Re-purposed use of a stiffening wire as a novel adjunct for direct cholangioscopy access

I read with great interest the paper “Direct peroral cholangioscopy with a new anchoring technique using the guide probe of Kautz – first clinical experiences” by Lenze et al. published in the recent issue of Endoscopy [1]. Based on their initial individual report, the authors provide an extended case series on their unique alternative anchoring technique for direct cholangioscopy access, relying on a historic nonendoscopic Kautz probe, which, however, is not widely available in endoscopy services [2]. From this perspective, it is interesting to see how a highly innovative endoscopic procedure is being pimped up by creative re-purposing of historic endoscopy (or, in this case, radiology) accessories, blurring the lines between new and old, for which the authors are to be commended.

Against this background, I would like to present as unpublished material another endoscopic ancillary device that was re-purposed to provide direct cholangioscopy access after failure of stable freehand intubation. This idea was entertained after endoscopic papillary large-balloon dilation up to 15 mm for revisional treatment of post-papillotomy stenosis and an episode of cholangitis [3]. Owing to marked bile duct dilation up to 30 mm in its proximal aspects, direct cholangioscopy to exclude remnant common bile duct (CBD) stones was indicated. However, because of an acutely angulated distal bile duct, stable freehand intubation using a standard-sized upper endoscope failed vis-à-vis an unfavorable force axis, which precluded further scope advancement after successfully entering the papillary orifice. In order to stabilize the scope position and signpost the curved track to the upper parts of the CBD, we inserted a re-usable stiffening wire with a soft, 20 mm, double-olive tip segment, which was initially developed for colonoscope stabilization (FDSP-30260 /DM; Mandel & Rupp, Erkrath, Germany) ([Fig. 1a,b]). Following this, negotiation beyond the acute angulation was possible ([Fig. 1c]), and advancement up to the liver hilum was achieved ([Fig. 1d]).

Fig. 1 Re-purposed use of a stiffening wire as a novel adjunct for direct cholangioscopy access. Fluoroscopic (a) and endoscopic (b) views of the inserted stiffening wire (FDSP-30260/DM; Mandel & Rupp, Erkrath, Germany). The device was used to stabilize and signpost the acutely angulated distal common bile duct (CBD) axis, which had precluded stable freehand intubation of the prepapillary CBD portion using a standard-sized upper endoscope (Fujinon EG590WR; Fujifilm, Düsseldorf, Germany – outer diameter 9.6 mm, working channel 2.8 mm) following endoscopic papillary large-balloon dilation up to 15 mm. c Stable intubation of the middle portion of the CBD was achieved after negotiating the sharp angulation; note the cystic duct orifice at the 7 o’clock position. d Procedural completion of direct cholangioscopy up to the liver hilum after withdrawal of the stiffening wire.

Direct cholangioscopy is a highly innovative field in pancreaticobiliary endoscopy. However, this modality is still fraught with limited dissemination for various reasons, such as the perceived technical and procedural intricacies, as well as the associated need for highly specialized equipment (e. g. anchoring balloons) [4]. The interest in freehand intubated direct cholangioscopy has been renewed following positive preliminary data on a next-generation double-bending prototype cholangioscope [5]. Notwithstanding these interesting new developments in the area, individual tricks of the trade to facilitate and/or rescue freehand-intubated direct cholangioscopy access that rely on ad hoc and ubiquitously available accessories may help to disseminate cholangioscopy in the future and move the field from academia into community-based endoscopy services.

• References

• 1 Lenze F, Nowacki TM, Beyna T. et al. Direct peroral cholangioscopy with a new anchoring technique using the guide probe of Kautz – first clinical experiences. Endoscopy 2017; DOI: 10.1055/s-0043-109864.
• 2 Beyna T, Lenze F, Hengst K. et al. A new anchoring technique for accessing the bile duct during direct peroral cholangioscopy using the guide probe of Kautz. Endoscopy 2012; 44 (Suppl. 02) E372-E373
• 3 Donatelli G, Dumont JL, Cereatti F. et al. Revision of biliary sphincterotomy by re-cut, balloon dilation or temporary stenting: comparison of clinical outcome and complication rate (with video). Endosc Int Open 2017; 5: E395-E401
• 4 Lee YN, Moon JH, Choi HJ. et al. A newly modified access balloon catheter for direct peroral cholangioscopy by using an ultraslim upper endoscope (with videos). Gastrointest Endosc 2016; 83: 240-247
• 5 Beyna T, Farnik H, Sarrazin C. et al. Direct retrograde cholangioscopy with a new prototype double-bending cholangioscope. Endoscopy 2016; 48: 929-933