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Intraductal Biliopancreatic Imaging: European Society of Gastrointestinal Endoscopy (ESGE) Technology Review

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Intraductal Biliopancreatic Imaging: European Society of Gastrointestinal Endoscopy (ESGE) Technology Review Review 739 Intraductal biliopancreatic imaging: European Society of Gastrointestinal Endoscopy (ESGE) technology review Authors Andrea Tringali1, Arnaud Lemmers2, Volker Meves3, Grischa Terheggen4, Jürgen Pohl3, Guido Manfredi5, Michael Häfner6, Guido Costamagna1, Jacques Devière2, Horst Neuhaus4, Fabrice Caillol7, Marc Giovannini7, Cesare Hassan8, Jean-Marc Dumonceau9 Institutions Institutions are listed at end of article. Bibliography This technology review expresses the current biliary strictures/intraluminal lesions, difficult DOI http://dx.doi.org/ view of the European Society of Gastrointestinal biliary stones) and to the setting of tertiary care 10.1055/s-0034-1392584 Endoscopy (ESGE) on the available techniques for centers. Published online: 0.0.2015 intraductal biliopancreatic imaging. Peroral pancreatoscopy may find an indication in Endoscopy 2015; 47: 739–753 © Georg Thieme Verlag KG The three cholangioscopy techniques are de- situations where other imaging modalities (main- Stuttgart · New York scribed: the “dual-operator” and “ single-opera- ly EUS) are inconclusive (i.e. delineation of main ISSN 0013-726X tor” mother-baby approaches using dedicated in- duct intraductal papillary mucinous neoplasia ex- struments, and the “direct” technique using cur- tension, sampling of indeterminate main pancre- Corresponding author rently available ultrathin gastroscopes. atic duct strictures) Andrea Tringali, MD PhD Digestive Endoscopy Unit, The mother-baby method is standardized and re- Intraductal ultrasonography (IDUS) has a poorer Catholic University producible, while direct cholangioscopy is techni- performance than EUS in the staging of pancreatic Largo A. Gemelli 8 cally demanding and its safety requires further malignancies and can increase the risk of pan- 00168 Rome, Italy evaluation. creatitis. A promising indication for IDUS could – – Fax: +39 06 30157220 As well as direct visualization of the bile ducts, be the evaluation of indeterminate biliary stric- [email protected] cholangioscopy has the further advantage of al- tures and ampullary tumors. lowing targeted biopsy. Probe-based confocal laser endomicroscopy (pCLE) Image quality is still suboptimal for single-opera- of the bile ducts is a difficult and expensive tech- tor cholangioscopy, while the other techniques nique. Appropriate training needs to be estab- have achieved adequately detailed imaging. lished, since interpretation of images is challen- The costs of mother-baby cholangioscopy are high ging. pCLE can be an important diagnostic tool in and its application in clinical practice should be the setting of indeterminate biliary strictures. restricted to selected cases (i.e. indeterminate Abbreviations IDUS intraductal ultrasonography ! IPMN intraductal papillary mucinous neo- 3D-IDUS three-dimensional intraductal ultra- plasia sonography MRI magnetic resonance imaging CBD common bile duct MRCP magnetic resonance cholangio- CI confidence interval pancreatography CLE confocal laser endomicroscopy NBI narrow band imaging CT computed tomography OR odds ratio DOC double-operator cholangioscopy pCLE probe-based confocal laser endomi- EHL electrohydraulic lithotripsy croscopy EPLBD endoscopic papillary large balloon POPS peroral pancreatoscopy dilation SOC single-operator cholangioscopy ERC endoscopic retrograde cholangio- graphy ERCP endoscopic retrograde cholangio- Introduction pancreatography ! ESWL extracorporeal shockwave lithotripsy Endoscopic retrograde cholangiopancreatogra- EUS endoscopic ultrasonography phy (ERCP) is a diagnostic and therapeutic inva- FNA fine needle aspiration sive imaging modality of the biliopancreatic duc- Tringali Andrea et al. Biliopancreatic intraductal imaging: ESGE technology review … Endoscopy 2015; 47: 739–753 740 Review tal system. It provides an “indirect” radiological visualization of lines; notable differences include the absence of key questions the biliopancreatic system. The first direct peroral visualization and recommendations. In September 2013, the project was en- of the biliopancreatic system was described in 1975 [1] and it dorsed by the ESGE Governing Board. Different topics were each has since become an important diagnostic tool in selected cases, assigned to a subgroup of experts after a general discussion dur- when other available techniques (e.g. endoscopic ultrasonogra- ing a meeting held in October 2013 (Berlin, Germany). phy [EUS], computed tomography [CT] scanning, magnetic reso- The final search of the relevant literature was performed in No- nance imaging [MRI], biopsy sampling) cannot provide a defini- vember 2014 using Medline (via Pubmed), the