Single operator choledochoscopy and its role in daily endoscopy routine

Different diagnostic procedures exist for the detection of bile duct lesions in clinical practice.However,neither retrograde contrast imaging of the bile duct endoscopic retrograde cholangiopancreatogram nor other imaging procedures allow a safe diagnosis of the lesions.Therefore choledochoscopy may be a useful diagnostic procedure in macroscopic assessing lesions of the bile duct.Even if the diagnostic sensitivity and specificity is not sufficient,first studies suggest an enhanced diagnostic accuracy for choledochoscopy.Since the progress of choledochoscopy has started in the 1970 different improvements were achieved.Meanwhile,the examination can be performed by an examiner and samples can be taken.Image and Resolution quality has improved over the past years,also.The SpyGlass system is a technically advanced cholangioscopic device to provide endoscopic diagnosis in case of inconclusive bile duct findings.Further more,two more lumina allow specific biopsy forceps and optical fibers for electrohydraulic or laser lithotripsy.The most frequent useful insert of SpyGlass in clinical practice are in complex gallstones and bile duct lesions of unclear dignity.

Choledochoscopy:An update

Choledochoscopy,or cholangioscopy,is an endoscopic procedure for direct visualization within the biliary tract for diagnostic or therapeutic purposes.Since its conception in 1879,many variations and improvements are made to ensure relevance in diagnosing and managing a range of intrahepatic and extrahepatic biliary pathologies.This ranges from improved visual impression and optical guided biopsies of indeterminate biliary strictures and clinically indistinguishable pathologies to therapeutic uses in stone fragmentation and other ablative therapies.Furthermore,with the evolving understanding of biliary disorders,there are significant innovative ideas and techniques to fill this void,such as nuanced instances of biliary stenting and retrieving migrated ductal stents.With this in mind,we present a review of the current advancements in choledochoscopy with new supporting evidence that further delineates the role of choledochoscopy in various diagnostic and therapeutic interventions,complications,limitations and put forth areas for further study.

Effect of endoscopic retrograde cholangiopancreatography combined with laparoscopy and choledochoscopy on the treatment of Mirizzi syndrome

Background Mirizzi syndrome is often difficult to diagnose before surgery, and is often accompanied by extensive adhesions in the cystohepatic （Calot＇s） triangle and the difficulty of separating tissue can lead to bile duct injury and other intraoperative and postoperative complications. The aim of this study is to investigate minimally invasive means of treating different types of Mirizzi syndrome. Methods Fifty-four patients diagnosed with Mirizzi syndrome were enrolled between July 2004 and May 2012. The diagnosis was further refined according to the Csendes classification. Twenty-seven patients were treated with a combination of endoscopic retrograde cholangiopancreatography （ERCP）, laparoscopy, and choledochoscopy （tripartite approach group）; type I in 16 cases, type II five cases, and type III in six cases. Twenty-seven patients were treated with laparotomy （routine approach group）; type I in 19 cases, type II in six cases, and type III in two cases. The operation time, blood loss during operation, initiation of intake time of food, postoperative complications, and hospital stays were compared between two groups. Results All patients were successfully cured in surgical operation. The operation time was （49.7±27.5） minutes, blood loss during operation was （21.1±15.9） ml, initiation of intake time of food was （6.3±2.7） hours, postoperative complications were with two cases （7%, 2/27）, and hospital stay was （6.7±1.8） days in the tripartite approach group. In the routine approach group, the operation time was （85.1±20.3） minutes, blood loss during operation was （150.3±20.5） ml, initiation of intake time of food was （36.6±10.3） hours, postoperative complications were with three cases （11%, 3/27）, and hospital stay was （10.9±3.4） days. Except for postoperative complications, there were significant differences in the operation time, blood loss during operation, initiation of intake time of food, and hospital stays between two groups （P 〈0.05）. Conclusions ERCP combined with laparoscopy and choledochoscopy is a safe and effective means of treating Mirizzi syndrome. The approach is minimally invasive and patients recover quickly requiring only brief hospitalization.

