Endoscopic approach to biliary diseases in 2020: Is there still a role for direct peroral cholangioscopy?

ard endoscopic retrograde cholangio-pancreatography (ERCP) as a diagnostic and therapeutic approach to biliary disorders, including biliary strictures and choledocholithiasis. Peroral cholangioscopy was first described in 1976, using a fiberoptic cholangioscope and mother-baby technique [1, 2]. However, the mother-baby technique, which uses a standard duodenoscope as a platform to advance a dedicated small caliber cholangioscope into the bile duct through the working channel of the duodenoscope, has never been widely adopted in clinical routine. This was mainly due to the fragility of the baby scope, its limited maneuverability, the minute accessory channel, and the need for a second experienced endoscopist [3]. A new video cholangioscope was introduced in 1999 with high-quality digital imaging [4]. However, two experienced operators were still needed for the procedure and the problem of the fragility of the baby scope and high associated costs for repairs persisted. In 2007, a disposable single-operator cholangioscopy (SOC) system was introduced with superior four-way deflection capabilities, eliminating the need for a second endoscopist; however, its use was limited by the low image quality provided by the fiberoptic system and the high procedural costs [5]. Basically, direct peroral cholangioscopy (DPOC) promises to merge advantages of two worlds, namely standard upper and biliopancreatic endoscopy, while enabling high-quality visualization of the biliary lumen using high-definition endoscopes with magnification capabilities and the latest image enhancement technologies, providing good maneuverability with four-way deflection of a standard ultraslim endoscope, and allowing for intraductal treatment with standard-sized accessories under optical control [3]. Furthermore, DPOC is a single-operator procedure and the use of a reusable endoscope may reduce the overall costs. Since 2006, DPOC has been increasingly performed using standard upper endoscopes [3, 6–8]. However, the efficacy of its clinical application is mainly determined by crucial procedural steps: (1) intubation of the papillary orifice; and (2) advancement to the region of interest and stabilization within the biliary tree. While free-hand access to the common bile duct (CBD) is cumbersome and often impossible, success rates with DPOC were significantly improved to greater than 90% by accessories and technical refinements, i. e. , stiff guidewires, anchoring balloons, overtubes and other devices, that are used to enable biliary access and to stabilize the position within the bile duct, in various studies [7–11] However, application of these accessories and techniques rendered the DPOC procedure even more complex. Dedicated reusable cholangioscopes with multi-bending (MB) technology recently have been proposed to overcome these limitations and have been evaluated in clinical trials, showing high success rates for free-hand biliary access and diagnostic and therapeutic success [3, 12]. A prospective randomized controlled trial comparing DPOC using multibending and conventional technique reported a significantly higher success rate of freehand intubation and advancement to the hilum or the obstructed segment of the bile duct, respectively, of 89.1% in the MB group compared to 30.4% in the conventional group. Remarkably, mean procedure time for MB DPOC was only 3.2 minutes. While there were reports of major complications associated with DPOC in previous trials [13], i. e. fatal gas embolism or severe cholangitis, associated with DPOC in previous trials, no such adverse events were docuEndoscopic approach to biliary diseases in 2020: Is there still a role for direct peroral cholangioscopy?