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  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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    Editor-in-Chief
    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

    Deputy Editor

    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
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    All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
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Revolution of Novel Direct Peroral Cholangioscopy: Another Step Beyond Limitations

Tanyaporn Chantarojanasiri

Division of Gastroenterology, Department of Internal Medicine, Rajavithi Hospital, Rangsit University, Bangkok, Thailand

Correspondence to: Tanyaporn Chantarojanasiri
ORCID https://orcid.org/0000-0001-5781-8696
E-mail chtunya@gmail.com

See “Utility of Direct Peroral Cholangioscopy Using a Multibending Ultraslim Endoscope for Difficult Common Bile Duct Stones” by Won Myung Lee, et al. on page 599, Vol. 16, No. 4, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2022;16(4):499-500

Published online July 15, 2022, Published Date July 15, 2022 https://doi.org/10.5009/gnl220274

Copyright © Gut and Liver.

Since the first endoscopic retrograde cholangiopancreatography (ERCP) was initiated in 1968, the diagnosis and treatment for pancreatic and biliary diseases have been made based on the fluoroscopic images. With increasing diagnostic and therapeutic indications, interventions that has been guided by the “shadow” on the cholangiogram has become insufficient for some particular interventions such as targeted intraductal biopsy or lithotripsy for stones. By the introduction of cholangioscopy in the 1970s,1 these intraductal modalities changed from the fluoroscopically guided to the direct visualization which enable more accurate diagnostic and therapeutic measures.

The development of peroral cholangioscopy has experienced many challenges. Firstly, the scope diameter is limited by the bile duct size or the size of the therapeutic ERCP working channel in case of single-operator cholangioscopy. This subsequently limited the diameter of the working channel of the cholangioscope and the diameter of the instruments especially for the biopsy forceps. Moreover, water irrigation and suction might not be sufficient especially in the presence of bleeding. Secondly, the bending property of the cholangioscope limits the scope movement, which usually start with an acute angulation from duodenum to the papilla and from the papilla to the desired segment of the bile duct. Thirdly, the resolution of endoscopic image is inferior to that of the luminal endoscope which hamper it use especially in the evaluation of the indeterminate biliary strictures. Early reports using mother-baby scope showed promising data but had several drawbacks since the technique need two endoscopists to perform and the scope was extremely fragile. This was soon replaced by single-use, single-operator cholangioscopy which is much more widely used but still carry the same limitation as mentioned above. With the development of ultraslim upper endoscope, 'direct cholangioscopy was possible to perform by a single endoscopist. Compared with single-operator cholangioscopy, direct cholangioscopy provide a better endoscopic image, a larger cholangioscopic working channel, and a better ability to clear the endoscopic view through separated water irrigation and suction channel. This system also requires only single operator and carry a better scope durability when compared with the mother-baby scope. However, bile duct intubation using direct cholangioscope is still a big challenge since loop formation inside the stomach and duodenum occurs and acute angulation between the bile duct and the duodenum makes deep bile duct insertion difficult with poor stability.

There have been several techniques to assist bile duct intubation for direct cholangioscopy, including the wire-guided method,2 duodenal overtube insertion,3 duodenal balloon insertion together with guidewire-assisted duodenal intubation,4 or using the specialized intraductal balloon as an anchor.5 These techniques improve the desired bile duct intubation significantly compared with free-hand cannulation6 but still have some limitations. Almost all accessories require duodenoscope or other endoscope insertion to place the instrument prior to the insertion of direct cholangioscope. Among these techniques, intraductal balloon anchor seems to provide a promising success rate which can be used along with other techniques (Table 1). Also, these ultraslim endoscope is durable since none of these reported scope damage during endoscopic interventions such as lithotripsy.

