Digital SpyGlass Cholangioscopy Confirmed Common Bile Duct Stones Clearance Without Fluoroscopy

Abstract

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line therapy for common bile duct stones (CBDS). In certain situations, fluoroscopy is prohibited or not available such as pregnant patient or critically ill patient in an intensive care unit. Although previous series reported the possibility of therapeutic ERCP without fluoroscopy, there is a need for confirmation of CBDS clearance otherwise biliary stenting is the only option. We prospectively evaluated the effectiveness of Digital SpyGlass (DS) cholangioscopy to facilitate CBDS removal without fluoroscopy. Methods: Between December 2015-June 2016, consecutive patients with suspected CBDS based on clinical presentations and/or imaging studies were recruited from our institute. Patients with stones > 15 mm, altered anatomy, and unstable medical condition were excluded. Following informed consent for the study, biliary cannulation with a papillotome using guide wire-assisted technique and sphincterotomy were performed without fluoroscopy. Successful biliarycannulation was confirmed by visible bile in the catheter during aspiration. After non-fluoroscopic CBDS removal (NCR) was successful by balloon extraction, a DS scope was applied into common duct to confirm complete CBDS clearance. If cholangioscopy still showed residual CBDS, another round of NCR was attempted. This process was repeated until there was no residual stone. The final occlusion cholangiogram (OC) under fluoroscopy was performed to confirm CBDS clearance. Results: Thirty eligible patients were enrolled (table 1). Without fluoroscopy, biliary cannulation was achieved in 97% (table 2). NCR was successful in 90%, which were confirmed with SpyGlass and OC. Two patients had failed cholangioscopy (failed standard cannulation requiring precut=1 and narrow CBD precluding SpyGlass insertion=1). Both DS and OC missed CBDS in 1 patient (3%). The reasons for missed CBDs clearance were dark bile obscuring the visibility, very small stone fragment, and over irrigation causing stone migration to intrahepatic duct. No patients had post procedure pancreatitis.Table 1: Baseline characteristics of patients who had Digital SpyGlass cholangioscopy performed in facilitating common bile duct stones removal without fluoroscopyTable 2: Clinical outcomes of patients who had Digital SpyGlass cholangioscopy performed in facilitatingcommon bile duct stones removal without fluoroscopyConclusion: DS cholangioscopy is feasible and safe to facilitate in CBDS removal without fluoroscopic guidance. Certain conditions may limit the effectiveness of this technique.Figure 1