Cholangio-Pancreatoscopy: What, When, Why & How
Jong H. Moon, MD, PhD
Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon/Seoul, Korea

Peroral cholangioscopy (POC) permits direct visualization of the biliary tree for diagnostic procedures and provides endoscopic guidance for therapeutic interventions. Peroral cholangioscopy using mother-baby scope system is improving on image quality, but, still not widely used because of its disadvantages. With technological developments, single operator cholangioscopy system is replacing POC using mother-baby scope system and can be the standard POC system. The firstly introduced single-operator POC system is the SpyGlass Direct Visualization System. Recently developed digital version of SpyGlass, SpyGlass DS system provides much improved image quality, integrated an optical probe in the catheter, channels for separate irrigation and suction, and easy set-up and plug and play function. It has been provided adequate tissue samples for histological diagnosis, and facilitated stone fragmentation as interventions on direct visualization. SpyGlass DSII system just launched to the market. It is providing higher visual acuity and less light flares and central hot spot. Direct POC using an ultra-slim upper endoscope has been proposed as another type of single-operator system for direct endoscopic examination of the biliary tree. Advantages of direct POC using an ultrathin endoscope include its use of conventional endoscopy equipment, its superior images of the biliary tree with large working channel. Especially therapeutic interventions can be expanded using widen working channel of ultra-slim scope up to 2.2mm. Intracorporeal lithotripsy with electrohydraulic or laser lithotripsy is a main therapeutic intervention of direct POC for patients with bile duct stones that are resistant to conventional endoscopic stone-removal procedures. Not only stone fragmentation on direct visualization, metal stenting, tumor ablation therapy including photodynamic therapy, argon plasma coagulation, or radiofrequency ablation can be applied on direct visualization for the palliation of malignant biliary obstruction. Accessories to assist direct POC, and endoscopes to be a dedicated scope for direct POC is developing to expand the function of direct POC. For this purpose, multibending ultraslim endoscope is developing for the dedicated scope for direct POC with easy insertion of a scope into the biliary tree, and stability of scope position inside of bile duct. In conclusion, with the technical development including scopes and equipment, POC is expected to expand the therapeutic roles for biliary lesions.