Single-operator Peroral Cholangioscopy Research Articles

Antibiotic prophylaxis and post-procedure infectious complications in endoscopic retrograde cholangiopancreatography with peroral cholangioscopy

Abstract Background and study aims Single-operator peroral cholangioscopy (SOC) has gained increasing attention in modern biliary and pancreatic therapy and diagnosis. This procedure has shown higher rates of infectious complications than conventional endoscopic retrograde cholangiopancreatography (ERCP); therefore, many guidelines recommend antibiotic prophylaxis (AP). However, whether AP administration decreases infectious or overall adverse events (AEs) has been little studied. We aimed to study whether AP affects post-procedure infectious or overall AEs in ERCP with SOC. Patients and methods We collected data from the Swedish Registry for Gallstone Surgery and ERCP (GallRiks). Of the 124,921 extracted ERCP procedures performed between 2008 and 2021, 1,605 included SOC and represented the study population. Exclusion criteria were incomplete 30-day follow-up, ongoing antibiotic use, and procedures with unspecified indication. Type and dose of antibiotics were not reported. Post-procedure infectious complications and AEs at 30-day follow-up were the main outcomes. Results AP was administered to 1,307 patients (81.4%). In this group, 3.4% of the patients had infectious complications compared with 3.7% in the non-AP group. The overall AE rates in the AP and non-AP groups were 14.6% and 15.2%, respectively. The incidence of cholangitis was 3.1% in the AP group and 3.4% in the non-AP group. Using multivariable analysis, both infectious complications (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.54–1.57) and AEs (OR 0.87, 95% CI 0.65–1.16) remained unaffected by AP administration. Conclusions No reduction in infectious complication rates and AEs was seen with AP administration for SOC. The continued need for AP in SOC remains uncertain.

Cost-effective analysis of preliminary single-operator cholangioscopy for management of difficult biliary stones.

Background and study aims Single-operator peroral cholangioscopy (SOC) is a therapeutic modality for difficult biliary stone disease. Given its high success rate and increasing availability, analysis of the economic impact of early SOC utilization is critical for clinical decision-making. Our aim is to compare the cost-effectiveness of different first and second-line endoscopic modalities for difficult-to-treat choledocholithiasis. Patients and methods A decision-tree model with a 1-year time horizon and a hypothetical cohort of 200 patients was used to analyze the cost-effectiveness of SOC for first, second and third-line intervention in presumed difficult biliary stones. We adopted the perspective of a Canadian tertiary hospital, omitting recurrence rates associated with endoscopic retrograde cholangiopancreatography (ERCP). Effectiveness estimates were obtained from updated meta-analyses. One-way sensitivity analyses and probabilistic sensitivity analyses were also performed to assess how changes in key parameters affected model conclusions. Results First- and second-line SOC achieved comparable clinical efficacy from 96.3 % to 97. 6 % stone clearance. The least expensive strategy is third-line SOC (SOC-3: $800,936). Performing SOC during the second ERCP was marginally more expensive (SOC-2: $ 816,584) but 9 % more effective. The strategy of first-line SOC incurred the highest hospital expenditures (SOC-1: $ 851,457) but decreased total procedures performed by 16.9 % when compared with SOC-2. Sensitivity analysis was robust in showing SOC-2 as the most optimal approach. Conclusions Second-line SOC was superior to first and third-line SOC for treatment of difficult biliary stones. When based on meta-analysis of non-heterogeneous trials, SOC-2 is more cost-effective and cost-efficient. Our study warrants a larger pragmatic effectiveness trial.

Comparison of tube-assisted mapping biopsy with digital single-operator peroral cholangioscopy for preoperative evaluation of biliary tract cancer.

Background/AimsDigital 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. MethodsWe 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. ResultsA 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. ConclusionsAdequate 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.

Digital single-operator cholangioscopy for biliary stricture after cadaveric liver transplantation.

