Saudi Journal of Gastroenterology
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SPECIAL ARTICLE Table of Contents   
Year : 1995  |  Volume : 1  |  Issue : 2  |  Page : 75-80
Nonsurgical cholangioscopy: The present state

From The II. Medizinische Klinik and Poliklinik, Klinikumrechts der Isar der Technischen Universitat Munchen. Prof. Dr med. Meinhard Classen II. Med. Klinik der TU Munchen, Klinikum rechts der Isar. Ismaninger Sir. 22, D - 81675 Munchen, Germany

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How to cite this article:
Neuhaus H, Classen M. Nonsurgical cholangioscopy: The present state. Saudi J Gastroenterol 1995;1:75-80

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Neuhaus H, Classen M. Nonsurgical cholangioscopy: The present state. Saudi J Gastroenterol [serial online] 1995 [cited 2022 Jul 6];1:75-80. Available from:

   Introduction Top

Ultrasonography, CT-scan, endoscopic retrog­rade cholangiopancreatography (ERCP) and per­cutaneous transhepatic cholangiography (PTC) are well-established diagnostic procedures for biliary tract diseases. These indirect imaging methods clearly demonstrate bile duct lesions but they may fail in differentiation of strictures or polyps. About 15 years ago, peroral and per­cutaneous cholangioscopy were introduced as complementary methods which allow a direct vis­ualization of the biliary system with target biop­sies of pathological findings [1],[2],[3],[4] . Since then, endoscopes and accessorial equipment have been continuously improved and facilitate not only a less invasive diagnostic approach but also offer a variety of therapeutic interventions for difficult stenoses or bile duct stones. These procedures are complementary to intraoperative or postopera­tive T-tube tract choledochoscopy developed for residual stones.

   Technique Top

Peroral cholangioscopy (POCS)

Retrograde transpapillary cholangioscopy can be safely achieved by the use of a mother-baby scope after endoscopic sphincterotomy (EST). The technique requires an adequate approach to the papilla. The procedure should be carried out by two skillful endoscopists. The conventional baby- cholangioscope has an outer diameter of 4.5 mm and 1.7 mm instrumentation channel so that target biopsies or introduction of guide-wires or probes for lithotripsy are possible. A recently­developed 3.4 mm miniscope (prototype CHF B 34; Olympus, Tokyo) can be inserted through a conventional therapeutic duodenoscope so that a change to the stiffer motherscope is not required [5] . This sophisticated instrument can be angu­lated in two directions and has a 1.2 mm channel. Intracorporeal lithotripsy using laser systems or electrohydraulic generators with probes < 3 FG is therefore possible. In contrast to electrohydraulic lithotripsy (EHL) the bile ducts can be continu­ously flushed beside the ultra-thin laser fiber so that a nasobiliary probe is not needed. The cholangioscopes for the peroral approach are fragile and must be carefully handled.

Percutaneous cholangioscopy (PTCS)

PTCS is usually performed according to the techniques initially described by Takada and Nim­ura [3],[4] . Following PTC, a drainage catheter is inserted into the bile ducts through the right lat­eral chest wall or the anterior abdominal wall. The cutaneobiliary fistula is sequentially dilated every second day by replacing catheters of progressively increasing diameters. Cholangioscopy can be car­ried out without using sheaths at the earliest 7 to 8 days after the initial procedure through a 14 to 18 FG sinus tract [6],[7] . The smallest steerable cholangioscopes which provide an instrumenta­tion channel of 1.0-1.2 mm have an outer diameter of 3.1-3.7 mm [5],[8] . These instruments are suita­ble for target brush cytology, biopsy, elec­trocoagulation and stone extraction with baskets. Lithotripsy can be carried out mechanically or by electrohydraulic or laser systems. After establish­ment of the sinus tract, the percutaneous endos­copic approach is much easier than the peroral access due to the better maneuverability of the directly inserted short cholangioscopes. The sinus tract can be preserved by leaving plastic prosthesis in situ which can be closed with a stop-cock at the skin level [7],[9] . After definitive removal of these drainage catheters, the fistula closes spontane­ously within 1-2 days.