Table 1. Feasibility of Direct Cholangioscopy Using Various Assistant Method

Author (year)MethodNo. of
cases
Cholangioscope modelSuccessfulness
Free handWith assistance
Larghi and
Waxman (2006)2
Wire-guided3GIF-XP 160Not attempt100% (3/3)
Choi et al. (2009)3Overtube-balloon12GIF-N230 or GIF-N260Not attempt83.3% (10/12)
Moon et al. (2009)5Intraductal balloon29GIF-XP260N, GIF-N260,
and GIF-N230
Not attemptWire-guided 45.5% (5/11)
Intraductal balloon-guided 95.2% (20/21)
Mori et al. (2012)4Duodenal balloon with
guidewire-assisted
40EG530N2, EG530NP, and EG530NWNot attempt92.5% (37/40)
Itoi et al. (2014)6Free-hand technique,
a guidewire alone, or
intraductal anchoring
balloon
41Prototype multibending
direct peroral cholangioscope
0% (0/7)Wire-guided 66.6% (4/6)
Anchoring balloon 92.9% (26/28)
Lee et al. (2022)7Free-hand technique
and intraductal
anchoring balloon
20CHF-Y001095% (19/20)Intraductal balloon 100% (1/1)


In this issue of Gut and Liver, Lee et al.7 introduce a newly developed cholangioscope. This multibending model allows easier free-hand insertion into the bile duct with better stability. Apart from having two bending sections to overcome the angulation, this model is longer than conventional ultraslim scope, with two working channels and stiffer shaft to reduce loop formation and facilitate free-hand insertion. These improvement changed remarkably from the previous version, in which free-hand insertion was not successful in all seven patients that free-hand insertion was attempted.6 The study was performed on 20 patients with difficult common bile duct stones in which cholangioscopy and lithotripsy were successfully performed in all patients with one case of mild complication. Although this study reported a small number of patients in which the procedures were performed under expert hands, it showed a promising future for the development of the direct peroral cholangioscopy.

No potential conflict of interest relevant to this article was reported.

  1. Urakami Y, Seifert E, Butke H. Peroral direct cholangioscopy (PDCS) using routine straight-view endoscope: first report. Endoscopy 1977;9:27-30.
    Pubmed CrossRef
  2. Larghi A, Waxman I. Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study. Gastrointest Endosc 2006;63:853-857.
    Pubmed CrossRef
  3. Choi HJ, Moon JH, Ko BM, et al. Overtube-balloon-assisted direct peroral cholangioscopy by using an ultra-slim upper endoscope (with videos). Gastrointest Endosc 2009;69:935-940.
    Pubmed CrossRef
  4. Mori A, Ohashi N, Nozaki M, Yoshida A. Feasibility of duodenal balloon-assisted direct cholangioscopy with an ultrathin upper endoscope. Endoscopy 2012;44:1037-1044.
    Pubmed CrossRef
  5. Moon JH, Ko BM, Choi HJ, et al. Intraductal balloon-guided direct peroral cholangioscopy with an ultraslim upper endoscope (with videos). Gastrointest Endosc 2009;70:297-302.
    Pubmed CrossRef
  6. Itoi T, Nageshwar Reddy D, Sofuni A, et al. Clinical evaluation of a prototype multi-bending peroral direct cholangioscope. Dig Endosc 2014;26:100-107.
    Pubmed KoreaMed CrossRef
  7. Lee WM, Moon JH, Lee YN, et al. Utility of direct peroral cholangioscopy using a multibending ultraslim endoscope for difficult common bile duct stones. Gut Liver 2022;16:599-605.
    Pubmed CrossRef

Article

Editorial

Gut and Liver 2022; 16(4): 499-500

Published online July 15, 2022 https://doi.org/10.5009/gnl220274

Copyright © Gut and Liver.

