Introduction

Single-operator cholangioscopy with SpyGlass™ DS Direct Visualization System (Boston Scientific Corp.) allows easier and more effective management of bilio-pancreatic diseases, with a relatively low rate of adverse events. Its main applications are the treatment of difficult biliary lithiasis and the diagnosis of indeterminate biliary strictures, although data confirming its efficacy are still limited. In the present study, we evaluated efficacy and safety of single-operator digital cholangioscopy in a secondary digestive endoscopy centre.

Aims & Methods

We retrospectively evaluated 113 consecutive patients undergoing SpyGlass™ DS cholangioscopy between February 2016 and September 2022 at our centre. Demographic and procedural characteristics and post-procedural outcomes were collected for the purpose of statistical analysis.

Results

A total of 126 SpyGlass™ DS procedures were performed on 113 patients (females 69, 61.1% - males 44, 38.9%) with a mean age of 73.4 ± SD 17 years. 92% of the patients underwent only one procedure, while the remaining 8% required 2 to 4 consecutive procedures. Indications were treatment of difficult biliary stones (85/126, 67.5%), diagnosis of indeterminate biliary strictures (30/126, 23.8%) and others (11/126, 8.7%). Holmium laser lithotripsy was the most frequently used (76/85, 89.4%). Complete clearance was achieved in almost all cases (80/85, 94.1%) with an average number of sessions of 1.05. The complete clearance rate at the first session was 93.75%.
40 diagnostic procedures were performed to characterise indeterminate biliary strictures, since diagnostic cholangioscopy was required for incidental biliary stricture in 10 patients who initially underwent lithotripsy. In 36/40 patients (90%) a stricture was confirmed and among these 72.2% required targeted biopsies with SpyBite™ forceps (21/36, 58.3% malignant biliary strictures - 15/36, 41.7% benign biliary strictures). The sensitivity, specificity and accuracy values at follow-up were 90%, 93% and 92% for the visual impression at cholangioscopic imaging and 86%, 100% and 88% for the histological examination of the targeted biopsy. A total of two cases of cholangioscopy-related adverse events were reported (2/126, 1.59%): one mild pancreatitis and one mild cholangitis.

Conclusion

The data obtained from our experience confirm the therapeutic and diagnostic value of digital single-operator cholangioscopy in the management of bilio-pancreatic diseases. Cholangioscopy-guided lithotripsy has been shown to have a high rate of complete clearance already at the first session. Regarding the management of indeterminate biliary stenosis, sensitivity of visual impression was superior to that of targeted biopsy; conversely, specificity of histological examination by targeted biopsy appeared superior. Prospective and multicentre studies would be advisable to consolidate the role of cholangioscopy in the management of bilio-pancreatic pathology.

Clinical Case Summary

A 90-year-old woman was referred to our endoscopy unit from another hospital for urgent rescue therapy because of impacted Dormia basket during ERCP performed for symptomatic recurrent choledochal lithiasis. In attempt to perform extracanalar lithotripsy Dormia basket was broken near the handle. Another ERCP was performed, and the contrast cholangiography showed dilated common bile duct (up to 13mm) with a constriction in the middle part and impacted Dormia basket with multiple gallstones, confirmed by Spyglass single-operator per-oral cholangioscopy with direct visualization. Electrohydraulics lithotripsy with Autolith EHL system (2437 pulses, medium-high power) was performed with stones fragmentation but Dormia basket entrapped stone fragments. Dormia basket distal margin was caught with a biopsy forceps and passed in duodenoscope working channel. Then biliary clearance was completed with ballon catheter and the following cholangiography confirmed successful biliary drainage and optimal bile outflow without contrast biliary or duodenal spreading. Postprocedural course was regular, and the patient was discharged after three days of hospitalization.

Introduction

Endoscopic biliary stenting is a well–established therapy in the management of hepatobiliary diseases. However, migration is reported in 5%-10% of cases. Management of proximally migrated stents using standard techniques(guidewire cannulation, snare, forceps, Schohenra stent retriever) can be technically challenging sometimes. Cholangioscopy and retrieval under direct visualization could be a useful tool in such difficult cases.

Aims & Methods

To evaluate the application of single-operator cholangioscopy in the management of proximally migrated biliary stents in terms of efficacy and safety.
Methods:We performed a retrospective analysis of the data of a prospective group of patients. The cohort included consecutive 100 cases of proximally migrated stents from January 2018 through March 2024. We evaluated the retrieval technique, success rate, and adverse events.

