Clinical Endoscopy

Review

Peroral cholangioscopy: past, present and future: Yuki Tanisaka, Robert Hawes; Clin Endosc 2025;58(3):360-369. Published online May 19, 2025; DOI: https://doi.org/10.5946/ce.2024.306

Abstract PDF PubReader ePub: Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the evaluation of biliary strictures and the management of bile duct stones. However, standard ERCP techniques sometimes fail for both indications. In such situations, peroral cholangioscopy (POCS), which allows direct visualization of the bile duct, can play a significant role in diagnosis and treatment. Direct visualization using POCS can help differentiate between malignant and benign conditions and is more accurate in defining the extent of cholangiocarcinoma. Furthermore, POCS enables visually guided biopsies. Certain types of difficult bile duct stones, such as impacted and intrahepatic stones, require POCS for visually guided lithotripsy. Recent advancements in POCS will broaden its applicability and improve its diagnostic utility. In this review, we provide perspectives on the past, present, and future of POCS.

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Original Article

Ex vivo cholangioscopy in liver grafts: a novel technique to assess the biliary tree during organ preservation and machine perfusion: a experimental non-clinical study: Mark Ly, Ngee-Soon Lau, Joanna Huang, Hayden Ly, Kasper Ewenson, Nicole Mestrovic, Paul Yousif, Ken Liu, Avik Majumdar, Geoffrey McCaughan, Michael Crawford, Carlo Pulitano; Clin Endosc 2025;58(2):303-310. Published online March 4, 2025; DOI: https://doi.org/10.5946/ce.2024.099

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: Biliary complications are a leading cause of morbidity after liver transplantation, but can be reduced using real-time assessment of the biliary tree. This study described a novel technique for performing ex vivo cholangioscopy during cold static storage and normothermic machine perfusion (NMP) to assess the biliary tree before liver transplantation.
Methods
Human donor livers, which were considered unsuitable for transplantation, were perfused at 36ºC using a modified commercial ex vivo perfusion system. Ex vivo cholangioscopy was performed using a SpyGlass Discover system. Cholangioscopy was performed during cold static storage and after 12 hours in NMP. Bile duct biopsies and confocal microscopy were performed.
Results
Ex vivo cholangioscopy was performed on eight grafts. During cold static storage, luminal debris was visualized throughout the biliary tree. After 12 hours of reperfusion, the bile ducts appeared hyperemic, heterogeneous, and mottled. Confocal microscopy confirmed perfusion of biliary microvasculature.
Conclusions
We describe the first use of ex vivo cholangioscopy to assess the biliary tree before liver transplantation. This real-time technique can be used to assess biliary trees during cold static storage and NMP. In addition, cholangioscopy-based interventions can be used to better assess intrahepatic bile ducts.

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Review

Intraductal ultrasonography for biliary strictures: Young Koog Cheon; Clin Endosc 2023;56(2):164-168. Published online February 17, 2023; DOI: https://doi.org/10.5946/ce.2022.184

Abstract PDF PubReader ePub

When diagnosing the nature of biliary strictures, it is sometimes difficult to perform non-invasive methods such as ultrasound, spiral computed imaging, magnetic resonance imaging, or endoscopic ultrasonography. Thus, treatment decisions are usually based on biopsy results. However, brush cytology or biopsy, which is widely used for biliary stenosis, has limitations owing to its low sensitivity and negative predictive value for malignancy. Currently, the most accurate method is bile duct tissue biopsy under direct cholangioscopy. On the other hand, intraductal ultrasonography administered under the guidance of a guidewire has the advantages of easy administration and being less invasive, allowing for adequate examination of the biliary tract and surrounding organs. This review discusses the usefulness and drawbacks of intraductal ultrasonography for biliary strictures.

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Chunyan Meng, Jing Wang, Peipei Zhang, Bo Wang
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Tongyi Huang, Zebang Yang, Xiaoli Wang, Jiaqian Yao, Lin Jiang, Xiaoyan Xie, Ming Xu, Xiaoer Zhang
Abdominal Radiology.2024; 50(5): 2078. CrossRef

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Case Report

Successful removal of remnant cystic duct stump stone using single-operator cholangioscopy-guided electrohydraulic lithotripsy: two case reports: Sung Hyeok Ryou, Hong Ja Kim; Clin Endosc 2023;56(3):375-380. Published online January 5, 2023; DOI: https://doi.org/10.5946/ce.2021.273

Abstract PDF PubReader ePub

Cholecystectomy is the best method for treating gallstone diseases. However, 10%–30% of patients who undergo a cholecystectomy continue to complain of upper abdominal pain, dyspepsia, or jaundice—this is referred to as postcholecystectomy syndrome. Cystic duct stump stones are a troublesome cause of postcholecystectomy syndrome. Conventionally, surgery is mainly performed to remove cystic duct stump stones. However, repeated surgery can cause complications, such as postoperative bleeding, biliary injury, and wound infection. As an alternative method of surgery, endoscopic retrograde cholangiopancreatography is sometimes used to remove cystic duct stump stones, although the success rate is not high due to technical difficulties. Recently, peroral cholangioscopy, which can directly observe the bile duct, has been suggested as an alternative method. We report two cases in which a cystic duct stump stone was successfully removed via a single-operator cholangioscopy, after failure with an endoscopic retrograde cholangiopancreatography.

