Patient Education and Consent

Patients should be instructed to fast overnight before the procedure.

Informed consent must be obtained from the patient. The procedure to be performed and risks involved with the anesthesia and the procedure should be explained.

Preprocedural Planning

The procedure should be explained to the assisting staff.

All required equipment should be checked before the procedure begins.

Prophylactic antibiotics are usually administered 30 minutes before the procedure.

Equipment

This section includes a few examples of cholangioscopes that have been introduced to date.^{[6, 54, 55, 53, 56, 36, 37, 38]}

Two-operator systems: mother-and-baby scopes and miniscopes

These endoscopes use a large “mother” scope for duodenoscopy and then introduce a smaller “baby” scope to cannulate biliary ducts. When it was introduced, it was a revolutionary technology that provided successful visualization of bile ducts and pancreatic ducts. It also offered excellent diagnostic and therapeutic potential in the management of biliary disorders.

However, these systems are limited. They are fragile and cumbersome; require two endoscopists; are limited to two-way endoscopic steering; lack adequate working channels, widespread availability, and expertise; and have high maintenance costs.

Miniscopes were then developed. They were introduced into bile ducts through standard duodenoscopes. Earlier versions were fragile, did not have tip deflection, and lacked working channels.

Larger miniscopes were later developed to overcome the limitations of earlier, smaller miniscopes. Advantages include therapeutic capability from the instrumentation channel, but they were limited by the absence of separate air and water channels.

Single-operator system: SpyGlass cholangiopancreatoscopy

The initial clinical feasibility study for the SpyGlass cholangioscopy system (developed by Boston Scientific, Marlborough, MA) was described by Chen et al in 2007.^[51] This system was considered a major breakthrough in cholangioscope technology and overcame many limitations of earlier versions.

The SpyGlass cholangioscopy system is operated by a single endoscopist. It has four-way tip deflection, separate irrigation and working (instrumentation) channels, and a four-lumen single catheter. It allows for significantly decreased time under fluoroscopy and thus decreased radiation exposure. Multicenter international trials showed promising results in the diagnosis and treatment of many biliary and pancreatic diseases.

The SpyGlass cholangioscopy system^[32] consists of capital components and consumable devices (see in the image below).

Spyglass System and images from the biliary system.

View Media Gallery

Capital components include the following:

Component cart and three-joint arm
Light source and cable (300-W high intensity white light)
Camera and camera head (autoshutter camera with color image sensor)
Ocular-optical coupler that interfaces with the probe and camera head
Isolation transformer
Power cable pack
Irrigation pump
Video monitor

Regarding consumable devices, the system makes use of a disposable access and delivery catheter (10-French outer diameter), a reusable optical probe, and disposable biopsy forceps.

The SpyScope access and delivery catheter is a single-operator, disposable catheter used for introducing the SpyGlass system into the biliary system. It has a length of 230 cm and an outer diameter of 10 French. It consists of four lumina: one for the SpyGlass optical probe, one lumen for the SpyBite forceps, and two for electrohydraulic lithotripsy or laser probes. Two irrigation channels exit at the end of the catheter for irrigation of ducts. It is unique because it has a four-way tip deflection to help with navigation and better visualization of the biliary ducts.

The SpyGlass fiberoptic probe is a multiple-use device with a length of 231 cm that conducts light to biliary ducts and captures fiberoptic endoscopic images. It consists of a 6000-pixel image bundle surrounded by an approximately 225-light transmission bundle. A lens connected at the distal end of the image bundle captures a 70º field of view. Images captured are inferior to those captured by video cholangioscopes.

The SpyBite forceps is a single-use device that has a 286-cm working length. The forceps is introduced through the 1.2-mm working channel of the SpyScope catheter. The forceps jaw is designed with a central spike and has an outer diameter of 1 mm for obtaining small target biopsies under direct visualization.

The SpyGlass system is compatible with a few electrohydraulic lithotripsy and laser probe devices introduced through the working channel of the SpyScope catheter.

Direct cholangioscopy

Direct cholangioscopy has superior image quality. Equipment that has been used includes the following:

Olympus Gastroscope GIF-Q 180 with a diameter of 8.8 mm, preloaded with an 11.5-French balloon
Olympus Ultraslim upper endoscope GIF-XP 160 with a diameter of 5.9 mm and a 2-mm instrument channel

Lee et al evaluated the use of a third-generation multibending ultraslim cholangioscope (CHF-Y0010; Olympus Medical Systems, Tokyo, Japan), in 20 patients with difficult bile duct stones for whom previous attempts at conventional endoscopic stone removal had been unsuccessful.^[57]Complete ductal clearance was achieved in 19 patients (95%). A median of 2 (range, 1-3) ERCP sessions were required for complete stone removal. One patient (5%) had an adverse event and was treated conservatively.

