Cholangioscopy

• Allows direct and optical contrast based (NBI) visualization of the biliary tree

• Particularly useful for assessing strictures and treating large stones and confirming their complete removal

• Role in assessing post-OLT biliary strictures???

• Can perform biopsies, laser or electrohydraulic lithotripsy, and even ablation

Cholangioscopy

• First done in 1974 (percutaneously)

• Mother-daughter scope – Fiber Optic (1976)– Video

• Probe based cholangioscopy (2005)

• Direct endoscope based cholangioscopy (1977)

Comparison of Cholangioscopy Options

Fiber Optic Baby Scope

Electronic Video Baby

Scope

Spyglass Probe

System

Ultraslim “Per oral” Electronic

Gastroscope

Number of operators

2 2 1 1

Tip Deflection 2-way (U-D) 2-way(U-D) 4-way(U-D, L-R)

4 way(U-D, L-R)

Separate Irrigation Channel

No No Yes No

Exchangeable optics

No No Yes No

Image Quality Moderate Good-excellent Moderate Excellent

Fragility Yes Yes Somewhat No

Monga et al, J Interv Gastro 1:2, 2011, p. 70-77

Mother Daughter Cholangioscopy

• Requires 2 operators• Fragile “Daughter”

endoscope• Only 1 degree of

freedom• Small working channel• Some versions without

working channels or are fiber optic

Probe-based Cholangioscopy

Probe-based Imaging: Biliary Stricture in PSC

Courtesy A. Sliva MD, Univ. of Pittsburgh

“Spyglass” Data

• Single center study in India• 36 pts (22 M) with

indeterminate biliary strictures• All received cholangioscopy

with directed biopsies• 22 patients with cancer

– Cholangioscopy + : 21/22 (95%)

• 14 patients with benign lesions– Cholangioscopy - : 11/14

(79%)• Overall accuracy: 89% (32/36)

Ramchandani et al, GIE, 2011, 74:3, p. 511-519.

77% (23/30) yield in patients with negative ERCP with brushingsand EUS-FNA and no mass on imaging – Siddiqui et al CGH, 2012

Per Oral Cholangioscopy• Start with ERCP

• Perform sphincterotomy• Use ultra-stiff wire• May require anchoring

balloon in bile ducts• Advantages

– Better optics

– Larger working channel

• May benefit from CO2 rather than water insufflation– Better visualization– Less risk of air embolism

Duodenal View

Intra-CBD View

Per Oral Cholangioscopy

Per Oral Cholangioscopy with NBI: Videos

CLE Devices: Endoscope & Probe-Based

CellVizio

Pentax

Resolution: 1, 3.5 µmFOV: 240 µm, 600 µmDepth of observation: 55-65 µm, 70-130 µmComp. Op. Channel: 2.8 mm

Multiple CLE probes available

CLE of the Normal Biliary Tree

CLE of Cholangiocarcinoma

CLE Videos from the Biliary Tree

Normal Cancer

Study Specifics• Prospective observational multicenter

registry

• 5 centers, 102 patients screened

• Indications for ERCP– 70% had indeterminate PBD stricture

– 17% with mass on imaging– 5% with jaundice– 5% with prior nondiagnostic ERCP

– 3% with dilated CBD or PD

– 1% PSC

pCLE to Evaluate Indeterminate Bile Duct Strictures

Of note, pCLE had 16 false positives Slivka, ASGE Plenary, DDW 2011