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Clinical perspectives on post-cholecystectomy syndrome: a narrative review
Changjin Nam, Jun Suh Lee, Ji Su Kim, Tae Yoon Lee, Young Chul Yoon
Annals of Medicine.2025;[Epub] CrossRef
Holmium Laser Lithotripsy in the Management of Difficult Biliary and Cystic Ductal Stones – A Case Series
Amit Kumar, Harindra Kumar Goje, Nimesh Kumar Tarway, Vivek Hande
Journal of Marine Medical Society.2024;[Epub] CrossRef
Laparoscopic management of remnant gall bladder with stones: Lessons from a tertiary care centre's experience
Gilbert Samuel Jebakumar, Jeevanandham Muthiah, Loganathan Jayapal, R. Santhosh Kumar, Siddhesh Tasgaonkar, K.S. Santhosh Anand, J.K.A. Jameel, Sudeepta Kumar Swain, K.J. Raghunath, Prasanna Kumar Reddy, Tirupporur Govindaswamy Balachandar
Laparoscopic, Endoscopic and Robotic Surgery.2024; 7(1): 27. CrossRef
A remnant cystic duct presenting as a duodenal subepithelial tumor
Gwang Ha Kim, Dong Chan Joo
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Original Article

Comparison of tube-assisted mapping biopsy with digital single-operator peroral cholangioscopy for preoperative evaluation of biliary tract cancer: Tsuyoshi Takeda, Takashi Sasaki, Takafumi Mie, Takeshi Okamoto, Chinatsu Mori, Takaaki Furukawa, Yuto Yamada, Akiyoshi Kasuga, Masato Matsuyama, Masato Ozaka, Naoki Sasahira; Clin Endosc 2022;55(4):549-557. Published online July 20, 2022; DOI: https://doi.org/10.5946/ce.2021.227

Abstract PDF PubReader ePub

Background
/Aims: Digital single-operator cholangioscopy (DSOC)-guided mapping biopsy (DMB) and tube-assisted mapping biopsy (TMB) are two techniques used for preoperative evaluation of biliary tract cancer (BTC). However, data regarding the diagnostic performance of these techniques are limited.
Methods
We retrospectively examined consecutive patients with BTC who underwent either technique at our institution between 2018 and 2020. We evaluated the technical success rate, adequate tissue acquisition rate, and diagnostic performance of these techniques for the evaluation of lateral spread of BTC.
Results
A total of 54 patients were included in the study. The technical success rate of reaching the target sites was 95% for DMB and 100% for TMB. The adequate tissue acquisition rate was 61% for DMB and 69% for TMB. The adequate tissue acquisition rate was low, especially for target sites beyond the secondary biliary radicles. The sensitivity of DMB alone was 39%, which improved to 65% when combined with visual impression. Experts demonstrated a higher negative predictive value and diagnostic accuracy with respect to both DSOC visual impression and DMB for the evaluation of lateral spread of BTC compared to trainees.
Conclusions
Adequate tissue acquisition rates were similar between the two techniques. Since DMB requires expertise, TMB may be an acceptable option when DSOC is unavailable or when DSOC expertise is limited.

Citations

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Usefulness of a novel 11F digital single‐operator cholangioscopy through a colonoscope in a patient with surgically altered anatomy
Takafumi Mie, Tsuyoshi Takeda, Takashi Sasaki
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Aymeric Becq, Adil Soualy, Marine Camus
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Case Report

Successful Removal of a Difficult Common Bile Duct Stone by Percutaneous Transcholecystic Cholangioscopy: Hyunsuk Lee, Sang Hyub Lee, Gunn Huh, Yeji Kim, Saebeom Hur, Moonhaeng Hur, Minwoo Lee, Byeongyun Ahn; Clin Endosc 2022;55(2):297-301. Published online May 4, 2021; DOI: https://doi.org/10.5946/ce.2020.301

Abstract PDF PubReader ePub

Common bile duct (CBD) stones are prevalent in 11% to 21% of patients with gallstones and can cause various clinical manifestations, from biliary colic to biliary sepsis. The treatment of choice is endoscopic retrograde cholangiopancreatography, but approximately 5% to 10% of CBD stones are difficult to remove using these conventional endoscopic methods. Although percutaneous transhepatic cholangioscopy and lithotripsy can be used as an alternative, it can be technically demanding and risky if the intrahepatic duct is not dilated. We report a case of a large CBD stone that was successfully removed using percutaneous transcholecystic cholangioscopy.

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PERcutaneous transhepatic CHOLangioscopy using a new single‐operator short cholangioscope (PERCHOL): European feasibility study
Enrique Pérez‐Cuadrado‐Robles, Simon Phillpotts, Michiel Bronswijk, Claudio Cim Conrad, Cecilia Binda, Laurent Monino, Kirill Basiliya, Marcus Hollenbach, Apostolis Papaefthymiou, Hadrien Alric, Lucille Quénéhervé, Alessandro Di Gaeta, Mathieu Pioche, Ari
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V. Sánchez-Cerna, G. Araujo-Almeyda, J. Aliaga-Ramos, T. Reyes-Mugruza, W. Celedonio-Campos
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V. Sánchez-Cerna, G. Araujo-Almeyda, J. Aliaga-Ramos, T. Reyes-Mugruza, W. Celedonio-Campos
Revista de Gastroenterología de México (English Edition).2024; 89(3): 451. CrossRef

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Review

Cracking Difficult Biliary Stones: Phonthep Angsuwatcharakon, Rungsun Rerknimitr; Clin Endosc 2021;54(5):660-668. Published online March 16, 2021; DOI: https://doi.org/10.5946/ce.2020.256-IDEN

Abstract PDF PubReader ePub

Apart from difficult biliary cannulation, biliary stone removal is considered one of the hurdles in endoscopic retrograde cholangiopancreatography. Generally, simple common bile duct (CBD) stones can be removed either with an extraction balloon or a basket. However, there are difficult stones that cannot be removed using these standard methods. The most difficult stones are large CBD stones and impacted stones in a tapering CBD. A few decades ago, mechanical lithotripsy was usually required to manage these stones. At present, endoscopic papillary large balloon dilation (EPLBD) of the biliary orifice has become the gold standard for large CBD stones up to 1.5 cm. EPLBD can reduce the procedural time by shortening the stone removal process. It can also save the cost of the devices, especially multiple baskets, used in mechanical lithotripsy. Unfortunately, very large CBD stones, stones impacted in a tapering CBD, and some intrahepatic duct stones still require lithotripsy. Peroral cholangioscopy provides direct visualization of the stone, which helps the endoscopist perform a probe-based lithotripsy either with an electrohydraulic probe or a laser probe. This technique can facilitate the management of difficult CBD stones with a high success rate and save procedural time without significant technical complications.