BACKGROUNDBiliary strictures after liver transplantation (LT) remain clinically arduous and challenging situations, and endoscopic retrograde cholangiopancreatography (ERCP) has been considered as the gold standard for the management of biliary strictures after LT. Nevertheless, in the treatment of biliary strictures after LT with ERCP, many studies show that there is a large variation in diagnostic accuracy and therapeutic success rate. Digital single-operator peroral cholangioscopy (DSOC) is considered a valuable diagnostic modality for indeterminate biliary strictures.AIMTo evaluate DSOC in addition to ERCP for management of biliary strictures after LT.METHODSNineteen patients with duct-to-duct biliary reconstruction who underwent ERCP for suspected biliary complications between March 2019 and March 2020 at Beijing Chaoyang Hospital, Capital Medical University, were consecutively enrolled in this observational study. After evaluating bile ducts using fluoroscopy, cholangioscopy using a modern digital single-operator cholangioscopy system (SpyGlass DS™) was performed during the same procedure with patients under conscious sedation. All patients received peri-interventional antibiotic prophylaxis. Biliary strictures after LT were classified according to the manifestations of choledochoscopic strictures and the manifestations of transplanted hepatobiliary ducts.RESULTSTwenty-one biliary strictures were found in a total of 19 patients, among which anastomotic strictures were evident in 18 (94.7%) patients, while non-anastomotic strictures in 2 (10.5%), and space-occupying lesions in 1 (5.3%). Stones were found in 11 (57.9%) and loose sutures in 8 (42.1%). A benefit of cholangioscopy was seen in 15 (78.9%) patients. Cholangioscopy was crucial for selective guidewire placement prior to planned intervention in 4 patients. It was instrumental in identifying biliary stone and/or loose sutures in 9 patients in whom ERCP failed. It also provided a direct vision for laser lithotripsy. A space-occupying lesion in the bile duct was diagnosed by cholangioscopy in one patient. Patients with biliary stricture after LT displayed four types: (A) mild inflammatory change (n = 9); (B) acute inflammatory change edema, ulceration, and sloughing (n = 3); (C) chronic inflammatory change; and (D) acute suppurative change. Complications were seen in three patients with post-interventional cholangitis and another three with hyperamylasemia.CONCLUSIONDSOC can provide important diagnostic information, helping plan and perform interventional procedures in LT-related biliary strictures.

S3233 The Safety of Single Operator Per-Oral Cholangioscopy: A Single Center Experience

INTRODUCTION: Single operator per-oral cholangioscopy (SOC) has been increasingly used to provide direct visualization of the biliary tree in conjunction with endoscopic retrograde cholangiopancreatography (ERCP). There is a prevalent notion that SOC increases the risk of pancreatitis and cholangitis in addition to the well-recognized complications of ERCP that also includes pancreatitis, cholangitis, bleeding, and perforation. This study aims to determine the rate of complications when SOC is performed. METHODS: This is a retrospective study which included consecutive adult (> 18 years old) patients who underwent ERCP with SOC from October 2017 until June 2020. SOC was performed utilizing SpyGlass Direct Visualization System. All procedures were performed by endoscopists who annually performed more than 200 ERCPs. Data on patient demographics, procedural indication, type, and complications were obtained. RESULTS: Thirty-three patients (male/female = 18/15) underwent a total of 35 ERCP with SOC procedures with an average of 67 years old. Most were Caucasian (64%) and the average body mass index was 25.3 kg/m2. Majority of the indications included choledocholithiasis (40%), indeterminate biliary stricture (34%), and imaging findings suspicious of cholangiocarcinoma (14%). A greater percentage underwent stone removal (66%), biopsy (46%) and lithotripsy (17%). 29 out of the 33 patients (88%) had previous ERCP. Despite administering rectal indomethacin in 60% (21/35) of the procedures and placement of pancreatic duct stent in 11% (4/35) of the procedures, 1 patient developed post-ERCP pancreatitis the day after the procedure. Pre-procedure intravenous antibiotics were given in 74% (26/35) and no patients developed cholangitis or died within the 30 days of follow-up. CONCLUSION: Although a few studies published in literature demonstrate a higher rate of procedural complications with ERCP and SOC compared to ERCP alone, this study suggests that SOC in addition to ERCP does not confer an additional procedural risk of pancreatitis or cholangitis. Our patient developed post-ERCP pancreatitis despite indomethacin and antibiotic use since balloon dilation and sphincterotomy were also performed which are known post-ERCP pancreatitis risk factors. SOC is a relatively safe procedure and should be performed in addition to ERCP in the evaluation of indeterminate biliary strictures and imaging suspicious of malignancy, and in the treatment of difficult biliary and pancreatic stones.Table 1.: Baseline Characteristics of the Study Population