Anesthesia

Cholangioscopy is a time-consuming and labor-intensive procedure. Deep sedation with parenteral midazolam/fentanyl by an anesthesiologist during the procedure is preferred. In few cases, general anesthesia may be required to perform the procedure. Protection of the airway is an important concern during a prolonged procedure such as cholangioscopy, which further emphasizes the need for an anesthesiologist.

The patient should be under continuous monitoring of blood pressure, heart rate, heart rhythm, respiratory rate, and pulse oximetry during the procedure.

Positioning

Patients are generally placed in a prone position during cholangioscopy.

Technique

Zhou Y, Wu XD, Zha WZ, Fan RG, Zhang B, Xu YH, et al. Three modalities on common bile duct exploration. Z Gastroenterol. 2017 Sep. 55 (9):856-860. [QxMD MEDLINE Link].
Rosch W, Koch H, Demling L. Peroral cholangioscopy. Endoscopy. 1976. 172–175.
Urakami Y, Seifert E, Butke H. Peroral direct cholangioscopy (PDCS) using routine straight-view endoscope: first report. Endoscopy. 1977 Mar. 9 (1):27-30. [QxMD MEDLINE Link].
Chen YK, Parsi MA et al. Peroral cholangioscopy (PO) using a disposable steerable single operator catheter for biliary stone therapy and assessment of indeterminate strictures - A multicenter experience using Spyglass. Gastrointest Endosc. 2008. 67:AB103.
Nakajima M, Akasaka Y, Yamaguchi K, Fujimoto S, Kawai K. Direct endoscopic visualization of the bile and pancreatic duct systems by peroral cholangiopancreatoscopy (PCPS). Gastrointest Endosc. 1978 May. 24 (4):141-5. [QxMD MEDLINE Link].
Judah JR, Draganov PV. Intraductal biliary and pancreatic endoscopy: an expanding scope of possibility. World J Gastroenterol. 2008 May 28. 14 (20):3129-36. [QxMD MEDLINE Link]. [Full Text].
Woo YS, Lee JK, Oh SH, Kim MJ, Jung JG, Lee KH, et al. Role of SpyGlass peroral cholangioscopy in the evaluation of indeterminate biliary lesions. Dig Dis Sci. 2014 Oct. 59 (10):2565-70. [QxMD MEDLINE Link].
Parsi MA. Peroral cholangioscopy in the new millennium. World J Gastroenterol. 2011 Jan 7. 17 (1):1-6. [QxMD MEDLINE Link]. [Full Text].
Yamauchi H, Kida M, Okuwaki K, Miyazawa S, Matsumoto T, Uehara K, et al. Therapeutic peroral direct cholangioscopy using a single balloon enteroscope in patients with Roux-en-Y anastomosis (with videos). Surg Endosc. 2018 Jan. 32 (1):498-506. [QxMD MEDLINE Link].
Lee YN, Moon JH, Choi HJ, Lee TH, Choi MH, Cha SW, et al. Direct peroral cholangioscopy for diagnosis of bile duct lesions using an I-SCAN ultraslim endoscope: a pilot study. Endoscopy. 2017 Jul. 49 (7):675-681. [QxMD MEDLINE Link].
Nakai Y, Sato T, Hakuta R, Ishigaki K, Saito K, Saito T, et al. Management of Difficult Bile Duct Stones by Large Balloon, Cholangioscopy, Enteroscopy and Endosonography. Gut Liver. 2020 May 15. 14 (3):297-305. [QxMD MEDLINE Link]. [Full Text].
Alshati A, Kurli V, Wittenberg A, Patel G, Kachaamy T. Management of malignant biliary diseases by the use of peroral and percutaneous cholangioscopy. VideoGIE. 2019 Sep. 4 (9):431-435. [QxMD MEDLINE Link]. [Full Text].
Moon JH, Terheggen G, Choi HJ, Neuhaus H. Peroral cholangioscopy: diagnostic and therapeutic applications. Gastroenterology. 2013 Feb. 144 (2):276-282. [QxMD MEDLINE Link].
Moon JH, Choi HJ. The role of direct peroral cholangioscopy using an ultraslim endoscope for biliary lesions: indications, limitations, and complications. Clin Endosc. 2013 Sep. 46 (5):537-9. [QxMD MEDLINE Link]. [Full Text].