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Cholangioscopy as a rescue for a post-cholecystectomy adherent stone formed around a migrated surgical clip in the common bile duct
Chukwunonso Ezeani, Samuel O. Igbinedion, Kwabena Asafo-Agyei, Erik A. Holzwanger, Sultan Mahmood, Mandeep S. Sawhney, Tyler M. Berzin, Moamen Gabr, Douglas K. Pleskow
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A. K. Uribe Rivera, B. Seeliger, C. A. Saldivar, E. Houghton, F. Rodríguez, P. Acquafresca, M. Palermo, M. E. Giménez
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Ruchi Sharma, Vikram Sharma, Umang Singhal, Madhusudhan Sanaka
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Case Report

Minimally Invasive Approach Using Digital Single-Operator Peroral Cholangioscopy-Guided Electrohydraulic Lithotripsy and Endoscopic Nasogallbladder Drainage for the Management of High-Grade Mirizzi Syndrome: Hyung Ku Chon, Chan Park, Tae Hyeon Kim; Clin Endosc 2021;54(6):930-934. Published online February 18, 2021; DOI: https://doi.org/10.5946/ce.2021.015

Abstract PDF PubReader ePub

Mirizzi syndrome is a rare complication of gallbladder disease that can be difficult to treat. In particular, endoscopic treatment often fails because of the inability to access or to capture the impacted cystic duct stone. We report a case of Mirizzi syndrome grade III that was successfully managed by digital single-operator peroral cholangioscopy-guided electrohydraulic lithotripsy with endoscopic nasogallbladder drainage and interval laparoscopic cholecystectomy. Based on our experience, digital single-operator peroral cholangioscopy-guided electrohydraulic lithotripsy with endoscopic nasogallbladder drainage is a feasible minimally invasive approach for the management of high-grade Mirizzi syndrome.

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Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques
Edoardo Troncone, Michelangela Mossa, Pasquale De Vico, Giovanni Monteleone, Giovanna Del Vecchio Blanco
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Rishi Pawa, Robert Dorrell, Swati Pawa
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Mirizzi Syndrome Type IV Successfully Treated with Peroral Single-operator Cholangioscopy-guided Electrohydraulic Lithotripsy: A Case Report with Literature Review
Hirokazu Kawai, Toshifumi Sato, Masaaki Natsui, Kotaro Watanabe, Ryosuke Inoue, Mayuki Kimura, Kazumi Yoko, Syun-ya Sasaki, Masashi Watanabe, Taku Ohashi, Akihiro Tsukahara, Norio Tanaka, Yoshihisa Tsukada
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Focused Review Series: Expanding Indication: Interventional Endoscopic Management for Pancreaticobiliary Diseases

Endoscopic Ultrasound-Guided Biliary Drainage for Benign Biliary Diseases: Yousuke Nakai, Hirofumi Kogure, Hiroyuki Isayama, Kazuhiko Koike; Clin Endosc 2019;52(3):212-219. Published online March 14, 2019; DOI: https://doi.org/10.5946/ce.2018.188

Abstract PDF PubReader ePub

Although endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for benign biliary diseases, this procedure is technically difficult in some conditions such as a surgically altered anatomy and gastric outlet obstruction. After a failed ERCP, a surgical or a percutaneous approach is selected as a rescue procedure; however, various endoscopic ultrasound (EUS)-guided interventions are increasingly utilized in pancreatobiliary diseases, including EUS-guided rendezvous for failed biliary cannulation, EUS-guided antegrade treatment for stone management, and EUS-guided hepaticogastrostomy for anastomotic strictures in patients with a surgically altered anatomy. There are some technical hurdles in EUS-guided interventions for benign biliary diseases owing to the difficulty in puncturing a relatively small bile duct and in subsequent guidewire manipulation, as well as the lack of dedicated devices. A recent major advancement in this field is the introduction of a 2-step approach, in which EUS-guided drainage is placed in the first session and antegrade treatment is performed in subsequent sessions. This approach allows the use of various techniques such as mechanical lithotripsy and cholangioscopy without a risk of bile leak. In summary, EUS-guided interventions are among the treatment options for benign biliary diseases; however, standardization of the procedure and development of a treatment algorithm are needed.

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Case Report

Treatment Using the SpyGlass Digital System in a Patient with Hepatolithiasis after a Whipple Procedure: Hirofumi Harima, Kouichi Hamabe, Fusako Hisano, Yuko Matsuzaki, Tadahiko Itoh, Kazutoshi Sanuki, Isao Sakaida; Clin Endosc 2018;51(6):596-599. Published online May 23, 2018; DOI: https://doi.org/10.5946/ce.2018.057

Abstract PDF Supplementary Material PubReader ePub: An 89-year-old man was referred to our hospital for treatment of hepatolithiasis causing recurrent cholangitis. He had undergone a prior Whipple procedure. Computed tomography demonstrated left-sided hepatolithiasis. First, we conducted peroral direct cholangioscopy (PDCS) using an ultraslim endoscope. Although PDCS was successfully conducted, it was unsuccessful in removing all the stones. The stones located in the B2 segment were difficult to remove because the endoscope could not be inserted deeply into this segment due to the small size of the intrahepatic bile duct. Next, we substituted the endoscope with an upper gastrointestinal endoscope. After positioning the endoscope, the SpyGlass digital system (SPY-DS) was successfully inserted deep into the B2 segment. Upon visualizing the residual stones, we conducted SPY-DS-guided electrohydraulic lithotripsy. The stones were disintegrated and completely removed. In cases of PDCS failure, a treatment strategy using the SPY-DS can be considered for patients with hepatolithiasis after a Whipple procedure.

