Percutaneous Biliary Endoscopy

Abstract

Biliary endoscopy is underutilized by interventional radiologists and has the potential to become an effective adjunctive tool to help both diagnose and treat a variety of biliary pathology. This is particularly true in cases where endoscopic retrograde cholangiopancreatography fails or is not feasible due to surgically altered anatomy. Both preoperative clinical and technical procedural factors must be taken into consideration prior to intervention. In this article, clinical evaluation, perioperative management, and procedural techniques for percutaneous biliary endoscopy are reviewed.

Percutaneous Biliary Endoscopy: History, Indications, Techniques, and Outcomes

“…When intervening on diffuse biliary stones, it is often advisable to start central in the biliary system and work peripherally toward the sheath access, as it is always easier to simply pull the endoscope back after traversing through the desired biliary segment rather than guide the endoscope forward through the bile duct network. 22 When managing biliary strictures and tumors, direct endoscopic visualization aids in evaluation and ensuring adequate tissue sampling for biopsy. Various characteristics of biliary lesions or strictures on inspection can suggest benign versus malignant etiologies.…”

“…When intervening on diffuse biliary stones, it is often advisable to start central in the biliary system and work peripherally toward the sheath access, as it is always easier to simply pull the endoscope back after traversing through the desired biliary segment rather than guide the endoscope forward through the bile duct network. 22…”

Gallbladder Drainage: IR and GI Perspective

“…16 A transperitoneal approach along the long axis of the gallbladder is preferred for subsequent stone extraction because transperitoneal fundal access is more direct and will avoid issues with dilating the tract through the liver. 17 However, with smaller disposable endoscopes, a transhepatic approach will work. Bleeding can be avoided by staged upsizing of the access.…”

“…21 Regarding timing of intervention, we typically perform gallstone extraction 4 to 6 weeks after initial placement of the cholecystostomy tube, consistent with previously reported techniques. 17,21 This allows time to perform a staged upsizing of the access approximately 2 weeks after initial placement, tract maturation to avoid intraperitoneal leaking, and time to be evaluated by outpatient surgical consultation to assess the patient's candidacy for interval cholecystectomy. We target and can generally achieve a single-session removal of all stone within one procedure, after which capping trial is performed for 2 weeks if the cystic duct is patent.…”

“…Reusable flexible and rigid endoscopes are available in a range of sizes. For the management of stones in the gallbladder, a 22.5-Fr rigid endoscope (Olympus) may translate to faster stone localization, destruction, and fragment removal, 17 but requires a capital investment. Recent developments in percutaneous gallstone extraction include the introduction of single-use disposable small-caliber endoscopes—such as the 10.5-Fr Boston Scientific Spyglass Discover—that avoid the large capital expenditure and sterilization requirements of reusable endoscopes and therefore hold promise to make these techniques more widely available to patients.…”