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2. Indications for Cholangioscopy, Pre-procedural Patient Care and Preparation
Indications
- 1.
Facilitating lithotripsy of ductal stones
- 2.
The evaluation of indeterminate biliary strictures
- 3.
Retrieval of migrated stents and other foreign bodies form the bile duct
- 4.
Facilitating guidewire and device access across tight biliary strictures
Cholangioscopy is principally used in the management of bile duct stones that are difficult to remove using conventional stone extraction methods, including mechanical lithotripsy [1–6]. Cholangioscopy facilitates the application of electrohydraulic lithotripsy (EHL) or laser lithotripsy to achieve fragmentation of stones, thereby aiding stone extraction and duct clearance [5, 7–11]. The platform used to perform cholangioscopy can additionally be used to access the pancreatic duct (pancreatoscopy) and treat pancreatic duct stones. In addition to treating stone disease, cholangioscopy and pancreatoscopy can be used to evaluate the biliary and pancreatic systems to identify, examine and sample biliary and pancreatic strictures [12–40]. Cholangioscopy and pancreatoscopy can be used to retrieve migrated stents from the bile duct or pancreatic duct when other extraction techniques have failed and can be used to direct and facilitate guidewire access across tight biliary strictures [41–49]. The utility and range of cholangioscopic platforms have rapidly expanded due to improvements in their imaging capabilities and therapeutic ability. These systems have integrated with other tools in the armamentarium of a hepatobiliary endoscopist.
Pre-procedural Patient Care and Preparation
Preparation for endoscopic retrograde cholangiopancreatography (ERCP) generally involves no food intake for 4–8 h, although clear fluids can be consumed up to 2 h prior to the procedure [50, 51].
Consent
Patients should be counselled about the risks and benefits of ERCP in advance. Cholangioscopy confers additional procedure-related risks of infection and bleeding and procedure leaflets with information pertaining, to ERCP in general, with a specific section on cholangioscopy serve as a useful tool to inform patients [19, 52]. Written, informed consent should be taken in advance for all elective procedures and patients should be allowed enough time to consider the information provided to them in order to make an informed decision.
Pre-assessment
- 1.
Risk of bleeding
Complete blood examination and coagulation profile should be obtained and assessed for the haemoglobin level, platelet count and International Normalized Ratio (INR). A platelet count of >50 × 109/l and INR of <1.5 are important pre-requisites for any therapeutic endoscopy. Anticoagulants and antiplatelets will generally need to be stopped prior to cholangioscopy owing to the risk of bleeding related to a sphincterotomy which is necessary for cholangioscopic access, and due to techniques likely to increase the risk of bleeding, such as sphincteroplasty and lithotripsy which may cause duct-wall injury. The risk of stopping anticoagulant and antiplatelet therapy needs to be balanced against the risk of thromboembolic events and detailed guidance on managing anticoagulant and antiplatelet therapy for diagnostic and therapeutic endoscopy has been published by the British Society of Gastroenterology (BSG) [53]. These have been summarised in Tables 2.1 and 2.2.
Table 2.1
Guidelines for management of patients on anticoagulant agents undergoing ERCP
Drugs
Low risk conditions
High risk conditions
Prosthetic aortic valve, xenograft heart valve, atrial fibrillation (AF) without valvular disease, >3 months after venous thromboembolism (VTE)
Prosthetic metal mitral valve, prosthetic heart valve and AF, AF and mitral stenosis, <3 months after VTE
Warfarin
Stop 5 days before
Stop 5 days before. Start *LMWH 2 days after stopping warfarin. Last dose >24 h before the procedure
Direct oral anticoagulants (Dabigatran, Rivaroxaban, Apixaban, Edoxaban)
Last dose >48 h before ERCP
For Dabigatran: if ¶eGFR 30–50 ml/min, last dose >72 h before procedure
Table 2.2
Guidelines for management of patients on antiplatelet agents undergoing ERCP
Drugs
Low risk conditions
High risk conditions
Ischaemic heart disease without stents, cerebrovascular disease, peripheral vascular disease
Coronary artery stents
Aspirin
Continue
Continue
Clopidogrel
Ticagrelor
Prasugrel
Stop 5 days before ERCP
Liaise with cardiologist
Consider stopping 5 days before if >12 months after insertion of drug-eluting coronary stents, and >1 month after insertion of bare metal stent
- 2.
Cardiopulmonary status
Patients with cardiac and pulmonary disease may need optimisation of cardiopulmonary status before ERCP with cholangioscopy owing to a potentially longer procedure time and greater risk of cardiopulmonary complications. Moreover, general anaesthesia (as opposed to deep sedation or monitored anaesthesia with Propofol) may be necessary for cholangioscopy with lithotripsy.
- 3.
Allergy status
Frequently used medications during ERCP include sedatives/anaesthetic agents, antibiotics and non-steroidal anti-inflammatory drug (NSAID) suppositories. Any drug allergies should be documented and should prompt use of alternatives.
- 4.
Airway issues
Cholangioscopy generally involves deep sedation/anaesthesia and any airway-associated issues need to be identified in advance. A pre-procedural anaesthetic assessment is an important aspect of planning and patient-preparation.
- 5.
Radiation exposure
ERCP involves use of X-rays in the form of fluoroscopy and cholangioscopy may lead to a longer period of fluoroscopic screening. Patients should be made aware of this issue and women of reproductive age should be asked for possibility of pregnancy. A pregnancy test may need to be performed pre-procedure.
Procedural Considerations
- 1.
Endoscopy safety checklist
A safety checklist should be performed for every patient before the start of the procedure. The World Health Organization (WHO) checklist was initially developed to reduce the adverse events from surgical procedures [54]. A safety checklist comprises two steps: an initial ‘time out’, when key information regarding the patient and procedure at hand are confirmed before starting endoscopy and a subsequent ‘sign out’ at the end of procedure confirming specimens, the endoscopy report and follow up plans.
- 2.
Team Brief
A team brief before the start of the list helps to prepare the endoscopy team for the procedure and patient specific and equipment related issues should be discussed with an outline of planned therapy. The following should be discussed:
- (a)
Patient position
ERCP is generally performed in the prone position. Airway management is particularly important in the supine position owing to risk of aspiration.
- (b)
Accessories
Endoscopic accessories needed for cholangioscopy should be discussed and identified as part of the team briefing. Radio-opaque contrast syringes should be prepared, and strength of the dye should be decided to suit the indication and endoscopist preference. Full strength contrast is used to delineate strictures and pancreatic duct anatomy, while half-strength contrast is more suitable to visualise duct stones [55].
- (c)
Endoscopic non-technical skills
Non-technical skills such as communication, decision-making, leadership and situation awareness are increasingly recognised as being central to effective functioning of the endoscopy team [56]. Good communication and coordination between the team members is important to ensure patient safety, prevent errors and lead to better patient outcomes.
- 3.
Radiation exposure to staff
ERCP utilises X-rays in the form of fluoroscopy. Appropriate measures should be taken to reduce the radiation exposure to staff. Limiting the duration of exposure, keeping a reasonable distance from radiation source and lead shielding helps to keep the overall incident radiation ‘As Low as Reasonably Achievable’. This is known as the ALARA principle [57].
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- (a)