Single-operator peroral cholangioscopy cystic duct cannulation for transpapillary gallbladder stent placement in patients with acute cholecystitis at moderate to high surgical risk (with videos)

One of the main reasons for failed endoscopic transpapillary gallbladder stenting (ETGS) under fluoroscopic guidance is the inability to cannulate the cystic duct. Single-operator peroral cholangioscopy (SOC)-assisted ETGS is an adjunct technique to facilitate ETGS. We aimed to demonstrate its efficacy. Between 2015 and 2019, 104 patients with acute cholecystitis at moderate to high surgical risk underwent ETGS, which involved 3 steps: (1) cystic duct cannulation under fluoroscopic guidance with or without additional SOC guidance; (2) guidewire placement; and (3) stent placement in the gallbladder. The technical success rate was determined when stent placement was confirmed endoscopically and radiographically. Of 104 patients, 55 (53%) patients had successful ETGS under fluoroscopic guidance. Of 49 patients who had failed fluoroscopy-guided ETGS, 41 patients underwent additional SOC-assisted ETGS and 5 patients proceeded to other interventions. Of patients who underwent SOC-assisted ETGS (n= 41), 23 (56%) cystic cannulation followed by stent placement were successful; cystic duct cannulations, guidewire, and stent placement failed in 8, 9, and 1 patients, respectively. The overall technical success rate of ETGS increased from 53% (55 of 104) to 75% (78 of 104) after additional SOC assistance. Adverse events and recurrence were not different between patients who underwent ETGS under fluoroscopic guidance and those who underwent SOC-assisted ETGS. In patients with acute cholecystitis who are not surgical candidates, SOC-assisted ETGS can increase the technical success rate after failed fluoroscopic guidance. SOC can help for the cystic duct cannulation and guidewire placement steps but not for the stent placement step.

New management of hepatolithiasis: Can surgery be avoided? (with video)

BackgroundThe presence of hepatolithiasis (HL) is prevalent in eastern countries. It is a clinical entity which is rarely reported in non-surgical series because the standard treatment is the surgical option. Currently, treatment has evolved, with the use of endoscopic techniques being increased and the number of hepatectomies being decreased.SpyGlass™ is a small-calibre endoscopic direct cholangiopancreatoscopy developed to explore and perform procedures in the bile and pancreatic ducts. Single-operator peroral cholangioscopy (POC) is an endoscopic technique useful for treating difficult bile duct stones. AimsTo assess the usefulness, efficacy, and safety of POC with the SpyGlass™ system in patients with HL. Primary objectives: to achieve technical success of the procedure and clinical success of patients with HL. Study design and patientsRetrospective, single-centre cohort study of patients with HL from April 2012 to August 2018. SpyGlass™ was chosen in symptomatic patients referred from the surgery unit as the first-line procedure. To perform electrohydraulic lithotripsy (EHL), we used a Northgate Autolith IEHL generator with a 0.66-mm biliary probe. ResultsWe performed a total of 13 procedures in 7 patients with HL. The mean age was 46 years (range 35–65) and 3/7 of patients were female. We achieved technical success in 5/7 cases (71.4%) and clinical success in 4/7 cases (57%). DiscussionSpyGlass™ is safe and effective in the treatment of HL. With these results, we confirm the need for management of patients with HL in a multidisciplinary team. When the endoscopic approach is the option, this procedure must be performed by experts in advanced endoscopy.

Limited diagnostic accuracy and clinical impact of single-operator peroral cholangioscopy for indeterminate biliary strictures.