Itoi T, Nageshwar Reddy D, Sofuni A, Ramchandani M, Itokawa F, Gupta R, et al. Clinical evaluation of a prototype multi-bending peroral direct cholangioscope. Dig Endosc. 2014 Jan. 26 (1):100-7. [QxMD MEDLINE Link].
Pohl J, Meves VC, Mayer G, Behrens A, Frimberger E, Ell C. Prospective randomized comparison of short-access mother-baby cholangioscopy versus direct cholangioscopy with ultraslim gastroscopes. Gastrointest Endosc. 2013 Oct. 78 (4):609-16. [QxMD MEDLINE Link].
Mori A, Ohashi N, Nozaki M, Yoshida A. Feasibility of duodenal balloon-assisted direct cholangioscopy with an ultrathin upper endoscope. Endoscopy. 2012 Nov. 44 (11):1037-44. [QxMD MEDLINE Link].
Pereira P, Peixoto A, Andrade P, Macedo G. Peroral cholangiopancreatoscopy with the SpyGlass® system: what do we know 10 years later. J Gastrointestin Liver Dis. 2017 Jun. 26 (2):165-170. [QxMD MEDLINE Link].
Monga A, Ramchandani M, Reddy DN. Per-oral cholangioscopy. J Interv Gastroenterol. 2011 Apr. 1 (2):70-77. [QxMD MEDLINE Link].
Wani S, Shah RJ. Probe-based confocal laser endomicroscopy for the diagnosis of indeterminate biliary strictures. Curr Opin Gastroenterol. 2013 May. 29 (3):319-23. [QxMD MEDLINE Link].
Itoi T, Kamisawa T, Igarashi Y, Kawakami H, Yasuda I, Itokawa F, et al. The role of peroral video cholangioscopy in patients with IgG4-related sclerosing cholangitis. J Gastroenterol. 2013 Apr. 48 (4):504-14. [QxMD MEDLINE Link].
Sugiyama H, Tsuyuguchi T, Sakai Y, Ohtsuka M, Miyazaki M, Yokosuka O. Potential role of peroral cholangioscopy for preoperative diagnosis of cholangiocarcinoma. Surg Laparosc Endosc Percutan Tech. 2012 Dec. 22 (6):532-6. [QxMD MEDLINE Link].
Sánchez-Ocaña R, Ramón Foruny Olcina J, Costas JV, Rojo FG, Pérez JJ, Domínguez-Muñoz E, et al. SEED Consensus Document on Spyglass-DS. Gastroenterol Hepatol. 2022 Sep 27. [QxMD MEDLINE Link].
Yamaguchi T, Shirai Y, Ishihara T, Sudo K, Nakagawa A, Ito H, et al. Pancreatic juice cytology in the diagnosis of intraductal papillary mucinous neoplasm of the pancreas: significance of sampling by peroral pancreatoscopy. Cancer. 2005 Dec 15. 104 (12):2830-6. [QxMD MEDLINE Link].
Parsi MA, Neuhaus H, et al. Peroral cholangioscopy guided stone therapy--report of an international multicenter registry. Gastrointest Endosc. 2008. 67:AB102.
Pleskow D, Parsi MA, et al. Biopsy of indeterminate biliary strictures--does direct visualization help? A multicenter experience. Gastrointest Endosc. 2008. 67:AB103.
Moon JH, Ko BM, Choi HJ, Hong SJ, Cheon YK, Cho YD, et al. Intraductal balloon-guided direct peroral cholangioscopy with an ultraslim upper endoscope (with videos). Gastrointest Endosc. 2009 Aug. 70 (2):297-302. [QxMD MEDLINE Link].
Arya N, Nelles SE, Haber GB, Kim YI, Kortan PK. Electrohydraulic lithotripsy in 111 patients: a safe and effective therapy for difficult bile duct stones. Am J Gastroenterol. 2004 Dec. 99 (12):2330-4. [QxMD MEDLINE Link].
Hui CK, Lai KC, Ng M, Wong WM, Yuen MF, Lam SK, et al. Retained common bile duct stones: a comparison between biliary stenting and complete clearance of stones by electrohydraulic lithotripsy. Aliment Pharmacol Ther. 2003 Jan. 17 (2):289-96. [QxMD MEDLINE Link].
Parsi MA, Guardino J, Vargo JJ. Peroral cholangioscopy-guided stricture therapy in living donor liver transplantation. Liver Transpl. 2009 Feb. 15 (2):263-5. [QxMD MEDLINE Link].
Matsumoto N, Yokoyama K, Nakai K, Yamamoto T, Otani T, Ogawa M, et al. A case of eosinophilic cholangitis: imaging findings of contrast-enhanced ultrasonography, cholangioscopy, and intraductal ultrasonography. World J Gastroenterol. 2007 Apr 7. 13 (13):1995-7. [QxMD MEDLINE Link].