Cochrane Library, tive diagnosis. Therapeutic goals were then pursued, mostly the Embase, and the internet. In March 2015, a draft prepared by A. T. extraction of biliary and pancreatic stones using electrohydraulic was sent to all group members. After agreement on a final ver- or laser lithotripsy. The main drawbacks of cholangiopancreato- sion, the manuscript was reviewed by two members of the ESGE scopy include costs, suboptimal imaging quality, and the fragility Governing Board and sent to all ESGE individual members for of the devices. During the last 20 years, the development of high comments. It was then submitted to the journal Endoscopy for quality video cholangioscopes (●" Table 1) has partially resolved publication. This technological review was issued in 2015 and some of these problems. Intraductal biliopancreatic imaging will be considered for update in 2019. modalities were expanded, with new and expensive techniques (●" Table 2) aiming at visualizing the thickness of duct walls as well as periductal structures (intraductal ultrasound, confocal la- Dual-operator “mother-baby” peroral cholangioscopy ser endomicroscopy [CLE]). ! This technology review expresses the current view of the Euro- Introduction pean Society of Gastrointestinal Endoscopy (ESGE) about the Dual-operator cholangioscopy (DOC) is commonly referred to as presently available techniques for intraductal biliopancreatic “mother-baby cholangioscopy”; it uses a very slim endoscope imaging. passed through the working channel of a duodenoscope. Two endoscopists are needed to control the instruments. Methods Equipment and technique ! A biliary sphincterotomy is usually performed to facilitate pas- The aim of this technology review is to clarify technical aspects sage of the cholangioscope (95% of 144 patients in a retrospective for those who actually perform endoscopic procedures [2]. The series) [3]. Then, the cholangioscope (“baby” scope) is passed methodology was adapted from that used for ESGE clinical guide- through the accessory channel of the duodenoscope (“mother” Table1 Characteristics of available “mother-baby” cholangiopancreatoscopes. Endoscope Type Opera- Tip Working Image Lumens, n Tip de- Deflection Field Focal dis- Working tors, n diameter, channel, enhance- flection angula- view tance, length, mm mm ment tion mm m CHF-BP30 Fiber 2 3.1 1.2 No 1 2-way 290°: 90° 1– 50 1.87 (Olympus) up 160° down 130° FCP-9P Fiber 2 3 1.15 No 1 2-way 180°: 90° 1– 50 1.9 (Pentax) up 90° down 90° CHF-B1601 Video 2 4 1.2 No 1 2-way 140°: 90° 3– 20 2 (Olympus) up 70° down 70° CHF-B2601 Video 2 3.4 1.2 Yes (NBI) 1 2-way 140°: 90° 3– 20 2 (Olympus) up 70° down 70° CHF-B2601 Video 2 2.6 0.5 Yes (NBI) 1 2-way 140°: 90° 3– 20 2 (Olympus) up 70° down 70° Spyglass Video 1 3.4 1.2 No 3 4-way 240°: 70° 1– 50 2.3 (Boston (1 working up 60° Scientific) channel, down 60° 2irrigation right 60° channels) left 60° Polyscope Video 2 2.7 1.2 No 1 1-way 180° 70° 2– 10 1.85 (Polydiagnost) NBI, narrow band imaging. 1 Not commercially available in Europe. Tringali Andrea et al. Biliopancreatic intraductal imaging: ESGE technology review… Endoscopy 2015; 47: 739–753 Review 741 Table2 Estimated costs (in euros) of intraductal biliopancreatic imaging devices commercially available (in Europe). Technique Imaging console Endoscope/catheter/optical fiber/probe Dual-operator “mother-baby” fiber pancreatocholangioscope Olympus, CHF-BP30 Standard light source 16 000 € Pentax, FCP-9P Standard light source 18 500 € Dual-operator “mother-baby” video pancreatocholangioscope Polydiagnost, Polyscope 45000 € Catheter (single use) 1000 € Optical fiber 10000 € Single-operator “mother-baby” video pancreatocholangioscope Boston Scientific, SpyGlass 65000 € Catheter (single use) 1400 € Optical fiber (20 uses) 5000 € Direct cholangioscopy (transnasal gastroscopes) Olympus, GIF-N180 Standard videoprocessor 29 000€ Pentax, EG16-K10 Standard videoprocessor 27000€ Fuji, EG-530NP Standard videoprocessor 28 500€ Intraductal ultrasonography (Olympus) 65000 € Probe (reusable) 7000 € Confocal laser endomicroscopy Mauna Kea, Cellvizio 150000 € Probe (10 uses) 8000 € scope), usually over a guidewire for easier biliary cannulation. indeterminate biliary strictures, and the information provided Once the target area has been reached, the guidewire is removed by the macroscopic appearance was judged more sensitive than to enhance visualization and to allow the use of the working brush cytology. The prospective multicenter study by Osanai et channel. Irrigation with sterile saline is commonly used to pro- al., summarized in●" Table 3, used NBI. vide a clear vision of the bile duct, while carbon dioxide has Cholangioscopy, with or without NBI, was of little help in the been reported to be an interesting alternative in two small com- evaluation of external biliary compression where the mucosa ap- parative nonrandomized series [4,5].
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