   Results Top

Diagnostic Indications

In contrast to percutaneous cholangioscopy only a few series with a limited number of patients on the peroral approach for diagnostic indications have been reported [10] . This may be due to tech­nical difficulties or the limited availability of the equipment. In particular, the efficacy of biopsy studies with 3 FG forceps for 3.4-3.7 mm minis­copes is yet to be determined. According to a recent study in patients with malignant or benign biliary stenoses, peroral cholangioscopy with a 4.5 mm babyscope yielded additional diagnostic information in 20 to 27 cases [11] . Diagnostic improvement is expected from recently developed electronic (video) cholangioscopes which provide a higher resolution and more brightness of the image.

In contrast to the peroral route, PTCS achieves excellent visualization of bile duct lesions even above ductal strictures. Although Nimura never observed pathological vessels in benign lesions, target biopsies are frequently required to differen­tiate abnormal findings [6] . The sensitivity for malignant stenoses is 76-81% [7],[12] [Figure - 1]. In a large series of PTCS, correct results for bile duct carcinoma were obtained in 101 of 111 patients (sensitivity, 96%) [12] . Therefore PTCS is obvi­ously the most reliable nonsurgical diagnostic pro­cedure for bile duct cancer which is difficult to detect with noninvasive methods. Apart from his­tological studies, diagnostic PTCS together with superselective cholangiography can evaluate the intrahepatic extension of biliary tumors. Nimura, one of the pioneers in this field, strongly advo­cates routine percutaneous cholangioscopy for preoperative staging of proximal bile duct car­cinoma [12] . The determination of the variations of each segmental duct and the tumor-involved hepatic segments allows a precisely-designed seg­mentectomy which can minimize the risk of post­operative hepatic failure. This strategy may explain the excellent surgical results for bile duct carcinoma of the same group. In 69.7% of 55 patients, curative resection was achieved with a 6.4 % operative mortality rate and a 37.8% five­year survival rate [13] .

Diagnosis of biliary parasites can be usually achieved by ERCP. Endoscopic papillotomy allows removal of echinococcus cysts obstructing the biliary tree [14] . In selected cases, cholangios­copy can be used as a complementary procedure for detection of minor lesions or intrahepatic find­ings not amenable to ERCP. In addition, this method is helpful for differentiation of postopera­tive strictures or recurrence of parasites after biliary surgery for treatment of E. multilocularis [Figure - 2].

Therapeutic Indications

Intracorporeal lithotripsy of bile duct stones not amenable to ERCP and mechanical lithotripsy is the most important therapeutic indication for peroral cholangioscopy (POCS). This technique provides for electrohydraulic lithotripsy and con­ventional laser lithotripsy since delivery of pulses to the bile duct wall may result in bleeding and perforation. In contrast to extracorporeal shockwave lithotripsy, POCS and intracorporeal stone disintegration usually achieve complete bile duct clearance within a single treatment session. In a recent trial, peroral cholangioscopic elec­ltrohydraulic lithotripsy succeeded in 64 of 65 patients [15] . Laser lithotripsy seems to be com­parably effective but more time consuming [Figure - 3]. On the other hand, the induced fragments are much smaller and the procedure can be carried out with miniscopes without need for the motherscope [5],[16] .

PTCS and intracorporeal lithotripsy of difficult bile duct stones offer an alternative to surgery when less invasive transpapillary maneuvers fail or prove to be impossible due to an inaccessible papilla or large stones above a biliary stricture. Depending on the size of the cholangioscopes extrahepatic as well as intrahepatic stones can be approached and disintegrated by electrohydraulic lithotripsy or laser under excellent direct visual control. The fragments can be easily flushed into the small bowel through the papilla or a biliodiges­tive anastomosis. According to two recent trials, percutaneous cholangioscopic electrohydraulic lithotripsy and laser lithotripsy seem to be com­parably effective with success rates of 93% and 96%, respectively [16],[17] .