Single-operator peroral cholangioscopy (sPOCS) is considered a valuable diagnostic modality for indeterminate biliary strictures. Nevertheless, studies show large variation in its characteristics and measures of diagnostic accuracy. Our aim was to estimate the diagnostic accuracy of sPOCS visual assessment and targeted biopsies for indeterminate biliary strictures. Additional aims were: estimation of the clinical impact of sPOCS and comparison of diagnostic accuracy with brush cytology. A retrospective single-center study of adult patients who underwent sPOCS for indeterminate biliary strictures was performed. Diagnostic accuracy was defined as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The clinical impact of sPOCS was assessed by review of medical records, and classified according to its influence on patient management. 80 patients were included, with 40 % having primary sclerosing cholangitis (PSC). Prior ERCP was performed in 88 %, with removal of a biliary stent prior to sPOCS in 55 %. The sensitivity, specificity, PPV, and NPV for sPOCS visual impression and targeted biopsies were 64 %, 62 %, 41 %, and 84 %, and 15 %, 65 %, 75 %, and 69 %, respectively. The clinical impact of sPOCS was limited; outcome changed management in 17 % of patients. Sequential brush cytology sensitivity, specificity, PPV, and NPV were 47 %, 95 %, 80 %, and 83 %. The diagnostic accuracy of sPOCS for indeterminate biliary strictures was found to be inferior to brush cytology, with a low impact on patient management. These findings are obtained from a select patient population with a high prevalence of PSC and plastic stents in situ prior to sPOCS.

Single-operator peroral cholangioscope in treating difficult biliary stones: A systematic review and meta-analysis.

Current evidence supporting the utility of single-operator peroral cholangioscope (SOPOC) in the management of difficult bile duct stones is limited. We conducted the present systematic review and meta-analysis to evaluate the efficacy and safety of SOPOC in treating difficult bile duct stones. We searched studies up to April 2018, using MEDLINE, EMBASE, the Cochrane Library, and Google Scholar. Quality assessment of the studies was completed with the Newcastle-Ottawa Scale. Main outcomes were complete stone clearance rate, single-session stone clearance rate, number of endoscopic sessions needed for stone clearance, and adverseevents. We calculated the pooled estimates with random-effects models. Potential publication bias was assessed. Twenty-four studies involving 2786 patients met the inclusion criteria. Pooled proportion of patients with complete stone clearance was 94.3% (95% confidence interval [95% CI]: 90.2-97.5%). Single-session stone clearance was achieved in 71.1% (95% CI: 62.1-79.5%) of the pooled patients. Pooled number of sessions needed for stone clearance was 1.26 (95% CI: 1.17-1.34%). Pooled adverse event rate was 6.1% (95% CI: 3.8-8.7%). Potential publication bias was detected but had no significant influence on the results. Single-operator peroral cholangioscope is an effective and safe treatment for difficult bile duct stones when conventional methods have failed. More randomized controlled trials are warranted to confirm the results.

Current role of endoscopic cholangioscopy.

Every year more than one million people worldwide undergo an endoscopic retrograde cholangiopancreatography (ERCP) for disorders of the bile duct system. This review aims to discuss recent clinical data with regard to single-operator peroral cholangioscopy (POC). Innovations and technical optimizations of POC devices have extended diagnostic and therapeutic options for patients with complex biliary disease. Most of the currently available clinically relevant data are obtained with the single-operator peroral cholangioscopy (SOC)-system SpyGlass, which in a period of a decade has evolved further to a digital platform with increasing applicability, usefulness and cost-effectiveness. POC allows endoscopists to treat patients with complicated diseases of the gallbladder, liver, biliary tract, and pancreas better. In recent years, this technique was optimized to overcome prior limitations. The implementation of the single-operator SpyGlass Digital System in daily practice becomes a reality. We make an overview of the history of cholangioscopy, the technical evolution, and usefulness of this platform and take a look at its economic impact.

The Safety and Efficacy of Single-Operator Cholangioscopy in the Treatment of Difficult Common Bile Duct Stones after Failed Conventional ERCP.