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Focused Review Series: Pancreatobiliary endoscopy in altered gastointestinal anatomy

Percutaneous Transhepatic Cholangioscopy in Bilioenteric Anastomosis Stricture: Hyoung-Chul Oh; Clin Endosc 2016;49(6):530-532. Published online September 19, 2016; DOI: https://doi.org/10.5946/ce.2016.125

Abstract PDF PubReader ePub

Bilioenteric anastomosis strictures are a serious complication of biliary surgery, and often result in recurrent cholangitis, choledocholithiasis, biliary cirrhosis, and hepatic failure. Bilioenteric reconstructive surgery is the standard treatment of choice for such complications. However, percutaneous transhepatic cholangioscopy (PTCS), also known as per-oral endoscopic-guided intervention, is a less invasive procedure that is becoming an increasingly popular alternative. This review describes the PTCS procedure (including the preparation process), as well as the diagnostic and therapeutic role of PTCS in bilioenteric anastomosis strictures.

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Focused Review Series: Image Enhanced Endoscopy

Advanced Imaging Technology in Biliary Tract Diseases:Narrow-Band Imaging of the Bile Duct: Hyun Jong Choi, Jong Ho Moon, Yun Nah Lee; Clin Endosc 2015;48(6):498-502. Published online November 30, 2015; DOI: https://doi.org/10.5946/ce.2015.48.6.498

Abstract PDF PubReader ePub

Newly introduced direct peroral cholangioscopy and the development of video choledochoscopes have enabled more defined observation of bile duct mucosal lesions with clearer images. Narrow-band imaging (NBI) is a unique endoscopic imaging technology that provides enhanced endoscopic images of surface mucosal structures and its superficial microvessels. Advanced cholangioscopy and NBI are expected to be useful for precise evaluation and correct diagnosis of biliary tract diseases. However, the diagnostic value of advanced bile duct imaging with cholangioscopy requires further evaluation.

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Special Issue Articles of IDEN 2013

The Role of Direct Peroral Cholangioscopy Using an Ultraslim Endoscope for Biliary Lesions: Indications, Limitations, and Complications: Jong Ho Moon, Hyun Jong Choi; Clin Endosc 2013;46(5):537-539. Published online September 30, 2013; DOI: https://doi.org/10.5946/ce.2013.46.5.537

Abstract PDF PubReader ePub

Advantages of direct peroral cholangioscopy (POC) using an ultraslim endoscope include use of conventional endoscopy equipment, operation by a single endoscopist, and superior image quality of the biliary tree with easy application of enhanced endoscopy and a large working channel. The major diagnostic indications of this system are an evaluation of biliary strictures, filling defects, or unclear findings on cholangiogram or other imaging studies. Therapeutic application using a direct POC system can be broadened by a larger working channel. However, direct POC is difficult to apply in patients with a narrow diameter bile duct, far distal common bile duct lesion, or failed anchoring of the scope with accessories. An air embolism is a rare complication of direct POC but can be a fatal problem. Cholangitis can also occur during or after the procedure. Use of a CO₂ system instead of room air during the POC procedure and administration of antibiotics before and after the procedure are strongly recommended. Continuous development of specialized endoscopes and accessories is expected to facilitate the diagnostic and therapeutic roles of direct POC.

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Percutaneous Transhepatic Cholangioscopy: Does Its Role Still Exist?: Joon Hyuk Choi, Sung Koo Lee; Clin Endosc 2013;46(5):529-536. Published online September 30, 2013; DOI: https://doi.org/10.5946/ce.2013.46.5.529

Abstract PDF PubReader ePub

Percutaneous transhepatic cholangioscopy (PTCS) is the most widely used modality for diagnosis and treatment of biliary disease. Although many other novel technologies have been developed based on recent advances in endoscopy, PTCS has its own role. In diagnostics, PTCS is used for evaluation of indeterminate biliary strictures, bile duct tumors, and postoperative biliary strictures that cannot be reached by a peroral approach. In therapeutics, the removal of bile duct stones, dilatation of bile duct strictures including postoperative anastomosis site strictures, and local tumor therapy are indications of PTCS. Especially in a therapeutic role, PTCS has the advantage of maneuverability due to a shorter endoscopic length compared to other cholangioscopic modalities. Hence, PTCS has its own indispensable diagnostic and therapeutic roles.

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Special Issue Articles of IDEN 2012

Spyglass Direct Visualization System: Michel Kahaleh; Clin Endosc 2012;45(3):316-318. Published online August 22, 2012; DOI: https://doi.org/10.5946/ce.2012.45.3.316

Abstract PDF PubReader ePub

Although endoscopic retrograde cholangiopancreatography is considered the gold standard to manage biliary disorders, it has its own limitations. The single-operator cholangioscopy (SOC) system (Spyglass) may offer an interesting compromise for most advanced biliary endoscopists, in terms of size (10 Fr diameter) and complexity of use. SOC is a great step toward intraductal visualization and therapy but the best is yet to come.

