Usefulness of digital single-operator cholangioscopy for biliary diseases

Abstract

Background and Aims: The single-operator peroral cholangioscopy (SOC) using SpyGlass Direct Visualization System has made significant progress in diagnosing and treating biliary disease. The current study subdivided the technical steps for each biliary indication of SOC and evaluated the technical feasibility of each substep to analyze the actual rate-limiting factor for successful SOC-guided biliary intervention. Methods: From November 2017 to April 2023, consecutive patients who underwent SOC using the SpyGlass DS Direct Visualization System as a rescue for conventional ERCP were retrospectively reviewed.This study focused on the following three main indications of SOC:1) Indeterminate biliary lesion or stricture, 2) Difficult bile duct stone, and 3) Guidewire insertion into the cystic duct for transpapillary gallbladder stenting. Results: Visualization of the target biliary lesion was possible in all 46 cases (100%). However, SOC's procedural success and diagnostic accuracy for indeterminate biliary lesion or stricture were 93.5% and 89.1%, respectively, with 3 cases of macroscopic insufficient tissue acquisition and 2 cases of sampling error. SOC-guided electrohydraulic lithotripsy (EHL) was attempted in 28 cases, but procedural success was achieved in 11 patients (39.3%). The SOC failure was derived from limited stone fragmentation with EHL in all 17 cases. SOC-guided cystic duct cannulation was successful in 9 patients (90.0%), but subsequent SOC-guided GB cannulation was successful in 3 patients (30.0%). In 4 patients, GB cannulation was finally achieved after withdrawing the SpyGlass system, leaving the guidewire in the cystic duct and newly introducing the rotatable papillotome over the guidewire. Conclusions: SOC using the SpyGlass system has limitations regarding EHL implementation for difficult stone fragmentation and cystic duct negotiation with a guidewire for gallbladder cannulation for transpapillary gallbladder drainage. ___________________________________________________________________________ Keyword: Spyglass, indeterminate biliary stricture, difficult bile duct stone, cystic duct