A new "smart" laser provides an automatic stone recognition system which allows lithotripsy even under a limited direct visual control or under fluoroscopy [18] . This flashlamp excited rhodamine 6G laser has a wave length of 594 m (Telemit Electronic, Munchen, Germany). The system provides an automatic cut-out upon tissue contact. The laser energy is transmitted via a 200 µm flexible quartz fiber. The laser light which is backscattered by a surface in the first hundreds of nanoseconds of the pulse is conducted back through the fiber, decoupled by a beam splitter and analyzed. Previous studies demonstrated that tissue and ureter stones can be differentiated using this method. If, therefore, the intensity of the reflected laser beam is below a threshold value which indicates that the fiber is not in contact with a concrement, the pulse is immediately inter­rupted with the aid of a polarizer by rotating the plane of polarization by 90° . Up to this moment, less than 10% of the total power of the laser pulse has been emitted and tissue damage is thus safely avoided. First clinical results of lithotripsy under fluoroscopy or cholangioscopy with miniscopes are promising [19],[20] .

   Complications Top

Peroral cholangioscopy is very safe after EPT provided that electrohydraulic lithotripsy is not performed under a limited visual control. The risks of percutaneous cholangioscopy are pre­dominately related to the placement of the trans­hepatic catheter and subsequent dilatation proce­dures [7] . The creation of a firm sinus tract is obvi­ously safer than the establishment of a large-bore cutaneobiliary fistula within a single session [15]. In the majority of the patients, measures for drain­age are required for therapeutic reasons so that the complications cannot be related strictly to endoscopy and are rarely mentioned in reports on cholangioscopy.

   Conclusions Top

Peroral cholangioscopy is still a sophisticated method for differential diagnosis of bile duct lesions or treatment of difficult stones. Further improvement of the endoscope system and the accessory equipment is desirable since the trans­papillary approach promises a rapid and safe vis­ualization of the biliary tree.

Percutaneous transhepatic cholangioscopy yields important diagnostic information including histological examinations in patients with unde­termined cholangiographic findings. Due to an exact mapping of the intraductal extension of malignant lesions cholangioscopy can improve the preoperative staging of biliary tumors. Percutane­ous cholangioscopic lithotripsy offers a highly effective and safe alternative to surgery in patients with difficult extrahepatic and intrahepatic ductal stones which are not amenable to routine endos­copy. In contrast to electrohydraulic lithotripsy, a new laser with automatic stone recognition does not require a precise direct visual control for stone targeting and is therefore appropriate for ultrathin endoscopes or for fluoroscopic target­ing.

