Clinical Experience of Using Choledochoscopy as a Cholangiocarcinoma Screening Tool in Patients with Primary Sclerosing Cholangitis

Abstract

Purpose: Cholangiocarcinoma (CCA) is an important cause of mortality in patients with primary sclerosing cholangitis (PSC) but there is no effective screening method available. Choledochoscopy (CDS) offers an attractive option for screening because more than 90% of CCAs are within the reach of the CDS. However, clinical experience of using CDS for cancer screening (sCDS) is limited. Here we summarize our experience of using sCDS as a CCA screening tool in patients with PSC. Methods: Patients with PSC seen at a single institution between 1/1/2006-1/1/2009 were offered CDS if they had abnormal liver function tests and/or symptoms (jaundice, weight loss, and abdominal discomfort). All procedures were performed by the same endoscopist, who was highly experienced with ERCP and CDS. Results: Twenty-nine patients (59% male) with PSC underwent a total of 40 sCDS procedures. Their median age was 49 years (range 28-72) and their median age at diagnosis was 40 years (range 22-72). The median duration between diagnosis and first sCDS was 9.0 years (range 0.5-18). Antibiotic prophylaxis (ciprofloxacin) was administered before the procedure. All procedures were technically successful, adding on average 15 minutes to the ERCP. All patients had undergone prior sphincterotomy. Fourteen patients had stricture(s) in their major bile ducts (8 of whom underwent balloon dilation), 7 had erythematous ductal mucosa, 12 had exudates, 1 had a right hepatic duct inflammatory mass and 1 had a choledochoenteric fistula. No patient had cholangiocarcinoma and none developed clinically apparent cholangiocarcinoma during a median follow-up of 1.5 years (range 0.5-3.5) after the procedure. There was only one serious complication in a patient who underwent a balloon dilatation performed for dominant stricture. The patient developed a small bile duct perforation requiring a biliary stent placement but recovered uneventfully. No patients developed cholangitis or pancreatitis. Conclusion: Choledochoscopy appears to be a feasible CCA screening tool in patients with PSC but its effectiveness, costs and safety will require further study. In addition, more studies are needed to clarify the clinical significance of mucosal findings on cholangioscopy in patients with PSC.