Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study

BACKGROUND: The search for an easier and less cumbersome technique to perform direct visual examination of the biliary tree is still underway. OBJECTIVE: To assess the feasibility of performing endoscopic direct cholangioscopy utilizing an ultra-slim upper endoscope designed for pediatric patients. DESIGN: Prospective, observational, pilot study. SETTING: Tertiary referral center. PATIENTS: Three patients who underwent endoscopic retrograde cholangiography for evaluation and treatment of choledocholithiasis. METHODS: Following the completion of the endoscopic retrograde cholangiography, a 0.035-inch diameter super-stiff Jagwire (Boston Scientific Corp, Natick, Mass) was placed in the common bile duct. Using the wire to maintain access, we removed the duodenoscope and backloaded the wire onto an ultra-slim upper endoscope (GIF-XP 160, Olympus America Inc, Melville, NY), which was advanced over the guidewire under fluoroscopic and endoscopic control into the duodenum and then across the ampulla of Vater into the common bile duct and upstream. RESULTS: Endoscopic direct cholangioscopy was attempted and successfully completed in all 3 patients. One patient was found to have persistent large amount of sludge and stones, and was referred for surgery. In the other two patients, endoscopic direct cholangioscopy demonstrated complete duct clearance, obviating the need for stent placement and repeat endoscopic retrograde cholangiography procedures. LIMITATIONS: Small sample size, pilot study. CONCLUSIONS: Endoscopic direct cholangioscopy with an ultra-slim upper endoscope originally designed for pediatric use is feasible. Future advances in endoscope development, as well as specifically designed accessories, could lead to the next generation of intraductal diagnosis and therapy.