Chathadi KV, Chen YK. New kid on the block: development of a partially disposable system for cholangioscopy. Gastrointest Endosc Clin N Am. 2009 Oct. 19 (4):545-55. [QxMD MEDLINE Link].
Itoi T, Osanai M, Igarashi Y, Tanaka K, Kida M, Maguchi H, et al. Diagnostic peroral video cholangioscopy is an accurate diagnostic tool for patients with bile duct lesions. Clin Gastroenterol Hepatol. 2010 Nov. 8 (11):934-8. [QxMD MEDLINE Link].
Igarashi Y, Okano N, Ito K, Suzuki T, Mimura T. Effectiveness of peroral cholangioscopy and narrow band imaging for endoscopically diagnosing the bile duct cancer. Dig Endosc. 2009 Jul. 21 Suppl 1:S101-2. [QxMD MEDLINE Link].
Wang HP, Chen JH, Wu MS, Wang HH, Chou AL, Chang YS, et al. Application of peroral cholangioscopy in an endemic area with high prevalence of hepatocellular carcinoma and choledocholithiasis. Hepatogastroenterology. 2000 Nov-Dec. 47 (36):1555-9. [QxMD MEDLINE Link].
Foerster EC, Schneider MU, Stömmer P, Runge U, Domschke W. Miniscopes in gastroenterological endoscopy--inspection of the gallbladder and the biliary and pancreatic duct systems in autopsy specimens. Endoscopy. 1988 Nov. 20 (6):316-20. [QxMD MEDLINE Link].
Neuhaus H, Schumacher B. Miniscopes. Baillieres Best Pract Res Clin Gastroenterol. 1999 Apr. 13 (1):33-48. [QxMD MEDLINE Link].
Technology Status Evaluation Report: Duodenoscope-Assisted Cholangio pancreatoscopy. Gastrointest Endosc. 1999. 50:943-945.
Sander R, Poesl H. Initial experience with a new babyscope for endoscopic retrograde cholangiopancreaticoscopy. Gastrointest Endosc. 1996 Aug. 44 (2):191-4. [QxMD MEDLINE Link].
Azeem N, Gostout CJ, Knipschield M, Baron TH. Cholangioscopy with narrow-band imaging in patients with primary sclerosing cholangitis undergoing ERCP. Gastrointest Endosc. 2014 May. 79 (5):773-779.e2. [QxMD MEDLINE Link].
Kalaitzakis E, Sturgess R, Kaltsidis H, Oppong K, Lekharaju V, Bergenzaun P, et al. Diagnostic utility of single-user peroral cholangioscopy in sclerosing cholangitis. Scand J Gastroenterol. 2014 Oct. 49 (10):1237-44. [QxMD MEDLINE Link].
Ali JM, See TC, Wiseman O, Griffiths WJ, Jah A. Salvage of liver transplant with hepatolithiasis by percutaneous transhepatic cholangioscopic hepatolithotomy. Transpl Int. 2014 Dec. 27 (12):e126-8. [QxMD MEDLINE Link].
Liu R, Cox Rn K, Siddiqui A, Feurer M, Baron T, Adler DG. Peroral cholangioscopy facilitates targeted tissue acquisition in patients with suspected cholangiocarcinoma. Minerva Gastroenterol Dietol. 2014 Jun. 60 (2):127-33. [QxMD MEDLINE Link].
Jang S, Stevens T, Kou L, Vargo JJ, Parsi MA. Efficacy of digital single-operator cholangioscopy and factors affecting its accuracy in the evaluation of indeterminate biliary stricture. Gastrointest Endosc. 2020 Feb. 91 (2):385-393.e1. [QxMD MEDLINE Link].
Bokemeyer A, Lenze F, Stoica V, Sensoy TS, Kabar I, Schmidt H, et al. Digital single-operator video cholangioscopy improves endoscopic management in patients with primary sclerosing cholangitis-a retrospective observational study. World J Gastroenterol. 2022 May 28. 28 (20):2201-2213. [QxMD MEDLINE Link]. [Full Text].
Sakamoto Y, Takeda Y, Seki Y, Kawahara S, Shimosaka T, Hamamoto W, et al. The Usefulness of Peroral Cholangioscopy for Intrahepatic Stones. J Clin Med. 2022 Oct 29. 11 (21):[QxMD MEDLINE Link]. [Full Text].
Kawakami H, Kuwatani M, Etoh K, Haba S, Yamato H, Shinada K, et al. Endoscopic retrograde cholangiography versus peroral cholangioscopy to evaluate intraepithelial tumor spread in biliary cancer. Endoscopy. 2009 Nov. 41 (11):959-64. [QxMD MEDLINE Link].
