Sa1304 A CLINICAL SCENARIO BASED APPLICATION OF SPYGLASS DIRECT VISUALISATION SYSTEM – A CASE CONTROLLED STUDY FROM AN ASIAN TERTIARY CENTRE

Abstract

The modern cholangioscope now enables access into the pancreaticobiliary system with opportunities for advanced diagnostic and therapeutic applications. We performed a retrospective descriptive analysis on procedures done in our centre between mid-2010 and mid-2017 using the SpyGlass DS System cholangioscope, which assisted in the management of difficult stones and indeterminate biliary strictures. We aim to identify factors that would yield benefit from early utilisation of cholangioscopy, which will reduce the need for multiple endoscopic retrograde cholangiopancreatographys (ERCPs). A retrospective analysis of all the patients recruited in our hospital's cholangioscopy database was performed. We describe the baseline demographics, clinical indications, duration, cost, adverse events and the number of non-helpful ERCPs prior to the use of the cholangioscope. Our primary outcomes were success in establishing the diagnosis and impact on clinical management. A total of 75 procedures in 61 candidates were analysed with stones comprising 68.9% (42/61) and strictures 26.2% (16/61) of the cases. Our overall success rate for the cholangioscope was 91.8% (56/61) and complication rate was 14.8% (9/61). Subgroup analysis was also performed based on the pathology (stone, stricture) in which we distinguish success rates of cholangioscopy in relation to stone-duct-disproportion (SDD), amount (stone load), size and location of stone, while we describe the location and length with respect to biliary strictures. Stone-duct-disproportion is considered present when the transverse dimension of the biggest stone is greater than the downstream portion of the duct on radiological scans or reports. As demonstrated in Figure 1 below, a higher tendency of non-helpful ERCP attempts prior to use of the cholangioscope was observed to correlate with SDD (observed in 65.0% of cases with biliary stones, p<0.005), but interestingly not to stone size (Spearman’s ρ = 0.27, p = 0.091) nor stone load (p=0.666). However, there was a strong correlation between stones ≥20mm and presence of SDD (p= 0.007). The median length of biliary strictures observed was 13mm with the majority (11/16) located above the cystic duct insertion. 66.7% (10/15) had at least 1 while 46.7% (7/15) had 2 or more non-helpful ERCPs prior to the use of the cholangioscope. Cholangioscopy was successful at first attempt in 80% (12/15) of cases with biliary strictures. We propose the early use of cholangioscopy according to the clinical scenarios listed in Table 1 based on our data and analyses. We conclude that early use of cholangioscopy in the right clinical context can potentially reduce the number of invasive procedures, thus saving precious time, cost and effort.Table 1Recommendations for early cholangioscopyView Large Image Figure ViewerDownload Hi-res image Download (PPT)