Revolution of Novel Direct Peroral Cholangioscopy: Another Step Beyond Limitations

Tanyaporn Chantarojanasiri

Division of Gastroenterology, Department of Internal Medicine, Rajavithi Hospital, Rangsit University, Bangkok, Thailand

Correspondence to:Tanyaporn Chantarojanasiri
ORCID https://orcid.org/0000-0001-5781-8696
E-mail chtunya@gmail.com

See “Utility of Direct Peroral Cholangioscopy Using a Multibending Ultraslim Endoscope for Difficult Common Bile Duct Stones” by Won Myung Lee, et al. on page 599, Vol. 16, No. 4, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

Since the first endoscopic retrograde cholangiopancreatography (ERCP) was initiated in 1968, the diagnosis and treatment for pancreatic and biliary diseases have been made based on the fluoroscopic images. With increasing diagnostic and therapeutic indications, interventions that has been guided by the “shadow” on the cholangiogram has become insufficient for some particular interventions such as targeted intraductal biopsy or lithotripsy for stones. By the introduction of cholangioscopy in the 1970s,1 these intraductal modalities changed from the fluoroscopically guided to the direct visualization which enable more accurate diagnostic and therapeutic measures.

The development of peroral cholangioscopy has experienced many challenges. Firstly, the scope diameter is limited by the bile duct size or the size of the therapeutic ERCP working channel in case of single-operator cholangioscopy. This subsequently limited the diameter of the working channel of the cholangioscope and the diameter of the instruments especially for the biopsy forceps. Moreover, water irrigation and suction might not be sufficient especially in the presence of bleeding. Secondly, the bending property of the cholangioscope limits the scope movement, which usually start with an acute angulation from duodenum to the papilla and from the papilla to the desired segment of the bile duct. Thirdly, the resolution of endoscopic image is inferior to that of the luminal endoscope which hamper it use especially in the evaluation of the indeterminate biliary strictures. Early reports using mother-baby scope showed promising data but had several drawbacks since the technique need two endoscopists to perform and the scope was extremely fragile. This was soon replaced by single-use, single-operator cholangioscopy which is much more widely used but still carry the same limitation as mentioned above. With the development of ultraslim upper endoscope, 'direct cholangioscopy was possible to perform by a single endoscopist. Compared with single-operator cholangioscopy, direct cholangioscopy provide a better endoscopic image, a larger cholangioscopic working channel, and a better ability to clear the endoscopic view through separated water irrigation and suction channel. This system also requires only single operator and carry a better scope durability when compared with the mother-baby scope. However, bile duct intubation using direct cholangioscope is still a big challenge since loop formation inside the stomach and duodenum occurs and acute angulation between the bile duct and the duodenum makes deep bile duct insertion difficult with poor stability.

There have been several techniques to assist bile duct intubation for direct cholangioscopy, including the wire-guided method,2 duodenal overtube insertion,3 duodenal balloon insertion together with guidewire-assisted duodenal intubation,4 or using the specialized intraductal balloon as an anchor.5 These techniques improve the desired bile duct intubation significantly compared with free-hand cannulation6 but still have some limitations. Almost all accessories require duodenoscope or other endoscope insertion to place the instrument prior to the insertion of direct cholangioscope. Among these techniques, intraductal balloon anchor seems to provide a promising success rate which can be used along with other techniques (Table 1). Also, these ultraslim endoscope is durable since none of these reported scope damage during endoscopic interventions such as lithotripsy.

Table 1 . Feasibility of Direct Cholangioscopy Using Various Assistant Method.

Author (year)MethodNo. of
cases
Cholangioscope modelSuccessfulness
Free handWith assistance
Larghi and
Waxman (2006)2
Wire-guided3GIF-XP 160Not attempt100% (3/3)
Choi et al. (2009)3Overtube-balloon12GIF-N230 or GIF-N260Not attempt83.3% (10/12)
Moon et al. (2009)5Intraductal balloon29GIF-XP260N, GIF-N260,
and GIF-N230
Not attemptWire-guided 45.5% (5/11)
Intraductal balloon-guided 95.2% (20/21)
Mori et al. (2012)4Duodenal balloon with
guidewire-assisted
40EG530N2, EG530NP, and EG530NWNot attempt92.5% (37/40)
Itoi et al. (2014)6Free-hand technique,
a guidewire alone, or
intraductal anchoring
balloon
41Prototype multibending
direct peroral cholangioscope
0% (0/7)Wire-guided 66.6% (4/6)
Anchoring balloon 92.9% (26/28)
Lee et al. (2022)7Free-hand technique
and intraductal
anchoring balloon
20CHF-Y001095% (19/20)Intraductal balloon 100% (1/1)