Citations

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A. K. Uribe Rivera, B. Seeliger, C. A. Saldivar, E. Houghton, F. Rodríguez, P. Acquafresca, M. Palermo, M. E. Giménez
Surgical Endoscopy.2023; 37(10): 7774. CrossRef
Single-operator peroral pancreatoscopy in the preoperative diagnostics of suspected main duct intraductal papillary mucinous neoplasms: efficacy and novel insights on complications
Sini Vehviläinen, Niklas Fagerström, Roberto Valente, Hanna Seppänen, Marianne Udd, Outi Lindström, Harri Mustonen, Fredrik Swahn, Urban Arnelo, Leena Kylänpää
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Endoscopic direct visualization of gallbladder polypoid lesion using peroral digital single-operator cholangioscopy
Hideki Kamada, Hideki Kobara, Hiroki Yamana, Keiichi Okano, Yasuyuki Suzuki, Naoki Fujita, Tsutomu Masaki
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Hirohito Minami, Shuntaro Mukai, Atsushi Sofuni, Takayoshi Tsuchiya, Kentaro Ishii, Reina Tanaka, Ryosuke Tonozuka, Mitsuyoshi Honjo, Kenjiro Yamamoto, Kazumasa Nagai, Yukitoshi Matsunami, Yasutsugu Asai, Takashi Kurosawa, Hiroyuki Kojima, Toshihiro Homma
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Gastrointestinal Endoscopy.2020; 91(2): 385. CrossRef
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Two Cases of Percutaneous Transhepatic Choledochoscopy Treatment of Intrahepatic Duct Stones that Occurred after Living Donor Liver Transplantation: Byung Jun Lee, M.D., Jong Yun Won, M.D.*, Nu Ri Chon, M.D., Se-Joon Lee, M.D. and Dong Ki Lee, M.D.; Korean J Gastrointest Endosc 2008;36(5):318-323. Published online May 30, 2008

Abstract PDF: Percutaneous transhepatic cholangioscopy (PTCS) is the primary treatment option for general cases of intrahepatic duct stones. However, there are no reports on the use of PTCS for intrahepatic duct stones in patients who had undergone living donor liver transplantation (LDLT). We experienced two cases of successful intrahepatic stone removal by the use of PTCS in LDLT patients. With these cases, we have confirmed that PTCS management can be safely performed not only for a general bile duct stone, but also for a bile duct stone that develops in a patient that had previously undergone liver transplantation. (Korean J Gastrointest Endosc 2008;36:318-323)

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Two Cases of Direct Peroral Cholangioscopy Using an Ultra-Slim Upper Endoscope Endoscopic after Stone Removal: Jong Chan Lee, M.D., Jong Ho Moon, M.D., Bong Min Go, M.D., Hyun Jong Choi, M.D., Hyun Cheol Koo, M.D., Young Koog Cheon, M.D., Young Deok Cho, M.D., Joon Seong Lee, M.D., Moon Sung Lee, M.D., Chan Sup Shim, M.D. and Boo Sung Kim, M.D.; Korean J Gastrointest Endosc 2007;35(5):373-376. Published online November 30, 2007

Abstract PDF: Peroral cholagioscopy is a good procedure that permits direct visualization of the biliary tree and target biopsies of lesions. However, peroral cholangioscopy with a mother- baby system requires two experienced endoscopists, and the procedure remains time consuming and expensive and the apparatus is easily broken. Therefore, an easier technique to get direct visual examination of the biliary tree is needed. Direct peroral cholangioscopy (direct POC) with using an ultra-slim upper endoscope was performed in two patients after endoscopic stone removal for diagnosing their biliary stricture. One patient had wire-guided direct POC performed and the patient was diagnosed benign biliary stricture on the proximal CBD after forcep biopsy. Another patient had overtube-assisted direct POC performed and that patient was found to have a polypoid lesion at the bifurcation. Future advances in endoscope development, as well as specifically designed accessories, are expected to increase its clinical utility. Korean J Gastrointest Endosc 2007;35: 373-377)

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Usefulness of Percutaneous Transhepatic Cholangioscopy for Treatment of Intrahepatic Duct and Common Bile Stones and Diagnosis of Intrahepatic Duct Lesions with Biopsy: Hyeon Woong Yang, M.D.*, Byung Seok Lee, M.D., Seon Moon Kim, M.D., Yoon Sae Kang, M.D., Jae Hoon Jung, M.D., Yeon Soo Kim, M.D., Gi Oh Park, M.D., Jae Kyu Seong, M.D., Seok Hyun Kim, M.D. and Heon Young Lee, M.D.; Korean J Gastrointest Endosc 2006;33(1):26-31. Published online July 30, 2006

Abstract PDF: Background
/Aims: Despite several limitations, percutaneous transhepatic cholangioscopy (PTCS) has been useful in patients with intrahepatic stone, common bile duct stone or intrahepatic bile duct stricture. We investigated the usefulness and limitation of PTCS, and the recurrence rate after stone removal. Methods: PTCS was performed on 49 patients with intrahepatic duct (IHD) stones or common bile duct (CBD) stones and 11 patients undergoing biopsy who visited Chung Nam university hospital between 1999 and 2003. Results: Complete removal rate of patients with IHD and CBD stones was 75% (21/28) and 91% (19/21), respectively. Biopsy results by PTCS were in agreement with the final result in 86% (6/7). In patients with IHD stones, the PTCS complication rate was 29% (8/28). Bleeding was most common (21%) but was self limited. In patients with CBD stones, the PTCS complication rate was 9% (2/9). One case was bleeding and the other was death by aggravation of general condition. In patients with IHD stones, the recurrence rate was 29% (5/17). Conclusions: In conclusion, PTCS is useful to treat patients with IHD stones, as well as the few patients with failed CBD stone removal by ERCP and diagnosis of stricture in the bile duct. (Korean J Gastrointest Endosc 2006;33:26⁣31)

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Percutaneous Transhepatic Therapy Using Cholangioscopy in Patients with Benign Bilio-Enteric Anastomotic Strictures: Jung-Ho Kim, M.D., Sung-Koo Lee, M.D., Do Hyun Park, M.D., Hyun Kuk Kim, M.D., Sun Young Kim, M.D., Sang Soo Lee, M.D., Dong-Wan Seo, M.D., Myung-Hwan Kim, M.D. and Young-Il Min, M.D.; Korean J Gastrointest Endosc 2003;26(3):133-140. Published online March 31, 2003

