Choledochoscopy: An update

Abstract

Choledochoscopy, or cholangioscopy, is an endoscopic procedure for direct visualization within the biliary tract for diagnostic or therapeutic purposes. Since its conception in 1879, many variations and improvements are made to ensure relevance in diagnosing and managing a range of intrahepatic and extrahepatic biliary pathologies. This ranges from improved visual impression and optical guided biopsies of indeterminate biliary strictures and clinically indistinguishable pathologies to therapeutic uses in stone fragmentation and other ablative therapies. Furthermore, with the evolving understanding of biliary disorders, there are significant innovative ideas and techniques to fill this void, such as nuanced instances of biliary stenting and retrieving migrated ductal stents. With this in mind, we present a review of the current advancements in choledo-choscopy with new supporting evidence that further delineates the role of choledochoscopy in various diagnostic and therapeutic interventions, complications, limitations and put forth areas for further study.

Cholangioscopy for biliary diseases

“…The first one encompasses technological advances such as the development of new multibending cholangioscopes to facilitate bile duct cannulation, technical improvements of forceps jaws for better sampling, novel enhanced imaging systems and video display techniques (i.e. 3D), artificial intelligence for automated neoplasia detection [2,[67][68][69][70]. The second one comprises uncommon procedures performed with the use of a cholangioscope.…”

“…Cholangioscopy can be performed by peroral (POCS), percutaneous transhepatic (PTCS) or intra-operative transcystic or transcholedochal access with various devices [2] (Fig. 1 and Table 1).…”

“…In this case, an ultra-slim endoscope is directly advanced into the bile duct. The main disadvantage is a large outer diameter (5.0-5.9 mm), which may complicate insertion and advancement in small bile ducts [2]. However, a new multiband ultra-slim endoscope seems to yield a high technical success rate [8].…”

“…Applications are multiple, ranging from visual impression and optical guided biopsies of indeterminate biliary strictures (as recommended by the European Society of Gastrointestinal Endoscopy [ESGE]) to difficult stone management, guidance before biliary stenting and retrieval of migrated ductal stents [2,3 ▪▪ ].…”

Innovative choledochoscope for simulation based training in resource limited setting

“…1 But it is plagued with several limitations including operator dependency, prohibitive cost and technical issues. 2 Factors related to operator dependency include a) inadequate endoscopic training, b) the steep learning curve and c) lack of simulated training models 2 , which currently exist of 3-dimensional printed (3DP) and ex-vivo models of the complex hepatobiliary system. All of these, however, primarily include the need for an original choledochoscope 3,4 , whose cost (US$ 3000) with the cost of the 3DP (1000 US) together makes this unafforable.…”