Intraductal biliary and pancreatic endoscopy: An expanding scope of possibility

Intraductal endoscopy describes the use of an endoscope to directly visualize the biliary and pancreatic ducts. For many years, technological challenges have made performing these procedures difficult. The "mother-baby" system and other various miniscopes have been developed, but routine use has been hampered due to complex setup, scope fragility and the time consuming, technically demanding nature of the procedure. Recently, the SpyGlass peroral cholangiopancreatoscopy system has shown early success at providing diagnostic information and therapeutic options. The clinical utility of intraductal endoscopy is broad. It allows better differentiation between benign and malignant processes by allowing direct visualization and targeted sampling of tissue. Therapeutic interventions, such as electrohydraulic lithotripsy (EHL), laser lithotripsy, photodynamic therapy, and argon plasma coagulation (APC), may also be performed as part of intraductal endoscopy. Intraductal endoscopy significantly increases the diagnostic and therapeutic yield of standard endoscopic retrograde cholangiography (ERCP), and as technology progresses, it is likely that its utilization will only increase. In this review of intraductal endoscopy, we describe in detail the various endoscopic platforms and their diagnostic and clinical applications.

Management of pancreaticobiliary disease using a new intra-ductal endoscope:The Texas experience

AIM:To evaluate a new single-operator mini-endoscope, Spyglass,for its performance,feasibility and safety in the management of pancreaticobiliary disease. METHODS:In a multicenter retrospective analysis of patients undergoing intraductal endoscopy,we evaluated 128 patients(71 men,mean age 57.6 years).Indications were therapeutic(TX)in 72(56%) and diagnostic(DX)in 56(44%). RESULTS:Peroral endoscopy was performed in 121 and percutaneous in seven.TX indications included CBD stones in 41,PD stones in six,and biliary strictures in 25.DX indications included abnormal LFT’s in 15, abnormal imaging in 38 and cholangiocarcinoma staging in three.Visualization of the stone(s)was considered good in 31,fair in six,and poor in four. Advancement of the electrohydraulic lithotripsy probe was not possible in three patients and proper targeting of the lesion was partial in four patients.A holmium laser was used successfully in three patients.Ductal clearance was achieved in 37 patients after one procedure and in four patients after two procedures.Diagnosis of biliary strictures was modified in 20/29 and confirmed to be malignant in 10/23.Of the modified patients,no diagnosis was available in 17.Spyglass demonstrated malignancy in 8/17 and non-malignancy in nine.Suspected pathology by imaging studies and abnormal LFT’s was modified in 43/63(66%).Staging of cholangiocarcinoma demonstrated multicentric cholangiocarcinoma in 2/3.There was no morbidity associated with the use of Spyglass. CONCLUSION:Spyglass Spyscopeis a first generation, single operator miniature endoscope that can evaluate and treat various biliary and pancreatic tract diseases.

Role of laparoscopic common bile duct exploration in the management of choledocholithiasis

Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by laparoscopic cholecystectomy(LC) is considered as optimal treatment till date. With refinements in technique and expertise in field of minimal access surgery, many centres in the world have started offering one stage management of choledocholithiasis by LC with laparoscopic common bile duct exploration(LCBDE). Various modalities have been tried for entering into concurrent common bile duct(CBD) [transcystic(TC) vs transcholedochal(TD)], for confirming stone clearance(intraoperative cholangiogram vs choledochoscopy), and for closure of choledochotomy(T-tube vs biliary stent vs primary closure) during LCBDE. Both TC and TD approaches are safe and effective. TD stone extraction is involved with an increased risk of bile leaks and requires more expertise in intra-corporeal suturing and choledochoscopy. Choice depends on number of stones, size of stone, diameter of cystic duct and CBD. This review article was undertaken to evaluate the role of LCBDE for the management of choledocholithiasis.

Combined laparoscopic and endoscopic treatment for bile duct diseases

BACKGROUND: Clinical application of laparoscopy, duo- denoscopy and choledochoscopy has been accepted as a mini-invasive surgical therapy for bile duct diseases; but ei- ther endoscopic or laparoscopic therapy alone is disadvanta- geous in its narrow indications and in failure to give full play to the individual superiority. The present study was to evaluate the procedures and therapeutic results of combined laparoscopic and endoscopic treatment for bile duct disea- ses. METHODS: Clinical data of 1990 patients with bile duct diseases treated by combination of laparoscopy, duodenos- copy and choledochoscopy in two hospitals were reviewed and analyzed. RESULTS: Patients with cholecystolithiasis and choledo- cholithiasis were treated with combined laparoscopy and duodenoscopy (n =1350) in a single operation with a cure rate of 93.6%. Those with choledocholithiasis (n =332) were treated with combined laparoscopy and choledocho- scopy with a cure rate of 100%. Combined laparoscopy, duo- denoscopy and choledochoscopy was used in 258 patients with choledocholithiasis (29 of them complicated with pan- creatitis) and 24 patients with Mirizzi's syndrome, with a cure rate of 100%. Laparoscopic choledochoenterostomy and preoperative endoscopic nasobiliary drainage were done in 26 patients with a cure rate of 100%. There were no serious operative complications. A follow-up study of 1051 patients for 3 months to 12 years (mean 7.8 years) showed that 10 patients had recurrence of stones but no stenosis of the bile duct. CONCLUSION: Combined laparoscopic and endoscopic procedures are mini-invasive and cause less pain and mini- mal operative complications.

