Operator Cholangioscopy

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© Springer Nature Switzerland AG 2020
S. Menon et al.Cholangioscopydoi.org/10.1007/978-3-030-27261-6_3



3. Single Operator Cholangioscopy



Shyam Menon1  , Venkata Lekharaju2  , Christopher Wadsworth3  , Laura Dwyer4   and Richard Sturgess4  


(1)
Department of Gastroenterology, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK

(2)
Department of Gastroenterology, Arrowe Park Hospital, Wirral University Teaching Hospital NHS Foundation Trust, Wirral, UK

(3)
Department of Gastroenterology, Hammersmith Hospital, Imperial College London, London, UK

(4)
Department of Gastroenterology, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK

 



 

Shyam Menon (Corresponding author)



 

Venkata Lekharaju



 

Christopher Wadsworth



 

Laura Dwyer



 

Richard Sturgess



Boston Scientific (Boston Scientific Corporation, USA) developed a fibreoptic cholangioscopy platform in 2007 called SpyGlass™ that revolutionized single operator cholangioscopy. This system included a cholangioscopy catheter that could be introduced through the working channel of a duodenoscope (over a guidewire) and strapped onto the side of the duodenoscope using a silastic strap, a pump to provide irrigation (sterile saline/water) and disposable devices that could be introduced through an instrumentation channel on the cholangioscope. The cholangioscope itself was a 10 Fr disposable 4-lumen catheter (Cholangioscope) with a 0.9 mm channel for the fibreoptic probe, a 1.2 mm channel to pass instruments/accessories and two 0.6 mm irrigation channels. A 3 Fr disposable biopsy forceps (SpyBite™) was available with the system and could be passed down the cholangioscope. Fibres to facilitate electrohydraulic lithotripsy (EHL) or laser lithotripsy could be additionally passed down the cholangioscope. The cholangioscope had 4-way tip deflection that facilitated manoeuvrability within the pancreaticobiliary system. The fibreoptic system was upgraded to a digital SpyGlass™ DS in 2007 and more recently, a further upgrade to a 3rd generation system called the SpyGlass™ DS II was launched [1]. The SpyGlass™ DS and DS II systems are single-use 10 Fr cholangioscopes and represent a significant improvement in image resolution in comparison to the legacy fibreoptic system. These digital cholangioscopes have retained the basic features of the legacy cholangioscope, with two irrigation channels and an instrumentation channel, and have a simple ‘plug-and-play’ setup onto a processor. Boston Scientific partnered with Northgate Technologies Inc (USA) in 2017 to distribute Northgate’s EHL system called Autolith™. The Autolith™ system delivers energy to facilitate EHL through a 1.9 Fr disposable probe. In 2018, Boston Scientific released a retrieval basket and snare with the SpyGlass™ DS II system.


The set up and technique described in this chapter relates to the digital SpyGlass platforms.


Cholangioscopy Technique


Please see online Video A that demonstrates the set-up, monitoring and use of the SpyGlass single operator cholangioscopy system.


The digital cholangioscope is generally inserted over a 450 cm guidewire that is initially placed in the pancreaticobiliary system at ERCP. Standard ERCP techniques are used for cannulation and duct access following which ‘long-wire’ (450 cm guidewire) access is achieved for biliary endotherapy. A biliary sphincterotomy is generally necessary to facilitate the advancement of the cholangioscope into the bile duct. A sphincterotomy additionally mitigates against increases in hydrostatic pressures in the biliary system by allowing flow around the cholangioscope. The cholangioscope is supplied in a sterile box and is assembled by plugging its cable onto the SpyGlass DS processor. The cholangioscope has an irrigation cable which is connected onto an irrigation pump generally delivering sterile saline and a separate suction cable with a three-way connector, which can be connected to a suction system. The processor and monitor are delivered on a dedicated stack that houses the Autolith™ generator and the cabling for the SpyGlass system.


