ity of 100% and 71% in the main duct
type, respectively, and sensitivities and
specificities of 43% and 100% of branch
type, respectively. 23
DSOCP also has therapeutic implications for other pancreatic diseases.
Pancreatic duct obstruction can be
caused by stones and strictures. A large
multicenter study of 1,000 patients with
chronic pancreatitis revealed obstruction of the main pancreatic duct (MPD)
in 50%; with 32% being caused by
strictures and stones, while 18% were
due solely to stones. 24 Currently accepted treatments for pancreaticolithiasis
include extracorporeal shock wave
lithotripsy, ERCP with stone clearance,
and stenting or surgery (
pancreaticojejunostomy) but these techniques have
limitations and can incur morbidity.
DSOCP has recently been evaluated
as an alternative technique in treating MPD stones. In a recent study,
Bekkali et al reviewed their 3-year
experience of digital pancreatoscopy
and EHL for pancreatic duct stones.
Of the pancreatoscopy procedures
performed, 7% were for pancreatic
stones. All the patients had painful
chronic pancreatitis, radiographic evidence of a dilated pancreatic
duct, and MPD stone disease. Stone
fragmentation and pancreatic duct
decompression were achieved in
83% without complications. Two patients required two EHL procedures
to achieve clearance. In the single
patient with failed clearance, pancreatoscopy revealed the stone to be in
adjacent parenchyma and not in the
pancreatic duct. All patients with successful pancreatoscopy and EHL had
pain relief and marked improvement
during follow up. 25
Other less common diagnostic indications for DSOCP include evaluation
of cystic lesions of the biliary tract,
verifying clearance of bile duct stones,
bile duct ischemia evaluation after liver
transplantation, hemobilia evaluation,
removal of a bile duct foreign body, and
evaluation of bile duct involvement in
the presence of an ampullary adenoma. 3, 14, 15, 20, 26, 27
Risks and complications
In general, complications from cholangioscopy systems are similar to traditional ERCP. These complications can
range from relatively mild to potentially life-threatening sequelae including:
cholangitis, bacteremia, abdominal
pain, pancreatitis, hypotension, nausea,
liver abscesses, radiculopathy, bile duct
drilling (from the guide-wire), clinically insignificant amylase and lipase
elevation, and systemic inflammatory
response syndrome. 24 A large retrospective study evaluated whether ERCP
with cholangiopancreatoscopy was associated with higher rates of complication than ERCP alone. A total of 4,214
ERCPs were included, of which 402
ERCPs with cholangiopancreatoscopy
were analyzed. Adverse event rates
for the ERCP alone group and ERCP
with cholangiopancreatoscopy were
2.9% and 7.0%, respectively, with an
odds ratio of 2. 5. This study revealed a
significantly higher rate of cholangitis,
which the authors proposed was due to
the saline irrigation needed for visualization during the procedure. 28 Duodenal perforation appears to be rare and
was treated conservatively. 14,29
Direct visualization of the biliary and
pancreatic ductal system with fiber-op-tic and now digital-based platforms
have greatly expanded the diagnostic
and therapeutic capabilities available to
gastroenterologists in the diagnosis and
management of biliary and pancreatic
disorders. The digital single-operator
cholangiopancreatascope system offers
greater diagnostic yield of pancreaticobiliary disorders over conventional diagnostic sampling techniques. In addition,
direct visualization has expanded our
therapeutic ability in complex stone disease allowing laser-based therapies that
are not available with traditional fluoroscopic based techniques. Cholangiopan-creatoscopic techniques and indications
are rapidly expanding and will continue
to expand the diagnostic and therapeutic
armamentarium available to gastroenterologists. n
1. Cohen S., et al. Gastrointest Endosc.
2. Lee J.G., et al. Am J Gastroenterol. 1995;90:722-
3. De Bellis M., et al. Gastrointest Endosc.
4. Fritcher E.G., et al. Gastroenterology.
5. Rosch T., et al. Gastrointest Endosc.
6. Byrne M.F., et al. Endoscopy. 2004;36:715-9.
7. De Witt J., et al. Gastrointest Endosc.
8. Rosch W., Endoscopy. 1976;8:172-5.
9. Takekoshi T., Takagi K. Gastrointest Endosc.
10. Chen Y.K. Gastrointest Endosc 2007;65:303-
11. Navaneethan U., et al. Gastrointest Endosc
12. Navaneethan U., et al. Gastrointest Endosc
13. Chen Y.K., Pleskow DK. Gastrointest Endosc.
14. Draganov P.V., et al. Gastrointest Endosc.
15. Ramchandani M., et al. Gastrointest Endosc.
16. Chen Y.K., et al. Gastrointest Endosc.
17. Draganov P.V., et al. Gastrointest Endosc.
18. Classen M., et al. Endoscopy 1988;20: 21-6.
19. Parsi M.A., et al. Gastrointest Endosc
20. Fishman D.S., et al. World J Gastroenterol.
21. Maydeo A., et al. Gastrointest Endosc.
22. Yamao K., et al. Gastrointest Endosc
23. Hara T., et al. Gastroenterology 2002;122:34-
24. Rösch T., et al. Endoscopy. 2002;34:765–71.
25. Bekkali N.L., et al. Pancreas. 2017;46:528-30.
26. Adwan H., et al. Dig Endosc. 2011;23:199-200.
27. Ransibrahmanakul K., et al. Clin Gastroenterol
28. Pereira P., et al. J Gastrointestin Liver Dis, June
2017;Vol. 26(No 2):165-70.
29. Kawakubo K., et al. Endoscopy 2011;43:E241-