Management hepatolithiasis with operative choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy

BACKGROUND: Hepatolithiasis is very common in East Asia. It is benign in nature, but has a high recurrence rate. It is likely to lead to biliary cirrhosis and increase the risk of cholangiocarcinoma. Hence, the treatment of hepatolithiasis is difficult but vital. In this report, we present a novel approach to manage hepatolithiasis using the choledochoscopic Frequency-Doubled Double pulse Nd:YAG (FREDDY) laser lithotripsy combined with or without hepatectomy. METHODS: Between July 2009 and October 2012, 45 patients underwent choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy (laser lithotripsy group). Fortyeight patients underwent a traditional operation (traditional method group) from January 2009 to June 2009. Comparative analysis was made of demographic and clinical characteristics of the two groups. RESULTS: The final stone clearance rate of the laser lithotripsy group was 93.3%, whereas that of the traditional method group was 85.4% (P=0.22). In the laser lithotripsy group, 2 patients experienced hemobilia and 3 patients had acute cholangitis. In the traditional method group, 3 patients had intraoperative hemorrhage, 1 patient had bile leakage, 6 patients had acute cholangitis, and 1 patient died of liver failure. Moreover, the operative time in the traditional method group was significantly longer than that in the laser lithotripsy group (P=0.01). The mean hospital stay of the patients in the traditional method group was longer than that in the laser lithotripsy group (9.8 vs8.2 days, P=0.17). Recurrent intrahepatic bile duct stones were not found during the follow-up period in the two groups. CONCLUSION: Operative choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy may be an effective and safe treatment for hepatolithiasis.

Laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct and traditional open operation

AIM: To investigate the possibilities and advantages of laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct compaired with traditional open operation.METHODS: Laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct and traditional open operation were performed in two groups of patients who had gallstones in the left lobe of liver and in the common bile duct. The hospitalization time, hospitalization costs, operation time, operative complications and post-operative liver functions of the two groups of patients were studied.RESULTS: The operation time and post-operative liver functions of the two groups of patients had no significant differences, while the hospitalization time, hospitalization costs and operative complications of the laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration in the common bile duct group were significantly lower than those in the traditional open operation group.CONCLUSION: For patients with gallstones in the left lobe of liver and in the common bile duct, laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct can significantly shorten the hospitalization time, reduce the hospitalization costs and the post-operative complications,without prolonging the operation time and bringing about more liver function damages compared with traditional open operation. This kind of operation has more advantages than traditional open operation.

COMBINED SURGICAL THERAPY FOR HEPATOLITHIASIS

Objective To evaluate the combined surgical therapy for calculi of intrahepatic duct. Methods One hundred and eight cases of hepatolithiasis treated in our hospital from January 1986 to September 2003 were summarized and analyzed retrospectively. The primary surgery included 57 cases of biliary tract exploration and cholangiolithotomy, 26 cases of cholangiojejunostomy, and 25 cases of partial hepatectomy. Of these cases, 156 operations were performed totally. There were 36 patients undergoing two or more operations for cholangiolithiasis problem. Fiberoptic choledochoscopy was employed to examine and remove the residual stones during and after operation in all cases. Results The residual stone rates were 57.89% (33/57), 26.92% (7/26), and 24.0% (6/25) for biliary tract exploration and cholangiolithotomy, cholangiojejunostomy, and partial hepatectomy, respectively. Fiberoptic choledochoscopy was utilized pre- and post-operatively for each patient, which was performed 2 to 9 times on each case. Following the combined treatment, the rate of residual stone after operation decreased to 12.96% (14/108). Conclusions The combined surgical therapy is valuable for resolving the problem of hepatolithiasis in most of the patients. Regarding the clinical outcomes of different surgical procedures, partial hepatectomy is superior to cholangiojejuno- stomy or biliary tract exploration and cholangiolithotomy. Fiberoptic choledochoscopy is also important to reduce the occurrence of residual stones and the rate of reoperation.