Results

Patients were divided into two groups. In the first collective of patients- cholangioscopy was not performed n=62/62%/. We found a technical success rate – defined as successful stent extraction in 69,35% of cases/n=43/. In 19 of the cases removal was not achieved, followed by placement of new plastic stent n=19/30.65%/.In the second group, n=38/38%/ cholangioscopy with single operator cholangioscope was the retrieval technique with a technical success rate of 100%. There was a statistical difference between the two groups in terms of technical success in favor of the group with cholangioscopy - Pearson chi-square χ 2 =21.534, p< 0.001. Cholangioscopy was performed either after the failure of standard techniques or as the first-choice tool for stent removal. In five cases we performed pancreatoscopy for extraction of migrated pancreatic stents with only one case of postprocedure pancreatitis. We experienced adverse events/AE/ in 17 cases as pancreatitis was the most common complication n=11/64,71% of all AE/, followed by cholangitis n=5/29,41% of all AE/ and one case of bleeding n=1/5,88%/. In the first group, the rate of adverse events was 17,74%/n=11/ against 13,95%/n=6/ for the second group. There was no significant statistical difference in the rate of AE between the two groups. The mean procedure duration was 34,35 minutes for the first group and 42,24 minutes for the second with a statistically significant difference p=0.029 in favor of the first group. However, it is important to note that in some cases cholangioscopy was performed after the failure of standard techniques which by ilself prolonged the procedure time.

Conclusion

Cholangioscopy is a safe and effective technique for the extraction of migrated biliary stents with a high rate of efficacy and an acceptable rate of adverse events. It could be proposed as a first choice in cases where failure of standard techniques is suspected/persistent stenosis, residual bile duct stones/.

Introduction

The evaluation of intraductal extension of perihilar cholangiocarcinoma (pCCA) is extremely challenging and affects the resectability of the disease. Digital Single-Operator Cholangioscopy (D-SOC) and D-SOC-guided biopsies are frequently used for diagnostic assessment of indeterminate biliary strictures.

Aims & Methods

In this study, we evaluated the role of D-SOC and D-SOC-guided biopsies in the pre-operative evaluation of intraductal extension of pCCA. We retrospectively analysed pCCA patients who underwent D-SOC and D-SOC-guided biopsies to assess the intraductal extension of the tumor prior to surgery for potentially resectable disease in our center between 2017 and 2021. The accuracy of endoscopic appearance and histological sampling were compared to surgical samples obtained at surgery.

Results

Among 48 patients who underwent surgery for pCCA, after multidisciplinary discussion, D-SOC and D-SOC-guided biopsies were performed for proximal biliary staging in 6 patients (M:F 5:1, mean age at diagnosis 67 y.o.), which had an unclear ductal extension. A total of 12 D-SOC -guided biopsies were performed (7 from common duct, 2 from right duct and 3 from left duct). Concordance between CS-guided biopsies and surgical samples histological evaluation was 83% (10/12), with 6/6 true positives, 4/6 true negatives and 2/6 false negatives. Among the histological false negatives, the first case had a cholangioscopic appearance compatible with CCA extension, thus the result of D-SOC-guided biopsies did not influence the therapeutic choice. In the second histological false negative, the evaluation of the surgical specimen showed perineural invasion and periductal tumor development. Radical surgery was achieved in all 6 patients.

Conclusion

Despite limited sample size, our preliminary data suggest a very high specificity of D-SOC and D-SOC -guided biopsies in the pre-operative evaluation of intraductal extension of potentially resectable pCCA patients. A multidisciplinary approach and an accurate pre-operative assessment of pCCA remain of paramount importance to correctly diagnose and stage the disease before surgery.

Introduction

Primary biliary cholangitis (PBC) is a chronic autoimmune inflammatory disease of the intrahepatic bile ducts. It is characterized by chronic cholestasis, the presence of specific auto immune antibodies, and distinctive histological lesions. PBC is frequently associated with other autoimmune diseases.

Aims & Methods

This study aims to describe the clinical, biological, morphological, and histological characteristics of PBC patients with associated autoimmune diseases, as well as the therapeutic approaches used.
This was a descriptive retrospective study conducted in the Medicine C of Hepatogastroenterology Department at Ibn Sina Hospital in Rabat, including 62 patients with PBC and associated autoimmune diseases between 2010 and 2025.