Abstract PDF: Background
/Aims: Percutaneous transhepatic therapy (PTT) is a non-operative procedure for anastomotic strictures after bilio-enteric anastomosis which cannot be reached via transpapillary route. The aim of this study was to evaluate immediate and long-term results of the PTT using cholangioscopy in patients with benign bilio-enteric anastomotic strictures. Methods: We conducted a retrospective analysis on 22 patients who had undergone PTT for bilio-enteric anastomotic strictures between October 1994 and March 2001. The follow-up duration was 12 to 79 months after PTT (mean 33.0 months). Results: The initial technical success rate was 100%, and the short-term morbidity and mortality rates were 13.5% and 0%, respectively. However, 9 patients developed recurrent strictures (40.9%) with a mean duration of 16.8 months (range: 2 to 38). The success rate without recurrence was 59.1% and the overall success rate was 77.3% when the procedures were repeated. The long term morbidity rate was 36%, but most morbidities resolved with medical treatments. In 18 patients (81.8%), bile duct stones were combined and successfully treated by percutaneous transhepatic cholangioscopy (overall clearance rate: 94.4%, recurrence rate: 39.8%). Conclusions: The PTT using cholangioscopy in patients with benign bilio-enteric anastomotic strictures is a safe and effective method, and it appears a minimally invasive alternative to surgery. (Korean J Gastrointest Endosc 2003;26:133⁣140)

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Efficacy of Percutaneous Treatment of CBD Stones Which Could: Jung In Seo, M.D., Dong Ki Lee, M.D., Yeun Jong Choi, M.D., Phil Ho Jeong, M.D.,Moon Young Kim, M.D., Dong Hoon Park, M.D., Hyun Soo Kim, M.D.,Soon Koo Baik, M.D. and Sang Ok Kwon, M.D.; Korean J Gastrointest Endosc 2002;25(6):443-448. Published online December 30, 2002

Abstract PDF: Background
/Aims: Common bile duct (CBD) stones can be removed by endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) in most cases. In addition, surgery or stenting as well as percutaneous transhepatic cholangioscopy (PTCS) with lithotripsy can be used to remove CBD stones also. In this study we evaluated the efficacy of percutaneous removal of CBD stones which could not be removed by per-oral endoscopic method. Methods: From Jan. 1998 to Sep. 2001, ERCP were tried to remove CBD stones in 395 patients. We reviewed causes of treatment failure through the peroral method and PTCS-results by the medical records and cholangiograms in 15 patients. Results: We successfully removed stones with PTCS in all 15 patients. The reasons for percutaneous approach were previous operation history in 8 (53.3%) and old age in 10 (66.7%). Mean number and size of stone were 4.4 and 17.4⁓13.1 mm, respectively. Complete fragmentation and removal of stones were achieved in a single session in 40%. Mean time to complete removal was 19 days. In 1 patient, bile peritonitis was developed but cured by conservative management alone. Conclusions: PTCS with or without lithoptripsy is an effective and safe method for the treatment of CBD stones which can not be removed by peroral endoscopic approach. (Korean J Gastrointest Endosc 2002;25:443⁣448)

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간문부 담관암의 담도내 종적 침윤 평가에 있어 자기공명 담관조영술과 경피경간 담도경 성적의 비교: Korean J Gastrointest Endosc 2001;23(5):318-318. Published online November 30, 2000

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원저 / 담도암 환자에서 담도경적 조직 검사 결과에 영향을 미치는 인자 ( Factors Affecting the Yield of Cholangioscopic Biopsy in the Patients with Bile Duct Cancer ): Korean J Gastrointest Endosc 2001;22(3):146-151. Published online November 30, 2000

Abstract PDF: Background
/Aims: This study analyzed the factors associated with the yield of percutaneous transhepatic cholangioscopic biopsies in patients with bile duct cancer. Methods: One hundred and sixteen patients who had received percutaneous transhepatic cholangioscopy and who had been confirmed as having bile duct cancer were enrolled in this study. Results: When the location of the tumor was divided into intrahepatic (IHD), hilar and common bile duct, the biopsy yield was significantly higher in IHD cancer (93.7%) than in cases of hilar cancer (69.6%) (p<0,05). After a bile duct cancer had been classified as a nodular (n=31), papillary (n=27) or infiltrative type (n=58) upon cholangioscopic findings, the biopsy yields from nodular (96.8%) or papillary types (96,3%) were significantly higher than from infiltrative types (58.6%; p<0.01). However, cholangioscopic classification of bile duct cancer was the only independent factor affecting biopsy yield by multiple logistic regression analysis (p=0,001). The sensitivity of the combination of cholangioscopic biopsy and tumor vessel in overall bile duct cancer, especially in the infiltrative type, was significantly increased when it was compared with that for cholangioscopic biopsies (p<0.01) or for tumor vessels alone (p<0,01). Conclusions: The cholangioscopic classification of bile duct tumors might provide important clues to predict biopsy yield. (Korean J Gastrointest Endosc 2001;22:146 - 151)

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담석과 관련이 없는 간내 담도의 국소적 협착을 가진 환자들에서의 담도경의 유용성 ( Usefulness of Cholangioscopy in Patients with Focal Stricture of the Intrahepatic Duct Unrelated to Intrahepatic Stones ): Korean J Gastrointest Endosc 2000;21(4):786-792. Published online November 30, 1999

Abstract PDF: Background
/Aims: Intrahepatic duct strictures are usually caused by intrahepatic duct stones and. cholangitis, However, focal strictures of the intrahepatic duct unrelated to intrahepatic stones often pose diagnostic problems. This study was undertaken to prospectively evaluate the usefuless of percutaneous transhepatic cholangioscopy in patients with a focal intrahepatic duct stricture and no evidence of a stone. Methods: Twenty two patients with a focal stricture of the intrahepatic duct not related to intrahepatic stones were included. Percutaneous transhepatic cholangioscopic examination including procurement of a biopsy specimen was performed after percutaneous transhepatic biliary drainage. Results: A histopathologic diagnosis was obtained in all patients (10 adenocarcinoma, 1 squamous cell carcinoma, 2 hepatocellular carcinoma, 2 adenoma and 7 benign strictures). Of the 10 patients with bile duct adenocarcinoma, 9 underwent surgery and a curative resection was possible in 8 patients (89%). Six patients (67%) had early-stage bile duct cancer in which the cancer invasion was limited to the mucosa or fibromuscular layer and there was no evidence of lymph node metastasis. Conclusions: Percutaneous transhepatic cholangioscopy in patients with focal stricture of the intrahepatic duct unrelated to choledocholithiasis seems to be very useful for the differential diagnosis including the detection of early bile duct cancer.