BackgroundCommon bile duct (CBD) stones are extracted with a basket or balloon during ERCP with sphincterotomy. However, some stones are difficult to extract by conventional means. Cholangioscopy with lithotripsy is a modality to treat these difficult stones. We describe the clinical efficacy of single-operator per oral cholangioscopy (SOPOC) for difficult stones and discuss cost savings by avoiding surgical intervention.MethodsRetrospective chart review was performed for all patients referred for difficult CBD stones. Clinical success was defined as clearing the duct of all stones. The cost of cholangioscopy (in $CDN) was calculated by adding all costs associated with the procedure(s), surgery, hospital stay or treatment of adverse events. This cost was compared with the projected cost of surgical bile duct exploration.ResultsA total of 51 patients (35 female) with a mean age of 66 years underwent 58 SOPOC procedures. Median procedure time was 67 minutes (95% CI, 61.5–73.5). The CBD was successfully cleared in 47 of 51 patients (93%). Minor adverse events were seen in seven patients (14%). The actual average per procedure cost was $4555±$2647. This compares with a projected cost of $7766 and $6175 for open and laparoscopic bile duct exploration, with a cost-per-case saving of $3210 and $1619, respectively.ConclusionSOPOC with lithotripsy is highly effective and safe for the treatment of difficult common bile duct stones. In addition, significant cost savings may be realized by avoiding surgical bile duct exploration.

A rare cause of obstructive jaundice: diagnosis by EUS and single-operator per-oral cholangioscopy.

A rare cause of obstructive jaundice: diagnosis by EUS and single-operator per-oral cholangioscopy.

P.06.21: Utility of Spyglass® Single-Operator Peroral Cholangioscopy for Diagnosis and Therapy of Intra-Ductal Biliary Diseases: One-Year Activity Report from two Italian ERCP High-Volume Centres

P.06.21: Utility of Spyglass® Single-Operator Peroral Cholangioscopy for Diagnosis and Therapy of Intra-Ductal Biliary Diseases: One-Year Activity Report from two Italian ERCP High-Volume Centres

Development of an invivo swine model of biliary dilatation-based direct peroral cholangioscopy.

A reproducible invivo swine model of bile duct dilation (BDD) was recently established and reported for preclinical testing of newly developed biliary devices or endoscopic techniques. The aim of the present study was to develop a more advanced large animal model in which it is possible to direct examination of the biliary tree. Methods Six mini pigs were prepared for the study. BDD models were first made by closure of the Vater's ampulla in all swine. Then endoscopic papillary balloon dilation (EPBD) was done in the animals. Feasibility of single-operator peroral cholangioscopy without assistance of accessories was evaluated using an ultra-slim upper endoscope in the animals. Results EPBD could be implemented using a dilation balloon catheter (10~13.5mm) in all BDD models (6/6, 100%). Success rate of freehand direct insertion of an ultra-slim endoscope into the common bile duct was 100% (6/6), and access to the common hepatic duct with examination was possible using direct peroral cholangioscopy in five animals (5/6, 83.3%). None of the animals died. In the cholangioscopic examination, a bile duct polyp and a benign biliary stricture occurred naturally, respectively, in two of the six swine. Conclusion An invivo swine model of biliary dilatation-based direct peroral cholangioscopy was established. This novel animal model may be useful for preclinical research of new materials or devices because direct visualization of the biliary tree is feasible.

PS122 - Single-Operator Peroral Cholangioscopy for Detection of Cholangiocarcinoma in Patients with Primary Sclerosing Cholangitis: A Prospective Evaluation and Costanalysis

PS122 - Single-Operator Peroral Cholangioscopy for Detection of Cholangiocarcinoma in Patients with Primary Sclerosing Cholangitis: A Prospective Evaluation and Costanalysis