Results

Among 130 patients with PBC, 62 had an associated autoimmune disease, representing a prevalence of 47%. The mean age was 47 years, with a sex ratio of 1M/9F. The most frequent symptoms were jaundice in 45.2% (n=28) of cases, asthenia in 41.9% (n=26), and pruritus in 35.5% (n=22). Clinical examination revealed signs of portal hypertension in 48.4% (n=30) of patients, jaundice in 51.6% (n=32), and scratch lesions in 19.4% (n=12).
Abdominal ultrasound showed liver with features of chronic liver disease in 71% (n=44) of patients, splenomegaly in 41.9% (n=26), ascites in 37.1% (n=23), and collateral venous circulation in 32.3% (n=20).
Biological abnormalities included cytolysis in 71% (n=44) of cases, cholestasis in 38.7% (n=24), and hepatocellular insufficiency in 22.6% (n=14). Regarding the autoimmune profile, 62.9% of PBC cases were seropositive, with anti-mitochondrial antibodies type 2 detected in 45% (n=28), anti-Sp100 antibodies in 19% (n=12), and anti-Gp210 antibodies in 16% (n=10) of patients.
Liver biopsy was performed in 40 patients and the Scheuer stages were classified as follows: stage 1 in 12.9% (n=8), stage 2 in 29% (n=18), stage 3 in 19.4% (n=12) and stage 4 in 3.2% (n=2) of cases.
Fibrosis assessment was carried out in 53 patients, using transient elastography (FibroScan) in 13 cases and liver biopsy in 40 cases. The fibrosis stage distribution was as follows: F3 in 38.7% (n=24), F2 in 25.8% (n=16), F4 in 11.2% (n=7), F1 in 8% (n=5), and F0 in 1.6% (n=1) of cases.
The main associated autoimmune diseases were autoimmune hepatitis in 40.3% (n=25) of cases and autoimmune thyroiditis in 40.3% (n=25), followed by Sjögren's syndrome in 21% (n=13), type 1 diabetes in 8.1% (n=5), and celiac disease in 4.8% (n=3). Less frequent associations included juvenile polyarthritis, Graves' disease, and vitiligo (each in 3.2% (n=2) of cases), as well as scleroderma and Addison's disease (each in 1.6% (n=1) of cases). Among these patients, 29% (n=18) had two associated autoimmune diseases, and 6.5% (n=4) had three.
All patients received ursodeoxycholic acid (UDCA) at doses of 13-15 mg/day, along with specific treatments for concomitant autoimmune diseases.
Treatment response assessment using the Paris II score showed a good response in 62% (n=38) of patients and a partial response in 38% (n=24) of patients.

Conclusion

This study confirms the high prevalence of autoimmune diseases associated with PBC, particularly autoimmune hepatitis and thyroiditis, with a strong female predominance. The most frequent stages of fibrosis were F2 and F3, highlighting the moderate to advanced disease progression at diagnosis in many patients. It emphasizes the importance of systematic screening for these comorbidities to ensure optimal management.

Introduction

Cholangiocarcinoma (CCa) is a complex neoplasm with poor prognosis, classified as intrahepatic (iCCa), perihilar (pCCa), or distal (dCCa) in the bile duct. Its variable phenotypes pose diagnostic challenges. Digital single-operator cholangioscopy (DSOC) aids diagnosis but has limitations, including suboptimal biopsy sensitivity, lack of a standardized morphology classification, as well as technical issues. Emerging evidence highlights AI’s potential to enhance DSOC diagnostic capacity, but the differential performance according to tumor characteristics, namely its topography, remains unassessed.

Aims & Methods

This study aimed to evaluate an AI algorithm’s effectiveness in detecting iCCa, pCCa, and dCCa. A deep learning model based on a convolutional neural network (CNN) was designed to automatically predict the malignancy status of biliary strictures. The model was built using DSOC images from four international high-volume centers: Centro Hospitalar Universitário de São João (Porto, Portugal), Hospital Universitario Puerta de Hierro Majadahonda (Madrid, Spain), New York University Langone Hospital (New York, USA) and University of Chicago Medicine (Chicago, USA). Images showing strictures due to cholangiocarcinoma or benign conditions were included. The model was trained with a learning rate of 0.0001, a batch size of 32, and a number of epochs of 10, using PyTorch framework. The detection rate of the algorithm was compared for each location category.

Results

A total of 18166 images from 32 patients from 4 centers. A total of 22 patients were male (69%) and the mean age was 63 years (SD: 11 years). Common bile duct (CBD) strictures represented 44% of the total (n=14) while intrahepatic and perihilar accounted for 22% (n=7) and 34% (n=11), respectively. The algorithm’s DR of strictures representing CCa was 91.6% for iCCa, 89.4% for pCCa and 92.4% for dCCa. Pairwise comparisons revealed a significant difference in the DR for iCCa and pCCa (p<0.05) and dCCa and pCCa (p<0.001).

Conclusion

Topographic characteristics of biliary strictures influence the diagnostic performance of DSOC. While AI shows promise in improving the diagnostic capacity of DSOC, its performance is impacted by DSOC technical limitations. To our knowledge, this is the first multicentric and transatlantic algorithm, capable of providing detection and differentiation of morphologic features of biliary strictures. Developing models should address and control for these issues before widespread clinical integration. Additionally, this evidence stresses the importance of keeping a “human on the loop”, providing clinical reasoning to guide the application of AI algorithms.