   References Top

1.Nakajima M, Akasaka Y, Fukumoto K et al. Peroral cholangiopancreatoscopy (PCPC) under duodenoscopic guidance. Am J Gastroenterol 1976;66:241.  Back to cited text no. 1    
2.Rosch W, Koch H, Demling L. Peroral cholangioscopy. Endoscopy 1976;8:172.  Back to cited text no. 2    
3.Takada T, Suzuki S, Nakamura K. Uchida Y, Nomoto T, Yamada AK. Studies on percutaneous biliary tract endoscopy. Gastroenterol Endosc 1974;16:106-1 l (in Japanese).  Back to cited text no. 3    
4.Nimura Y, Hayakawa N, Toyoda S, Iyomasa Y, Nakazawa S. Percutaneous transhepatic cholangios­copy. Stomach Intestine 1981;16:681-9 (in Japanese).  Back to cited text no. 4    
5.Neuhaus H, Hoffmann W, Classen M. Laser Lithotripsy of pancreatic and biliary stones via 3.4 and 3.7 mm minis­copes: First clinical results. Endoscopy 1992;24: 208-14.  Back to cited text no. 5    
6.Nimura Y, Shionoya S, Hayakawa N, Kamiya J, Kondo S. Value of percutaneous transhepatic cholangioscopy (PTCS). Surg Endosc 1988;2:213-9.  Back to cited text no. 6    
7.Neuhaus H, Hoffmann W, Classen M. Nutzen and Risiko der perkutanen transhepatischen cholangios­kopie. Dtsch Med Wschr 1993;118:574-81 (in German and in Japanese).  Back to cited text no. 7  [PUBMED]  
8.Komiya O. Technical potential and limitations of cholangioscopes. Endoscopy 1989;21:338-40.  Back to cited text no. 8  [PUBMED]  
9.Yamakawa T. Percutaneous cholangioscopy for man­agement of retained biliary tract stones and intrahepatic stones. Endoscopy 1989;21:333-7.  Back to cited text no. 9  [PUBMED]  
10.Yasuda K, Nakajima M, Cho E, Mukai H, Kawai K. Comparison of peroral and percuataneous cholangios­copy. Endoscopy 1989;21:347-50.  Back to cited text no. 10  [PUBMED]  
11.Riemann J F, Kohler B, Harloff M, Weber J. Die trans­papillare cholangioskopie. Dtsch Med Wschr 1989;114:1175-9 (in German and in Japanese).  Back to cited text no. 11    
12.Nimura Y. Staging of biliary carcinoma: Cholangiog­raphy and cholangioscopy. Endoscopy 1993;25:76-80.  Back to cited text no. 12  [PUBMED]  
13.Nimura Y, Hayakawa N, Kamiya J, Kondo S, Shionoya S. Hepatic segmentectomy with caudate lobe resection for bile duct carcinoma of the hepatic hilus. World J Surg 1990;14:535-44.  Back to cited text no. 13  [PUBMED]  
14.Al Karawi MA, Mohammed AE, Yassawy I, Haleem A. Nonsurgical endoscopic transpapillary treatment of rup­tures echinococcus cyst obstructing the biliary tree. Endoscopy 1987;19:81-3.  Back to cited text no. 14    
15.Binmoeller K F, Bruckner M, Thonke F, Soehendra N. Treatment of difficult bile duct stones using mechanical, electrohydraulic and extracorporeal shock wave litho­tripsy. Endoscopy 1993;25:201-6.  Back to cited text no. 15    
16.Neuhaus H, Hoftmann W, Zillinger C, Classen M. Laser lithotripsy of difficult bile duct stones under direct visual control. Gut 199334:415-21.  Back to cited text no. 16    
17.Bonnel DH, Liguory CE, Cornud FE, Lefebvre JFP. Common bile duct and intrahepatic stones: Results of transhepatic electrohydraulic lithotripsy in 50 patients. Radiology 1991;780:345-8.  Back to cited text no. 17    
18.Neuhaus H. Hoffmann W, Classen M. Endoscopic laser lithotripsy with an automatic stone recognition system for basket impaction in the common bile duct. Endos­copy 1992;24:596-9.  Back to cited text no. 18    
19.Neuhaus H, Hoffmann W, Gottlieb K. Classen -M. Endoscopic lithotripsy of bile duct stones using a new laser with automatic stone recognition. Gastrointest Endosc. (in press).  Back to cited text no. 19    
20.Ell C. Hochherger J. May A, Fleig WE, Bauer R, Men­dez L. Hahn EG. Laserlithotripsy of difficult bile duct stones by means of a rhodamine-6G laser and an integ­rated automatic stone-tissue detection system. Gastroin­test Endosc 1993;39:755-62.  Back to cited text no. 20    

Correspondence Address:
M Classen
From The II. Medizinische Klinik and Poliklinik, Klinikumrechts der Isar der Technischen Universitat Munchen. Prof. Dr med. Meinhard Classen II. Med. Klinik der TU Munchen, Klinikum rechts der Isar. Ismaninger Sir. 22, D - 81675 Munchen
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PMID: 19864854

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