PTU-028 Peroral cholangioscopy – experience with conscious sedation

<h3>Introduction</h3> Per-oral Cholangioscopy (POC) offers the facility for direct visualisation of bile ducts, targeted biopsy and interventional techniques including Electro Hydro lithotripsy (EHL). Procedure completion time is often longer than conventional Endoscopic Retrograde Cholangio-Pancreatography (ERCP), patients often require high doses of standard sedation or general anaesthesia. We present our data where POC is performed under conscious sedation. <h3>Method</h3> Retrospective analysis was performed for all POC cases between January 2013 –December 2014. Definitions and endpoints were as used by Kalaitzakis <i><i>et al</i></i>.¹Procedural success was defined as direct visualisation of the lesion enabling tissue sampling. Adequacy of tissue samples were analysed against the final Multidisciplinary meeting (MDM) decision-detailing both benign and malignant diagnosis. <h3>Results</h3> 47 cases of POC were performed in 43 patients. Median age was 63 years (IQR 22–86 years). 31 cases were performed for non stone-related disease (28 for indeterminate lesions 3 for other reasons). 16 patients underwent POC for choledocholithiasis, 9 of which had EHL. All patients had conscious sedation during POC. Median midazolam dose was 7 mg (IQR 5–11 mg), fentanyl 150 mcg (IQR 50–225 mcg). Buscopan was used in 42 cases (range 20–60 mg) and glucagon (1 mg) in 6 cases. Lowest oxygen saturations recorded were 95% (range 95–99%). Where a score of 1 represented maximum discomfort and 5 least, worst comfort score recorded was 3 for a single case. There were 4 failed procedures, 1 due to patient related factors and 3 due to equipment failure. Median procedure time was 86 min (IQR 34–114 min) for non-EHL and 92 min (IQR 76–132 min) for EHL cases. Procedural success was established in in 42 (89%) cases with positive visualisation of the target lesion. For non-stone related disease, 27 were successful (87%). For suspected malignancy, POC performance was again comparable with published data (sensitivity 70%, specificity 93%, positive predictive value 88%, negative predictive value 81%), when compared against the final MDT decision. Overall complication rate was comparable with other published data (6.3%). Over sedation requiring reversal was not encountered in the study. <h3>Conclusion</h3> Diagnostic results and complication rates, in our study, were comparable with published UK outcomes. Our practice demonstrates that POC can be performed under conscious sedation without compromising patient safety, test tolerance or efficacy. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> Kalaitzakis E, Webster GJ, Oppong KW, Kallis Y, Vlavianos P, Huggett M, <i>et al</i>. Diagnostic and therapeutic utility of single-operator peroral cholangioscopy for indeterminate biliary lesions and bile duct stones. Eur J Gastroenterol Hepatol. 2012;24(6):656–64

Su1588 Performance Characteristics and Lack of Factors Affecting Diagnostic Yield of Single Operator PerOral Cholangioscopy for Indeterminate Biliary Strictures

Su1588 Performance Characteristics and Lack of Factors Affecting Diagnostic Yield of Single Operator PerOral Cholangioscopy for Indeterminate Biliary Strictures

ERCP-guided cholangioscopy using a single-use system: nationwide register-based study of its use in clinical practice.

Single-operator peroral cholangioscopy enables direct visualization of duct lesions, biopsy, and therapeutic interventions in the biliary and pancreatic ductal systems. The aim of this study was to address the use and outcome of this technology in wider clinical practice. A nationwide study of endoscopic retrograde cholangiopancreatography (ERCP) procedures, with or without cholangioscopy, was conducted. Procedures that were registered in the Swedish Registry for Gallstone Surgery and ERCP (GallRiks), between 2007 and 2012 were included. The primary outcome was ERCP-specific adverse events. Data from 36 352 ERCP procedures were analyzed, including 408 cholangioscopy procedures. Postprocedural adverse events were more prevalent when cholangioscopy was used (19.1 % vs. 14.0 %). Pancreatitis (7.4 % vs. 3.9 %) and cholangitis (4.4 % vs. 2.7 %) were ERCP-specific adverse events that were elevated in the cholangioscopy group. However, in multivariate analysis, the risks of intraprocedural and postprocedural adverse events were significantly increased in the cholangioscopy group whereas the risks of pancreatitis and cholangitis, when adjusted for confounders, were not. The single-operator peroral cholangioscopy technique is an advanced technique for intraluminal visual inspection, and for therapeutic intervention of the biliary and pancreatic ducts. However, there is a significantly increased risk of intra- and postprocedural adverse events. Thus, this method should preferably be performed at tertiary referral centers in carefully selected patients.

