Direct Transnasal Cholangioscopy with Ultraslim Endoscopes: a One-step Intraductal Balloon-guided Approach

Background: Direct cholangioscopy using an ultraslim endoscope is an attractive alternative to the conventional mother-baby endoscope system because it provides a single-operator platform and high-resolution image quality and allows advanced therapeutic interventions. However, biliary access is cumbersome and usually requires previous guidewire placement via retrograde cholangiography.

Objective: To evaluate the feasibility of a 1-step transnasal cholangioscopy (TNC) technique using an ultraslim endoscope with an intraductal balloon to maintain access without previous guidewire placement.

Design: Prospective, observational clinical feasibility study.

Setting: Single tertiary referral center.

Main Outcome Measurements: Overall procedure success rates and complications. A successful procedure was defined as one in which the endoscope was advanced into the bifurcation or stenotic segment of the biliary system.

Patients And Methods: Twenty-five patients with biliary disease and previous sphincterotomy underwent direct TNC.

Results: TNC was successful in 18 of the 25 patients (72%). The procedure revealed 3 common bile duct stones, 4 benign biliary strictures, 1 intraductal adenoma, and 3 cholangiocarcinomas. Eight patients underwent forceps biopsies under direct visualization, and 7 patients underwent therapeutic interventions, including argon plasma coagulation (n = 2), laser lithotripsy (n = 1), stent (n = 1), and stone extraction (n = 3). Other than 1 patient with procedure-related cholangitis, no complications were observed.

Limitations: Small number of patients and no comparison with conventional cholangioscopy.

Conclusions: One-step TNC with an ultraslim endoscope allows direct visual examination and therapeutic intervention in the bile ducts in the majority of patients with biliary disease. However, development of further accessory instruments will be needed to improve the success rate.