In this issue of Gut and Liver, Lee et al.7 introduce a newly developed cholangioscope. This multibending model allows easier free-hand insertion into the bile duct with better stability. Apart from having two bending sections to overcome the angulation, this model is longer than conventional ultraslim scope, with two working channels and stiffer shaft to reduce loop formation and facilitate free-hand insertion. These improvement changed remarkably from the previous version, in which free-hand insertion was not successful in all seven patients that free-hand insertion was attempted.6 The study was performed on 20 patients with difficult common bile duct stones in which cholangioscopy and lithotripsy were successfully performed in all patients with one case of mild complication. Although this study reported a small number of patients in which the procedures were performed under expert hands, it showed a promising future for the development of the direct peroral cholangioscopy.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

Table 1 Feasibility of Direct Cholangioscopy Using Various Assistant Method

Author (year)MethodNo. of
cases
Cholangioscope modelSuccessfulness
Free handWith assistance
Larghi and
Waxman (2006)2
Wire-guided3GIF-XP 160Not attempt100% (3/3)
Choi et al. (2009)3Overtube-balloon12GIF-N230 or GIF-N260Not attempt83.3% (10/12)
Moon et al. (2009)5Intraductal balloon29GIF-XP260N, GIF-N260,
and GIF-N230
Not attemptWire-guided 45.5% (5/11)
Intraductal balloon-guided 95.2% (20/21)
Mori et al. (2012)4Duodenal balloon with
guidewire-assisted
40EG530N2, EG530NP, and EG530NWNot attempt92.5% (37/40)
Itoi et al. (2014)6Free-hand technique,
a guidewire alone, or
intraductal anchoring
balloon
41Prototype multibending
direct peroral cholangioscope
0% (0/7)Wire-guided 66.6% (4/6)
Anchoring balloon 92.9% (26/28)
Lee et al. (2022)7Free-hand technique
and intraductal
anchoring balloon
20CHF-Y001095% (19/20)Intraductal balloon 100% (1/1)

References

  1. Urakami Y, Seifert E, Butke H. Peroral direct cholangioscopy (PDCS) using routine straight-view endoscope: first report. Endoscopy 1977;9:27-30.
    Pubmed CrossRef
  2. Larghi A, Waxman I. Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study. Gastrointest Endosc 2006;63:853-857.
    Pubmed CrossRef
  3. Choi HJ, Moon JH, Ko BM, et al. Overtube-balloon-assisted direct peroral cholangioscopy by using an ultra-slim upper endoscope (with videos). Gastrointest Endosc 2009;69:935-940.
    Pubmed CrossRef
  4. Mori A, Ohashi N, Nozaki M, Yoshida A. Feasibility of duodenal balloon-assisted direct cholangioscopy with an ultrathin upper endoscope. Endoscopy 2012;44:1037-1044.
    Pubmed CrossRef
  5. Moon JH, Ko BM, Choi HJ, et al. Intraductal balloon-guided direct peroral cholangioscopy with an ultraslim upper endoscope (with videos). Gastrointest Endosc 2009;70:297-302.
    Pubmed CrossRef
  6. Itoi T, Nageshwar Reddy D, Sofuni A, et al. Clinical evaluation of a prototype multi-bending peroral direct cholangioscope. Dig Endosc 2014;26:100-107.
    Pubmed KoreaMed CrossRef
  7. Lee WM, Moon JH, Lee YN, et al. Utility of direct peroral cholangioscopy using a multibending ultraslim endoscope for difficult common bile duct stones. Gut Liver 2022;16:599-605.
    Pubmed CrossRef
Gut and Liver

Vol.16 No.5
September, 2022

pISSN 1976-2283
eISSN 2005-1212

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