The cholangioscope is advanced over the guidewire into the biliary system and is strapped onto the side of the duodenoscope. The cholangioscope sits just underneath and slightly to the right of the duodenoscope instrument channel. The duodenoscope position is stabilised once the cholangioscope is advanced out of the duodenoscope. Plugging the cholangioscope immediately generates a digital image on the SpyGlass monitor with the light on the cholangioscope activated. The light is generally turned off in order to reduce glare and facilitate visibility whilst advancing the scope into the bile duct. Advancement of the cholangioscope into the distal bile duct is generally easy over a guidewire, although freehand cannulation across a wide, sphincterotomised papillary orifice is also feasible. The cholangioscope has a single lock for its wheels, which can be applied to stabilise the tip and prevent excessive deflection. Advancement into the proximal bile duct is facilitated by a combination of insertion of the cholangioscope, adjustment of wheels and irrigation using the foot pump to aid visualisation. Once the cholangioscope is stabilised adjacent to a target (stone, stricture, etc.), the guidewire is removed to facilitate the deployment of accessories for therapy. Deep sedation or anaesthesia is generally required to facilitate cholangioscopy and lithotripsy.


Lithotripsy


Lithotripsy or fragmentation of stones is carried out using electrohydraulic lithotripsy or laser lithotripsy.


Electrohydraulic Lithotripsy (EHL)


Please see online Video cases 1–7 and 11 that demonstrate the use of EHL to fragment stones in the bile duct.


The principle of EHL is the creation of shock waves in a fluid column that delivers energy needed for stone fragmentation [2, 3]. Shock waves are created following the delivery of a rapid electric discharge centred at the tip of a probe. This generates a spark ‘plasma’ and the resultant development and implosion of a ‘cavitation bubble’ creates shock waves that deliver energy. EHL is delivered using a 1.9 mm probe inserted through the cholangioscope [4]. Once a stable position has been achieved in the bile duct, the guidewire is withdrawn from the cholangioscope and the EHL probe is inserted. Delivering the EHL probe out of the cholangioscope into the bile duct may be occasionally challenging due to friction within the accessory channel of the cholangioscope and manipulation of the scope (either inserting further into the duct or withdrawing it slightly) and/or releasing the elevator of the duodenoscope facilitates insertion of the EHL probe around the duodenal angle of the duodenoscope and into the bile duct. The tip of the EHL probe (seen at the 6 O’clock position on the cholangioscopic view) is then positioned adjacent to the stone in order to provide a fluid cushion between the tip of the probe and the stone. This fluid cushion serves to create shock waves. Care must be taken to not be too close to the stone to prevent damage to the cholangioscope. The EHL probe is connected to the Autolith™ generator to deliver energy. The Autolith™ Touch [4] system has three energy settings (low/medium/high: equating to 70–100 W) and different pulse settings (5, 15, 30 pulses). The pulse settings represent the number of pulses of energy delivered by a single activation of a foot pedal that controls the delivery of energy. Generally, energy and pulse settings are set low and are increased progressively depending on the lithotripsy effect. Saline is irrigated into the duct to provide a fluid column and lithotripsy is performed by pressing on the foot pedal of the Autolith™ system. Delivery of energy is seen as rapid pulses observed on the cholangioscopic view and stone fragmentation is observed in real time. Lithotripsy is continued by progressive application of energy across fracture points within the stone surface or by applying energy directly onto stone fragments to break these down to smaller pieces. This is enabled by manoeuvring the cholangioscope within the duct. EHL can cause trauma to the bile duct wall resulting in a risk of bleeding or perforation, so care must be taken to avoid being too close to the duct wall. Stone fragmentation can result in poor visibility and may need removal of the cholangioscope over the wire and the use of stone removal techniques using balloons or baskets to deliver fragments prior to successive sequences of lithotripsy. The process is iterative until stone fragmentation and duct clearance is achieved (Figs. 3.1, 3.2 and 3.3).

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Aug 3, 2021 | Posted by in GASTROENTEROLOGY | Comments Off on Operator Cholangioscopy
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