Abstract
Endoscopic Retrograde Cholangiopancreatography (ERCP) in primary sclerosing cholangitis (PSC) subjects with dominant biliary strictures can be challenging to: 1) access and treat strictures; 2) treat intrahepatic calculi; or 3) exclude cholangiocarcinoma (CCA). This study aimed to evaluate the utility and safety of digital SpyGlassTM cholangioscopy (Boston Scientific, Massachusetts) in PSC patients with complex biliary strictures. Prospective data was collected on cholangioscopy subjects between June 2015-August 2019 including demographics, biochemistry, cholangioscopy indications, cross sectional imaging, endoscopic and fluoroscopic videos, histopathology and cytology. 27 PSC patients median age 60 (21-81) yrs, 17M, 10F underwent 40 (1-4) procedures. 6 (21%) patients had cirrhosis. Indications (often multiple) included indeterminate biliary strictures (17); cholangitis (6); biliary stones (5) or segments not accessed by ERCP (12). The median pre-procedural bilirubin was 36 (2-235) μmol/L. Cholangioscopy procedural time was median 36 (17–126) mins. Dominant biliary strictures treated were intrahepatic (15) and/or extrahepatic (12). In 25 (92%) patients, all obstructed biliary segments were eventually accessed. In the 2 where all segments could not be accessed, 1 proceeded to liver resection and 1 orthotopic liver transplantation (OLT). Strictures were balloon dilatated in 23 patients while 7 required biliary stents. Three of 5 patients had intrahepatic calculi completely cleared with Holmium laser lithotripsy, 2 others with multiple stones had incomplete clearance (1 sent for OLT, the other confirmed CCA stented). CCA was diagnosed in 4 of 27 patients, all had preceding negative cross-sectional imaging. Cholangioscopy-directed biopsies were at least suspicious for malignancy in 3 of 4 cases while aspiration cytology was suspicious in 2 of 3. The stricture cholangioscopy visual appearance appeared benign in 12 of 27 cases (final diagnosis [FD] benign 12); malignant in 2 (FD malignant 2) and; indeterminate in 13 (FD malignant 2, benign 11) (Figures 1 & 2). Two of the 4 cases with early CCA were able to be referred for OLT. Complications (all mild) occurred in 7 of 40 (15%) procedures (cholangitis 4, pancreatitis 1, haemobilia 1, pneumonia 1). In certain PSC patients undergoing cholangioscopy:
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