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담도 종양들의 조직학적 특성에 따른 담도경 소견 ( Cholangioscopic Findings of Various Bile Duct Tumors According to Histology ): Korean J Gastrointest Endosc 2000;21(4):780-785. Published online November 30, 1999

Abstract PDF: Background
/Aims: The technique of cholangioscopy has been used in the treatment of bile duct stones or for the diagnosis of various bile duct tumors. However, the cholangioscopic characteristics of the various types of bile duct tumors have not yet been clearly described. Therefore, we analyzed the results of our cholangioscopic examinations and classified the cholangioscopic findings according to tumor histology. Methods: The cholangioscopic finding from 111 patients who had benign or malignant bile duct tumors were reviewed. The mucosal changes, the presence of neovascularization, and the patterns of luminal narrowing were analyzed and compared with the histologic diagnosis, Results: Bile duct adenocarcinoma can be classified into three different types according to the cholangioscopic findings: nodular, papillary, and infiltrative. Bile duct adenoma, hepatocellular carcinoma and other types of bile duct cancer such as mucin-hypersecreting cholangiocarcinoma, biliary cystadenocarcinoma, squamous cell carcinoma also presented with their unique cholangioscopic characteristics. Conclusions: Bile duct tumors seem to show characteristic cholangioscopic findings according to their histology. Cholangioscopic examination seems to be a useful technique in the differential diagnosis of bile duct tumors.

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간내 담도의 유두종으로부터 악성 변화한 유두상 선암 1예 ( A Case of Papillary Adenocarcinoma of Intrahepatic Duct ; Malignant Transformation from Papillary Adenoma ): Korean J Gastrointest Endosc 2000;20(4):317-321. Published online November 30, 1999

Abstract PDF: Biliary papilloma usually consists of single or multiple papillary adenomas in the biliary tract and has a potential for recurrence and malignant transformation. We described herein a case of papillary adenoma of intrahepatic duct that transformed into papillary adenocarcinoma. A 49-year-old male patient was admitted to our hospital because of right upper quadrant pain. A CT scan revealed marked dilatation of S7 segmental duct and cholangioscopy and biopsy revealed mucin-secreting papillary adenoma in the right intrahepatic duct. Three years later, a follow up of CT scan showed aggravated S7 ductal dilatation and inner ill-defined mass. Cholangioscopy revealed multiple papillary mucosal projections with large amount of mucin in the right intrahepatic duct and biopsy revealed well differentiated papillary adenocarcinoma. The patient underwent right lobectomy, the papillary adenocarcinoma was extended in the dilated right intrahepatic duct and also showed hepatic parenchymal invasion. (Korean J Gastrointest Endosc 2000;20:317-321)

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원저 : 담도 췌장 : 담도의 다발성 유두종 9예 ( Original Articles : Biliary Tract & Pancreas ; An Analysis of Nine Cases of Multiple Biliary Papillomatosis ): Korean J Gastrointest Endosc 1998;18(5):681-689. Published online November 30, 1997

Abstract PDF: Background
and Study Aims: Multiple biliary papillomatosis (MBP) is an uncommon disease. This study was undertaken to review cases with respect to describing clinical features and characteristical cholangiographic findings, and to define the role of cholangioscopy in the diagnosis and treatment of this disorder. Patients and Methods: from 1990 to 1997, nine patients (mean age; 57.3 years, 6 men and 3 women) were diagnosed as having MBP arnong 5,361 cases of endoscopic retrograde cholangiography (ERC) conducted at our center. A retrospective analyses of the cholangiographic and cholangioscopic findings as well as clinieal features were performed.(Korean J Gastrointest Endosc 18: 681-687, 1998)

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원저 : 담도 췌장 ; 담도계 질환에 있어서 경구적 담도내시경검사의 유용성 ( Case Reports : Biliary Tract & Pancreas ; Clinical Application of Peroral Cholangioscopy in Biliary Diseases ): Korean J Gastrointest Endosc 1998;18(2):176-182. Published online November 30, 1997

Abstract PDF: Background
Peroral cholangioscopy (PCS) was usually conducted for a differential diagnosis in cases which were difficult to diagnose on a routine endoscopic retrograde cholangiogram (ERC) or during fragmentation of a large bile duct stone with electrohydraulic lithotripsy. This study was conducted to evaluate the clinical utility of a PCS in biliary diseases. Method: We retrospectively reviewed the clinical records of 31 patients in whom a PCS was performed to evaluate various biliary diseases from July 1991 to Aug. 1996. Result: A peroral cholangioscope was successfully inserted into the bile duct in 90.3% (28/31) of the patients. The underlying diseases included bile duct stones (11 cases), bile duct cancer (9 cases), benign bile duct strictures (2 cases), benign bile duct turnors (2 cases), biliary cystadenocarcinoma (2 cases), emboli of the HCC in the bile duct(1 case), and common bile duct polyposis (1 case). Most PCSs were performed for the differential diagnosis between benign and malignant bile duct strictures or obstructions (14 cases) and fragmentation of large bile duct stone with electrohydraulic lithotripsy (10 cases). Overall, the success rate was 78.6% (22/28) in achieving the purpose 88.9% (16/18) in diagnostic aim and 60.0% (6/10) in therapeutic aim. Complications from the PCS occurred in 4 cases (14.3%). Cholangitis and acute pancreatitis was found in 1 case and asymptomatic hyperamylasemia were discovered in 2 cases. Conclusion: PCS plays a major role in confirming difficult cases to diagnose using on ERC and fragment to remove large cornmon bile duct stones. (Korean J Gastrointest Endosc 18: 176-182, 1998)