Appropriate number of biliary biopsies and endoscopic retrograde cholangiopancreatography sessions for diagnosing biliary tract cancer

BACKGROUND Biliary ductal cancer(BDC) is a lethal disease; however, diagnosing BDC is challenging. Biliary biopsies are performed to pathologically diagnose BDC, but the appropriate parameters for biliary biopsy [number of biliary biopsies, number of endoscopic retrograde cholangiopancreatography(ERCP) sessions, etc.] are unknown.AIM To clarify what constitutes an adequate method for biliary biopsy.METHODS In total, 95 patients who underwent endoscopic biliary biopsy without choledochoscopy and who were pathologically diagnosed with BDC were enrolled in this study. The patients were divided into two groups. Seventy-six patients who were diagnosed by biliary biopsy were defined as the positive group(P group), and nineteen patients who were not diagnosed by biliary biopsy were defined as the negative group(N group). The patient characteristics and ERCP-related procedures were compared between the P and N groups.RESULTS The numbers of ERCP sessions and biliary biopsies were significantly different between the two groups [ERCP sessions(one/two), P group 72/4 vs N group15/4, P value = 0.048; number of biliary biopsies, P group 2(1-6) vs N group 2(1-7), P value = 0.039]. In a multivariate analysis, fewer than 2 ERCP sessions was an independent factor influencing the positivity of the biliary biopsies.CONCLUSION This study clarified that ERCP and biliary ductal biopsy should only be performed once. If biliary cancer is not pathologically diagnosed after the first ERCP session, other methods(Endoscopic ultrasonography-guided fine needle aspiration or choledochoscopy-guided biliary ductal biopsy) should be employed.

Analysis of 87 Cases of laparoscopic Choledochotomy with Primary Suture

To investigate the feasibility and clinical effect of laparoscopic choledochotomy for primary suture of bile duct.Methods:There were 190 cases of cholecystolithiasis with choledocholithiasis.They were randomly divided into endoscopic group and open group.In the endoscopic group,87 patients underwent laparoscopic choledocholithotomy and primary bile duct suture.A total of 103 patients in open group were treated with open bile duct incision and T tube drainage.The operative time,intraoperative blood loss,postoperative ventilation time,hospital stay and postoperative complications were compared between the two groups.Results:The length of hospital stay,the amount of bleeding during operation and the time of postoperative ventilation were less than those in open group.The operation time was longer than that in open group,P<0.01.There were 0 cases of postoperative incision infection,2 cases of bile leakage and 1 case of residual stone in endoscopic group.The incidence of complications was 5.7%.The open group was 5,3,3 and 10.7% respectively.Comparison of complications between the two groups,P<0.01.Conclusion:Select the right case strictly,Laparoscopic and choledochoscopy combined with cholecystolithiasis with choledocholithiasis is effective,safe and minimally invasive,short hospitalization time and less complications.

Strategies of minimally invasive treatment for intrahepatic and extrahepatic bile duct stones

Cholellthiasis is a kind of common and multiple diseases. In recent years, traolttonal laparommy has been challenged by a minimally invasive surgery. Through literature review, the therapeutic method, effect, and complications of minimally invasive treatment of intrahepatic and extrahepatic bile duct stones by combining our practical experience were summarized as follows. （1） For intrahepatic bile duct stones, the operation may be selected by laparoscopie liver resection, laparoscopic common bile duct exploration （LCBDE）, or percutaneous transhepatic cholangioscopy. （2） For concomitant gallstones and common bile duct stones, the surgical approach can be selected as follows： laparoscopic cholecystectomy （LC） combined with endoscopic sphincterotomy （EST） or endoscopic papillary balloon dilatation, LC plus laparoscopic transcystic common bile duct exploration, LC plus LCBDE, and T-tube drainage or primary suture. （3） For concomitant intrahepatic and extrahepatic bile duct stones, laparoscopic liver resection, choledochoscopy through the hepatic duct orifice on the hepatectomy cross section, LCBDE, EST, and percutaneous transhepatic cholangioscopic lithotripsy could be used. According to the abovementioned principle, the minimally invasive treatment approach combined with the surgical technique and equipment condition will be significant in improving the therapeutic effect and avoiding the postoperative complications or hidden dangers of intrahepatic and extrahepatic bile duct stones.