Peroral cholangioscopy is useful in differentiating benign from malignant biliary strictures. However, when conventional biliary access via endoscopic retrograde cholangiopancreatography (ERCP) fails, percutaneous transhepatic cholangioscopy (PTCS) via the SpyGlass cholangioscopy system can be used to achieve a diagnosis. Four patients with biliary strictures in whom conventional ERCP was not possible and percutaneous brushings were either nondiagnostic or unsatisfactory were investigated with PTCS. The technique of PTCS involves insertion of the SpyGlass cholangioscope through a percutaneous transhepatic sheath, placed just prior to the procedure, to visualize the stricture and obtain biopsies with the SpyBite forceps. On the basis of our early observations, we conclude that PTCS using the SpyGlass cholangioscopy system for the assessment of biliary strictures is feasible, safe, and provides high diagnostic accuracy.
Background Primary sclerosing cholangitis (PSC) is a chronic inflammatory condition causing bile duct strictures. Differentiating inflammatory strictures from malignant transformation is challenging. Cholangioscopy allows direct visualization with the option to biopsy. We describe our experience of cholangioscopy in PSC and propose a novel stricture classification system based on cholangioscopic findings. Methods All patients with PSC and a dominant stricture referred for cholangioscopy were reviewed. Based on visual characteristics with direct cholangioscopy, we propose a novel classification system for the extrahepatic form of PSC. Results The proposed Edmonton Classification system for extrahepatic PSC strictures consists of the following phenotypes: 1) ‘inflammatory type’, with mucosal erythema and active inflammatory exudate, 2) ‘fibro-stenotic type’, with concentric fibrotic scars, and 3) ‘nodular or mass-forming type’, with a mass in the involved segment of extrahepatic bile duct. From 2011–2017, 30 patients with PSC and a dominant stricture (21 M, mean age 46 years) underwent 32 cholangioscopy procedures. Cholangioscopy was technically successful in 29 of 32 procedures (91%). In these 29 stricture cases, inflammatory type was seen in 16 (55%), fibro-stenotic type in seven (24%) and nodular or mass-forming type in five (17%). In one (4%) procedure, there was no stricture or abnormality identified. Conclusion Cholangioscopy is effective and safe for the evaluation of dominant biliary strictures in PSC. Based on our experience with cholangioscopy, we propose a novel classification system of extrahepatic PSC phenotypes: the Edmonton Classification.
Background While most pancreatic fluid collections (PFCs) resolve spontaneously, endoscopic ultrasound-guided transluminal drainage (EUS-TD) may be necessary. EUS-TD has evolved from multiple double-pigtail plastic stents (DPPS) to fully covered self-expanding metal stents (FCSEMS) and lumen-apposing metal stents (LAMS). This study compares clinical attributes of DPPS, FCSEMS and LAMS. Methods This is a single-centre retrospective review of EUS-TD for PFCs. The primary outcome was clinical success. Secondary outcomes were technical success, procedure time, hospital length of stay (HLOS), number of endoscopies, need for necrosectomy, adverse events (AEs) and overall cost. Results Fifty-eight patients (37 male, average age 49 years) underwent a total of 60 EUS-TD procedures for PFCs (average size 11.2 cm with 29 pseudocysts and 29 walled-off necrosis). Ten patients (17%) underwent EUS-TD with DPPS and 48 patients (83%) with metal stents (32 FCSEMS, 16 LAMS). Overall technical and clinical success was 100% and 84%, respectively. Lumen-apposing metal stents had shorter procedure times (14.9 versus 63.6 DPPS, 39.1 min FCSEMS, P < 0.001), and no difference in AEs (3 of 16 versus 4 of 10 DPPS, 12 of 34 FCSEMS, ns). Double-pigtail plastic stents required more endoscopies (3.7 versus 2.3 LAMS, 2.3 FCSEMS, P = 0.013) and necrosectomies (4 of 10 [40%]) compared with 5 of 34 [15%] in the FCSEMS group and 3 of 16 [19%] in the LAMS group, respectively, P = 0.001) to achieve clinical resolution. The overall cost and HLOS was not significantly different between groups. Conclusion The use of LAMS for PFCs is not associated with any significant increase in cost despite technical (shorter procedure time) and clinical advantages (shorter indwell time, reduced need for necrosectomy and no increase in AEs).
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