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원저 : 담도 췌장 ; 췌담도계 질환에서 관내 내시경 ( Intraductal endoscope ) 의 유용성 ( Original Articles : Biliary Tract & Pancreas ; Usefulness of Intraductal Endoscopy for Pancreaticobiliary Disease ): Korean J Gastrointest Endosc 1997;17(1):32-40. Published online November 30, 1996

Abstract PDF: Background
/Aims: The aim of this study was to evaluate the usefulness of intraductal endoscopy in pancreaticobiliary tract disease by means of percutaneous cholangioscopy(PCS), peroral cholangioscopy(POCS) and peroral pancteatoscopy(POPS). Methods: PCS was performed in 33 patients, including 24 patients with biliary tract stones, and 8 patients with malignant biliary tract disease, and one with villous adenoma of common bile duct(CBD), POCS was performed in 5 patients, including two with cholangiocarcinoma, two with icteric hepatoma and one with benign stenosis of bile duct. POPS performed in 6 patients, ineluding 3 patients with chronic pancreatitis, two with pancreatic cancer and one with mucinous ductal ectasia. Results: 1. Complete removal of the stones was achieved in 22 of 24 patie~nts(91.7%). 2. Accuracy rate of forceps biopsy in PCS was achieved 13 fo 14 patients(92.9%). 3. Success rate of therapeutic PCS was 100%. 4. Accuracy rate of forceps biopsy in POCS was achieved 3 of 5 patients(60%). 5. Diagnostic gain of POPS was achieved 5 of 6 patients(83.3%). 6. There was no serious complications with only mild complications in 3 patients, including mild bleeding in 2 patients and cholangitis in only one. Conclusions: Intraductal endoscopy of biliary tract, including PCS and POCS were useful diagnostic and therapeutic methods with advantages of direct visualization of intraductal disease and POPS using ultrathin pancreatoscope could provide direct assessment of the pancreatic duct. (Korean J Gastrointest Endosc 17: 32-40, 1997)

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증례 : 담도 췌장 ; 담도경검사법 ( Cholangioscopy ) 으로 확진된 폐쇄성황달을 동반한 간세포암 3예 ( Case Reports : Biliary Tract & Pancreas ; Hepatocellular Carcinoma with Obstructive Jaundice Confirmed by Percutaneous Transhepatic Cholangioscopy ( PTCS ) and Peroral Cholangioscopy ( POCS ) ): Korean J Gastrointest Endosc 1996;16(4):681-691. Published online November 30, 1995

Abstract PDF: Jaundice associated with hepatocellular carcinoma usually occurs in the later stages due to the advanced underlying liver cirrhosis or tumor infiltration of the liver parenchyme. In the rare cases, obstructive jaundice presents as the ininitial manifestation of hepatocellular carcinoma. The possible mechanisms of bile duct obstruction associated with hepatocellular carcinoma include extrinsic compression of bile duct by extensive tumor infiltration of the liver or enlarged lymph node, direct tumor invasion of the biliary duct system, and bile duct obstruction by tumor thrombus, necrotic debris, or blood clots. We experienced three cases with hepatocellular carcinoma in whom obstructive jaundice were caused by intraductal involvement of the tumor, which were confirmed by percutaneous transhepatic cholangioscopy(PTCS) and peroral cholangioscopy(POCS). PTCS and POCS finding showed multiple, irreguarly shaped, yellowish soft tissue(chicken fat) and blood clots and, round protruded mass in the ble duct. Biopsy specimens revealed pathologically hepatocelluar carcinoma. (Korean J Gastrointest Endosc 16: 681-689, 1996)

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원저 : 담도 췌장 ; 담도계 질환에 있어서 경구적 담도경 검사법의 이용 ( Original Articles : Biliary Tract & Pancreas ; Application of Peroral Cholangioscopy in Biliary Diseases ): Korean J Gastrointest Endosc 1996;16(1):49-54. Published online November 30, 1995

Abstract PDF: Retrograde transpapillary cholangioscopy can be safely performed by use of a mother-baby-scope system after endoscopic sphincterotomy. Improved endoscopes are now available and may lead to a better acceptance of this technique. Cholangioscopy is complementary to cholangiography for differential diagnosis of various types of bile duct lesions. From march 1992 to September 1994, we performed 15 cases of peroral cholangioscopy for evaluation of bile duct lesions. Indications of peroral cholangioscopy were 6 cases of benign biliary diseases and 9 cases of malignant biliary diseases. In benign diseases, two cases of extrahepatic bile duct stones, 1 case of intrahepatic duct stone with stricture, 2 cases of benign elevated lesions of bile duct and 1 case of occluded expandable metallic stent were involved. In malignant diseases, 7 cases of primary bile duct cancer, 2 cases of hepatocellular carcinoma with bile duct invasion were involved. By use of peroral cholangioscopy with biopsy, differential diagnosis of bile duct lesion was possible. As a complication, severe abdominal pain and hypotension was developed in one case during the procedure and in another case, cholangitis was developed after the procedure. In conclusion, peroral cholangioscopy is a safe and useful procedure in various types of biliary diseases especially in the differential diagnosis of malignancy. (Kor J Gastrointest Endose 16: 49~54, 1996)

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