Balloon catheter cannulation for route identification and axis stabilization during direct freehand cholangioscopy
Abstract
Freehand techniques for direct cholangioscopy access have received little attention, given disappointing initial results and high perceived and/or real technical challenges. However, while pure freehand intubation appears feasible in a significant proportion of individuals, technical advancements and tricks of the trade are being developed. Along these lines, herein I present another rescue technique assisting in freehand access for direct cholangioscopy, the “balloon-catheter-cannulation technique”, which may be instrumental in overcoming two major hurdles of the procedure, i.e., stable intubation of the papillary orifice with adequate orientation and scope advancement in the common bile duct vis-à-vis gastric loop formation. To further disseminate direct cholangioscopy in the endoscopy community, technical beyond technological advancements, as for instance dedicated next-generation cholangioscopes, appear essential. Herein, I present a technical case report focussing on the limitations of the pure freehand and relative advantages of the “balloon catheter cannulation-assisted” approach for direct cholangioscopy access.
Introduction
Recent developments in direct cholangioscopy (DC) have renewed interest in this innovative biliary endoscopy modality with potential benefits, among others, in management of complex bile duct stone disease, clinical work-up of indeterminate biliary stricture, and inconclusive cholangiographic findings.1 While implementation of specifically dedicated accessories, such as second-generation anchoring balloons, has been propagated, successful freehand intubation of the bile duct after wide-incision papillotomy and/or papillary balloon dilation has been reported in case series and individual reports using ultra-slim as well as standard-size scopes.2,3 Of interest, recently high rates of ancillary-free bile duct intubations were reported for a next-generation double-bending cholangioscope.4A priori freehand DC access may reduce procedure-related accessory consumption and, thus, costs, and may help disseminate this disruptive endoscopic approach to a wider range of endoscopy services. However, in cases where pure freehand approaches fail, re-purposed use of endoscopic or radiologic equipment has been reported, e.g., by using a so-called Kautz probe or a colonoscopy-devoted stiffening wire.5,6 Furthermore, in a recent case series snare-assisted DC has been introduced.7 Herein, I present a video paper demonstrating the limitations of the pure freehand approach and present the relative advantages of the “balloon catheter cannulation-assisted” DC access.
During the procedure, there are typically three categories of challenges encountered: (1) stable intubation of the papillary orifice itself with adequate visual orientation, (2) stable scope advancement in the distal bile duct portion during loop resolution, and (3) navigation up to or, at least, adequate endoscopic visualization of the liver hilum as a proxy of procedural completeness.
Case Report
This is a case, in which DC was indicated for definitive exclusion of remnant common
bile duct (CBD) stones, given a markedly dilated biliary system up to 25 mm, in which
the sensitivity of cholangiography is known to become utterly decreased (Fig. 1A). Beforehand, a revisional endoscopic papillary large-balloon dilation up to 12 mm
(CRE Balloon Dilator; Boston Scientific, Ratingen, Germany) was performed due to papillary
stenosis after re-do papillotomy up to the duodenal wall.8 As is illustrated in the supplementary video sequence (
Discussion
To conclude, DC remains a fascinating area in interventional pancreaticobiliary endoscopy, in which both innovative technological and technical progess is underway to move the field forward and disseminate the modality. Beyond pure freehand techniques, accessory-assisted troubleshooter approaches such as the “balloon-catheter-cannulation technique” may be instrumental to rescue DC access. While there are no direct systematic analyses comparing rescue biopsy forceps- versus balloon-assisted freehand DC and, in principle, consumption of accessories may increase, cost estimates may nonetheless indicate significant earnings relative to specialized cholangioscopy accessories such as dedicated access balloon and/or implementation of next-generation scope technologies.4,11 As for now, the presented “balloon-catheter-cannulation technique” might be attractive in individual cases to overcome DC access-related difficulties in route identification and axis stabilization. Limitations of the technique include, as has been presented, the reduced anchoring capability in a profusely dilated biliary system; however, true anchoring to facilitate pull movements is not invariably necessary for advancement in the bile duct.
Supplementary Information
Conflicts of Interest
No potential conflict of interest relevant to this article was reported.
Supplementary Materials
Supplementary data is available at https://doi.org/10.18528/ijgii180002.
Article information
Articles from International Journal of Gastrointestinal Intervention are provided here courtesy of International Journal of Gastrointestinal Intervention
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