Current and future role of cholangiopancreatoscopy (CPS)

CPS was introduced approximately 50 years ago. However, the technique was never widely used mainly because of its complexity. This has changed with the introduction of slim disposable single operator cholangioscopes (SOC) because they are safe, effective and easy to use. They can be deflected in 4 ways, which greatly improves the manipulation and permits easy advance even into the intrahepatic bile ducts. Videochips and LED`s provide an excellent image quality. An instrumentation channel with a diameter of up to 1.3 mm allows insertion of specially designed accessories like forceps, baskets or snares. Irrigation through separate channels ensures a clear picture. This advanced technology allows a variety of biliopancreatic interventions under direct visual control. The main diagnostic indication is the evaluation of indeterminate ductal stenoses by characterization of mucosal and vascular patterns. Recent studies show that tissue acquisition with special forceps is more accurate than fluroscopically guided biopsies or brush cytology. Delineation of intraductal tumor margins improves preoperative staging. Therapeutic options of ERCP can be expanded in combination with CPS. Difficult strictures can be negotiated by targeted advancement of guidewires. Precise positioning of laser fibers or EHL probes allows fragmentation of complex bile duct and pancreatic duct stones. Data from an Asian multicenter registry on SOC for difficult bile duct stones demonstrated a clearance rate of 80% of the cases in a single session. Two recent prospective multicenter trials showed excellent technical and clinical results of pancreatoscopic treatment of ductal stones in patients with symptomatic chronic pancreatitis as an alternative to ESWL. Further therapeutic indications of CPS are radiation free interventions and removal of migrated stents or foreign bodies under direct visual control. A modification of the peroral SOC instrument has with a short insertion length that facilitates percutaneous transhepatic cholangioscopy through a 12 FG sheath in cases that are not amenable to ERCP. First data showed excellent results even in difficult cases. In conclusion CPS has been established for evaluation of indeterminate ductal lesions and treatment of difficult bile duct stones. It should be also considered for intraductal tumor staging, targeted cannulation of difficult strictures and for treatment of pancreatic duct stones. It offers other new opportunities for biliopancreatic interventions under direct visual control and may increasingly replace fluoroscopically controlled procedures. SOC is the method of choice because of its easy handling, approved efficacy and safety. CPS should be preferably performed in an interdisciplinary setting for management of biliopancreatic diseases.