Peroral Cholangiopancreatoscopy with the SpyGlass® System: What do we Know 10 Years Later

Abstract

Smaller endoscopes and catheters have been developed that permit direct visualization of the bile and pancreatic ducts (cholangioscopy and pancreatoscopy, respectively). These endoscopes and catheters are passed through the working channel of a standard therapeutic duodenoscope during endoscopic retrograde cholangiopancreatography (ERCP). The SpyGlass Direct Visualization System (Boston Scientific Corp, Natick, MA, USA) is currently the most widely used and studied device. Cholangioscopy with intraductal lithotripsy has become an established modality in the treatment of difficult biliary lithiasis. When used in the evaluation of indeterminate biliary strictures by experienced endoscopists in recognizing intraductal pathology, it increases the diagnostic yield of tissue sampling. Pancreatoscopy is complementary to other imaging modalities in the evaluation of intraductal papillary mucinous neoplasms of the pancreas and is emerging as a sole or adjunctive therapy to extracorporeal shock wave lithotripsy for the treatment of main pancreatic duct stones. It remains investigational in the diagnosis of pancreatic adenocarcinoma. Complications specific to the performance of cholangiopancreatoscopy include cholangitis, which is related to intraductal fluid irrigation.Abbreviations: EHL: Electrohydraulic lithotripsy; ERCP: Endoscopic retrograde cholangiopancreatography; ESWL: Extracorporeal lithotripsy by shock waves; ET: Endoscopic therapy; EUS: Endoscopic ultrasound; IPMN: intraductal papillary mucinous neoplasm; LL: Laser lithotripsy; MDCT: Multi-detector computed conventional tomography; MPD: Main pancreatic duct; MRCP: Magnetic resonance cholangiopancreatography; MRI: Magnetic resonance imaging; POCPS: Peroral cholangiopancreatoscopy; PSC: Primary sclerosing cholangitis

Peroral Cholangiopancreatoscopy: New Advances Bring New Concerns

“…One of the major challenges includes the evaluation of indeterminate biliopancreatic strictures, regarding malignancy concern [1, 2]. Despite available methods of indirect visualization of the pancreatobiliary tract, such as endoscopic ultrasonography, computed tomography, magnetic resonance imaging, and endoscopic retrograde cholangiopancreatography (ERCP) using brush cytology and/or intraductal blind biopsy, up to 30% of pancreatobiliary strictures remain indeterminate [1].…”

“…Since cholangiocarcinoma often shows superficial mucosal spread [5], the early and accurate diagnosis of preneoplastic and operable lesions could reasonably improve prognosis [3, 4]. On the other hand, a precise diagnosis is required to avoid unnecessary surgery in patients with benign stenosis [2]. …”

“…Regarding diagnosis of biliary lesions, brush cytology and standard forceps biopsy obtained by indirect visualization under fluoroscopic guidance of the biliary tract have a limited diagnostic accuracy (39–54%) with low sensitivity (6–51%) and specificity (55%) [2, 5, 6, 10, 11]. Recent systematic reviews and meta-analyses evaluated the diagnostic power of peroral cholangioscopy for malignant biliary stricture based on visual impression and CCS-guided biopsies, with a success rate of 90–100% [10, 12, 13].…”

“…Recent systematic reviews and meta-analyses evaluated the diagnostic power of peroral cholangioscopy for malignant biliary stricture based on visual impression and CCS-guided biopsies, with a success rate of 90–100% [10, 12, 13]. Although visual criteria suggesting malignancy are not yet standardized, they include some worrisome features, such as dilated and tortuous vessels (also called tumor vessels), intraductal nodular or papillary masses, and irregular mucosal surface pattern [2, 5, 6]. The reported accuracy of visual diagnosis was 78–89%, with 84–95% sensitivity and 82% specificity [12].…”

“…The reported accuracy of visual diagnosis was 78–89%, with 84–95% sensitivity and 82% specificity [12]. However, the low specificity of direct visualization alone implies pathologic analysis for definitive diagnosis [2]. Most studies reported an adequate quality sampling in 82–97% of biopsies obtained by CCS [6, 11, 12, 14] with a diagnostic accuracy, sensitivity, and specificity of 49–93%, 49–82%, and 97–98%, respectively [6, 10-12, 14, 15].…”