Cholangiopancreatoscopy-guided laser dissection and ablation for pancreas and biliary strictures and neoplasia

Abstract

Background and study aims Cholangiopancreatoscopy-guided laser dissection or ablation (CPL) is a novel therapeutic modality for refractory benign strictures. Our aim was to describe the safety and efficacy of CPL for pancreaticobiliary disorders. Patients and methods Patients who underwent CPL using holmium or thulium laser between February 2017 and September 2019 were included. For stricture dissection, gentle strokes of the laser fiber from a distal to proximal approach were applied until luminal patency permitted advancement of the cholangiopancreatoscope. Immediate technical success was defined as ability to traverse the stricture with the cholangiopancreatoscope after CPL. Short-term technical success was defined as > 90 % resolution of the stricture on follow-up pancreatogram. Results Eleven patients underwent a mean of 3.6 ERCPs (mean total diameter of 14.2 Fr of stenting) prior to CPL. Indications included pancreatic duct stricture (n = 8), pancreaticojejunostomy anastomotic stricture (n = 1), bile duct stricture (n = 1) and pancreatic intraductal papillary mucinous neoplasm ablation (n = 1). Immediate technical success was 94.1 % and short-term technical success rates was 88.2 %. At a mean follow-up of 12.1 months, there have been no stricture recurrences. Conclusions CPL may be an effective therapy for strictures refractory to conventional dilation and multiple stenting.

Endoscopic treatment of a refractory benign biliary stricture using cholangioscopy-guided thulium laser stricturoplasty

“…ERCP with balloon dilation and placement of multiple plastic stents or covered metal stents for distal biliary strictures has been established as the standard of care in the management of benign biliary strictures. 1,2 Etiologies include chronic pancreatitis, chronic inflammation from biliary stone disease, postsurgical injury following cholecystectomy, primary sclerosing cholangitis, and biliary anastomotic strictures. 1 Some biliary strictures, especially at the bifurcation and above, remain refractory to standard endoscopic therapies, with successful stricture resolution reported only in approximately 75% of patients.…”

“…3,4 Recently, we described cholangiopancreatoscopy-guided laser dissection/stricturoplasty as a novel therapeutic modality in the treatment of recalcitrant pancreaticobiliary strictures. 2,5 In this report, we present a patient in whom thulium laser stricturoplasty was used in the management of a refractory, benign biliary stricture.…”

Pancreatoscopy-guided laser dissection of obstructing pancreatic duct stricture: pancreas-preserving endotherapy

“… 1 , 2 Standard ERCP techniques may be insufficient for complex lesions such as severe stricture(s) or extensive stone burden, whereby the degree of obstruction or ductal tortuosity may not permit passage of the wire or catheter. 3 Peroral pancreatoscopy (POP) promotes direct ductal visualization and use of additional devices to treat such advanced pathology, which includes laser therapy that can be used for stone fragmentation or tissue dissection as a means of stricturoplasty. 4 These techniques have been previously described, 3 , 5 , 6 , 7 with benefits of potentially reducing or delaying the need for surgery.…”

“… 3 Peroral pancreatoscopy (POP) promotes direct ductal visualization and use of additional devices to treat such advanced pathology, which includes laser therapy that can be used for stone fragmentation or tissue dissection as a means of stricturoplasty. 4 These techniques have been previously described, 3 , 5 , 6 , 7 with benefits of potentially reducing or delaying the need for surgery.…”

Effect of pancreatic endotherapy on quality of life in chronic pancreatitis patients: A systematic review

“…For PD stones, per-oral pancreatoscopy (POP)-guided lithotripsy using electrohydraulic lithotripsy or laser lithotripsy have dramatically increased the rates of successful PD stone clearance[ 5 , 6 ]. For pancreatic duct strictures, the use of fully covered metal stents, wire-guided cystotomes, and POP-guided laser dissection have greatly expanded the armament of the endoscopist for these refractory stenoses[ 7 - 11 ]. Lastly, the development of lumen-apposing metal stents has revolutionized the drainage of pancreatic fluid collections by facilitating endoscopic transmural drainage in a single step[ 12 , 13 ].…”