Is single-operator peroral cholangioscopy a useful tool for the diagnosis of indeterminate biliary lesion? A systematic review and meta-analysis

Differentiating between malignant and benign biliary lesions is critical in clinical practice but is difficult. To systematically evaluate the diagnostic performance of single-operator peroral cholangioscopy on indeterminate biliary lesions. A systematic review and meta-analysis. Patients with indeterminate biliary lesions or equivocal ERCP findings. The diagnostic performance of single-operator peroral cholangioscopy onindeterminate biliary lesions. The area under the summary receiver-operating characteristic curve was used as the main indicator for the overall diagnostic performance of single-operator peroral cholangioscopy visualimpression (VI) and SpyBite biopsy (SB). The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were also synthesized. A total of 8 studies met the inclusion criteria, involving 335 patients who had data on VI and 337 who haddata on SB. The area under the curve values on the summary receiver-operating characteristic curve of single-operator peroral cholangioscopy VI and SB were 0.94 (95% confidence interval [CI], 0.92-0.96) and 0.93 (95% CI,0.90-0.95) respectively. The combined sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were 90% (95% CI, 73%-97%), 87% (95% CI, 76%-94%), 7.1 (95% CI, 3.8-13.3), 0.12 (95% CI, 0.04-0.33) for VIand 69% (95% CI, 57%-79%), 98% (95% CI, 92%-99%), 30.1 (95% CI, 8.5-106.9), and 0.32 (95% CI, 0.23-0.44) forSB, respectively. Small number of included studies; comparison with ERCP could not be made. Single-operator peroral cholangioscopy is a good tool for differentiating malignant and benignbiliary lesions. VI is useful for detecting malignant lesion, whereas SB is better at confirming a malignant diagnosis, but VI is not perfect in excluding biliary cancer, nor is SB, and their negative results should be interpreted with caution.

Spyglass-Assisted Management of a Large Impacted Cystic Duct Stone

Introduction: Endoscopic therapy of an impacted cystic duct stone can be very challenging. Successful passage of a guidewire beyond the impaction is necessary for successful further treatment with extractor balloon or lithotripsy basket. We present a unique case of a large impacted cystic duct stone where we used spyglass cholangioscopy to direct the guidewire into the cystic duct with subsequent removal of the stone in a patient who failed conventional ERCP techniques. A 52-year-old woman with a history of cholecystectomy 10 years ago is referred to our center for further management of a large impacted cystic duct stone. She initially presented to an outside hospital with severe abdominal pain, nausea, vomiting and was subsequently diagnosed with gallstone pancreatitis. An ERCP was performed at the outside hospital that revealed a common bile duct dilated to 2cm and a 1.5cm cystic duct stone. A sphincterotomy was performed followed by removal of sludge and stone fragments. Multiple attempts to traverse the cystic duct remnant with a guidewire were unsuccessful. A temporary biliary stent was placed and the patient was referred to our center for further management. At presentation at our institute, the patient reported intermittent abdominal pain. Physical exam was unremarkable. She underwent a repeat ERCP at our institution. Cholangiogram revealed a markedly dilated bile duct to 2cm.The cystic duct remnant contained a 1.5cm stone causing extrinsic compression/obstruction of the bile duct suggestive of Mirrizzi’s Syndrome. We were unable to traverse the cystic duct using traditional ERCP maneuvers due to the large impacted stone. The spyglass system was then introduced into the biliary tree and a large stone was visualized in the cystic duct remnant. A guidewire was passed into the cystic duct remnant under direct vision. The papillary orifice was then dilated with a 15mm CRE balloon followed by balloon sweep with extraction of the large cystic duct stone. Abdominal pain, nausea and vomiting resolved after the procedure.The removal of an impacted cystic duct stone can be very challenging and time consuming. In our case, placement of a guidewire into the cystic duct under direct view lead to successful removal of an impacted stone. In addition, spyglass cholangioscopy allows for targeted therapy of refractory bile duct and cystic duct stones with electrohydraulic lithotripsy or laser therapy as well as targeted biopsy sampling of indeterminate biliary strictures. SpyGlass single-operator peroral cholangioscopy system is a safe and effective diagnostic and therapeutic tool.