Fukuda Y, Tsuyuguchi T, Sakai Y, Tsuchiya S, Saisyo H. Diagnostic utility of peroral cholangioscopy for various bile-duct lesions. Gastrointest Endosc. 2005 Sep. 62 (3):374-82. [QxMD MEDLINE Link].
Tischendorf JJ, Krüger M, Trautwein C, Duckstein N, Schneider A, Manns MP, et al. Cholangioscopic characterization of dominant bile duct stenoses in patients with primary sclerosing cholangitis. Endoscopy. 2006 Jul. 38 (7):665-9. [QxMD MEDLINE Link].
Siddique I, Galati J, Ankoma-Sey V, Wood RP, Ozaki C, Monsour H, et al. The role of choledochoscopy in the diagnosis and management of biliary tract diseases. Gastrointest Endosc. 1999 Jul. 50 (1):67-73. [QxMD MEDLINE Link].
Awadallah NS, Chen YK, Piraka C, Antillon MR, Shah RJ. Is there a role for cholangioscopy in patients with primary sclerosing cholangitis?. Am J Gastroenterol. 2006 Feb. 101 (2):284-91. [QxMD MEDLINE Link].
Itoi T, Sofuni A, Itokawa F, Tsuchiya T, Kurihara T. Evaluation of peroral videocholangioscopy using narrow-band imaging for diagnosis of intraductal papillary neoplasm of the bile duct. Dig Endosc. 2009 Jul. 21 Suppl 1:S103-7. [QxMD MEDLINE Link].
Raijman I. Cholangiopancreatoscopy. Sridhar S, Yu G, eds. Diagnostic and Therapeutic Procedures in Gastroenterology. 2nd ed. Cham, Switzerland: Humana Press; 2018. 375-86.
Coté GA, Azar RR, Edmundowicz SA, Jonnalagadda SS. Balloon-assisted peroral cholangioscopy by using an 8.8-mm gastroscope for the diagnosis of Mirizzi syndrome. Gastrointest Endosc. 2010 Jan. 71 (1):181-2; discussion 182. [QxMD MEDLINE Link].
Moon JH, Choi HJ, Ko BM. Therapeutic role of direct peroral cholangioscopy using an ultra-slim upper endoscope. J Hepatobiliary Pancreat Sci. 2011 May. 18 (3):350-6. [QxMD MEDLINE Link].
Weersma RK. Per oral cholangioscopy. Monkemuller K, Wilcox CM, Munoz-Navas M. Interventional and Therapeutic Gastrointestinal Endoscopy. Basel: Karger; 2010. 403-406.
Lee WM, Moon JH, Lee YN, Shin IS, Lee TH, Yang JK, et al. Utility of Direct Peroral Cholangioscopy Using a Multibending Ultraslim Endoscope for Difficult Common Bile Duct Stones. Gut Liver. 2022 Jul 15. 16 (4):599-605. [QxMD MEDLINE Link]. [Full Text].
Chen YK. Preclinical characterization of the Spyglass peroral cholangiopancreatoscopy system for direct access, visualization, and biopsy. Gastrointest Endosc. 2007 Feb. 65 (2):303-11. [QxMD MEDLINE Link].
Inamdar S, Trindade AJ, Sejpal DV. Bile Duct Mass Determined to Be Eosinophilic Cholangitis by Digital Cholangioscopy. Clin Gastroenterol Hepatol. 2017 Dec. 15 (12):e173-e174. [QxMD MEDLINE Link].
Larghi A, Waxman I. Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study. Gastrointest Endosc. 2006 May. 63 (6):853-7. [QxMD MEDLINE Link].
Barakat MT, Girotra M, Choudhary A, Huang RJ, Sethi S, Banerjee S. A prospective evaluation of radiation-free direct solitary cholangioscopy for the management of choledocholithiasis. Gastrointest Endosc. 2018 Feb. 87 (2):584-589.e1. [QxMD MEDLINE Link].
Waxman I, Dillon T, Chmura K, Wardrip C, Chennat J, Konda V. Feasibility of a novel system for intraductal balloon-anchored direct peroral cholangioscopy and endotherapy with an ultraslim endoscope (with videos). Gastrointest Endosc. 2010 Nov. 72 (5):1052-6. [QxMD MEDLINE Link].

Media Gallery

Spyglass System and images from the biliary system.
Cholangioscopic view of (A) bile duct stone and (B) electrohydraulic lithotripsylithotripsy.
Cholangioscopic view of normal intrahepatic biliary mucosa.