions: One-step TNC with an ultra-slim endoscope is a single operator technique that allows for direct visual examination and therapeutic intervention of bile ducts in the majority of patients with biliary disease. It enables endoscopic interventions under direct high resolution visualization without the need to purchase dedicated endoscopic systems. However, further developments of accessories are necessary to improve the success rate