Cholangioscopy Technique

Updated: Sep 13, 2017
  • Author: Mohammad Wehbi, MD; Chief Editor: Kurt E Roberts, MD  more...
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Technique

Spyglass Cholangioscopy

Cholangioscopy using the Spyglass cholangioscopy system [29, 47, 51, 52, 16]  can be performed by a single endoscopist. The Spyscope access and delivery catheter is attached to duodenoscope by a silastic band below the working channel of duodenoscope. The duodenoscope along with the Spyglass cholangioscopy system is held by one hand of endoscopist. The other hand of the endoscopist is used for operating the deflection wheels of the duodenoscope and Spyglass system. The procedure is always performed in conjunction with endoscopic retrogrado cholangiopancreatography (ERCP).

The Spyglass direct visualization probe is inserted into the optical channel of the Spyglass catheter.

Under direct vision, the duodenoscope is passed through the oral cavity and pharynx. Then the esophagus is intubated and the duodenoscope is passed through the esophagus and stomach to reach the second portion of the duodenum to visualize ampulla of Vater and the papillae.

A selective and deep cannulation of the biliary tree is performed. A guide wire is then introduced and positioned in the bile duct (or pancreatic duct) under fluoroscopy.

Sphincterotomy is usually performed for better access of the biliary tree.

The Spyscope catheter, along with the optical probe, are introduced into the duodenoscope together as a unit and advanced into the biliary ducts for direct visualization. Once inside the common bile duct, the Spyglass catheter is slowly advanced under fluoroscopy. Once the Spyscope catheter is positioned in the common bile duct, the guide wire is removed.

The optical probe is then advanced beyond the tip of Spyglass catheter. Direct visualization of biliary ducts is performed by repeated advancing and withdrawal of Spyscope catheter in the biliary duct. Four-way tip deflection of the Spyscope catheter aids in better visualization of the biliary ducts.

If a suspicious lesion is found in the biliary ducts, the Spybite forceps are introduced through the operating channel for obtaining targeted small biopsies. If biliary stones are found, Spyglass-directed electrohydraulic or laser lithotripsy is performed.

Irrigation of the biliary ducts is performed through the two irrigation ports built within the Spyscope catheter that exit at the tip of the catheter. This clears the debris in the bile ducts and provides better visual images throughout the procedure. Lack of a suction port is a drawback of this system, but manual suction can be achieved by attaching a syringe to the operating channel.

After completion of the procedure, patients are generally kept without oral intake until the next day.

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Mother-Baby Scopes

Cholangioscopy using a mother duodenoscope and baby cholangioscope requires two experienced endoscopists working together to complete the procedure. [50]

The procedure starts as a regular ERCP, with the introduction of duodenoscope under direct visualization through the mouth. It is advanced to the second portion of duodenum to visualize the ampulla of Vater.

Selective cannulation of the common bile duct is performed. A sphincterotomy is usually performed.

Cholangiography is then performed and a guide wire is placed in the biliary system.

The cholangioscope is introduced into the working channel of duodenoscope to cannulate the common bile duct. Under fluoroscopy, cholangioscope is slowly advanced over the guide wire to the common bile duct.

Once the cholangioscope is within the common bile duct, the guide wire may be removed. The working channel available in the cholangioscopes is used for diagnostic and therapeutic interventions. Targeted small biopsies can be obtained by introducing forceps through the working channel of the cholangioscope.

Electrohydraulic or laser lithotripsy also may be performed through the working channel of the cholangioscope.

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Direct Cholangioscopy

Direct cholangioscopy is a relatively new technique with limited available data. [53, 48, 49, 54]  It is a technically difficult procedure that needs a larger sphincterotomy and dilated bile duct, but the image quality is superior.

This procedure can be performed by either wire-guided or balloon-assisted procedure.

A standard therapeutic duodenoscope is advanced to the second portion of the duodenum, similar to earlier mentioned methods for cholangioscopy.

A guide wire is then introduced into the bile ducts under fluoroscopy.

The duodenoscope is removed, leaving the guide wire in the bile ducts.

An ultraslim endoscope is then back loaded over the guide wire using a standard ERCP cannula.

Under fluoroscopic guidance, an ultraslim endoscope is advanced into the bile ducts.

If a balloon-assisted method is used, a balloon is introduced and inflated in the common hepatic duct. This is used as an anchor to advance the ultraslim endoscope into the bile ducts. [55]

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Complications

The potential complications associated with cholangioscopy are numerous and range from relatively mild sequelae to life-threatening conditions, including the following:

  • Cholangitis (most common complication)
  • Abdominal pain
  • Hypotension
  • Nausea
  • Radiculopathy
  • Perforation of bile duct (from the guide wire)
  • Elevated amylase and lipase without clinical pancreatitis
  • Inflammatory syndrome
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