Introduction

Digital single-operator cholangioscopy (DSOC) stands as an invaluable diagnostic and therapeutic instrument, offering direct visualization of the biliary ducts. The use of cholangioscopes with higher diameter may raise concerns regarding patient discomfort and safety. Smaller diameter cholangioscopes could offer enhanced maneuverability and decreased risk of adverse events, improving procedural success rates.

Aims & Methods

The aim of this study is to compare the impact of cholangioscope diameter variation on cholangioscopy outcomes, with a focus on procedure success rates. A retrospective, comparative study performed in patients who underwent either diagnostic or therapeutic DSOC from January 2021 to August 2023 were retrospectively collected. A p <0.05 was considered statistically significant.

Results

A total of 128 procedures were performed in 119 patients. Median age was 62.5 (44 – 71) and 46.1% were female. 52.3% of procedures were performed with the 9.3F cholangioscope, 53 (41.4%) were performed with the 11.1F, and 6.2% procedures were performed with the 7F cholangioscope. The 9.3F cholangioscope was used mainly for diagnostic procedures (61.2%) when compared to the 11.1F (39.6%) (P= .01). The most common diagnostic indication was indeterminate biliary stricture (9.3F: 31.3% vs 11.1F: 13.2%) (P= .01). Most lesions were in the common bile duct (CBD). Two procedures performed with the 9.3F scope switched to a lower caliber scope (7F) to surpass the lesions, while 4 procedures performed with 11.1F required the application of a 9.3F to surpass the lesions and finish the procedures (P=.176). The 9.3F allowed the evaluation of the intrahepatic ducts in 6 procedures. More therapeutic procedures were performed with the 11.1F cholangioscope (60.4%), while 38.8% with the 9.3F. The main indication was lithotripsy. Most procedures with a stone size >20mm were performed with the 11.1F (61%) (P=.01), with a total removal of stones of 64.5%. Technical success was higher in the 9.3F (97.0% vs 90.6%), clinical success was higher in the 11.1F (96.2% vs 94.0%). All cases performed with the 7F cholangioscope were diagnostic, 7/8 procedures with 7F allow a complete evaluation of the intrahepatic ducts, 1/8 had a complete post-surgical CBD stenosis, and achieved a 100% technical and clinical success rate.

Conclusion

Cholangioscope diameter should be tailored to the specific diagnostic or therapeutic needs. While the 9.3F cholangioscope is more suitable for diagnostic procedures and has a higher technical success rate, the 11.1F is preferable for therapeutic interventions, particularly for larger biliary stones where higher caliber lithotripter is required. The 7F cholangioscope presents an effective alternative for complete intrahepatic duct evaluations.

References

1. Gerges C, Beyna T, Tang RSY, et al. Digital single-operator peroral cholangioscopy-guided biopsy sampling versus ERCP-guided brushing for indeterminate biliary strictures: a prospective, randomized, multicenter trial (with video). Gastrointestinal Endoscopy. 2020;91(5):1105–13.
2. Kahaleh M, Gaidhane M, Shahid HM, et al. Digital single-operator cholangioscopy interobserver study using a new classification: the Mendoza Classification (with video). Gastrointestinal Endoscopy. 2022;95(2):319–26.

Disclosure

Carlos Robles-Medranda is a key opinion leader and consultant for Pentax Medical, Steris, Medtronic, Motus, Micro-tech, G-Tech Medical Supply, CREO Medical, EndoSound, and mdconsgroup. All other authors have nothing to declare.

Introduction

Sarcopenia is increasingly recognized as a major prognostic factor in patients with hepatocellular carcinoma (HCC). Its evaluation may improve patient risk stratification and therapeutic decision-making

Aims & Methods

To assess the prevalence of sarcopenia among patients with hepatocellular carcinoma (HCC), identify associated factors, and evaluate the MELD-sarcopenia score as a potential predictor of mortality.
We conducted a retrospective monocentric study over a 10-year period, including patients aged over 18 years with a confirmed diagnosis of HCC based on radiological, biological, and/or histological criteria. Only patients with an available abdominal CT scan including the L3 vertebral level were included. Exclusion criteria were liver transplantation, other primary liver tumors, non-HCC malignancies, incomplete records, or poor-quality imaging. Sarcopenia was diagnosed by calculating the Total Psoas Area Index (TPAI) on CT, using thresholds of 5.45 cm²/m² for men and 3.85 cm²/m² for women. MELD and MELD-sarcopenia scores were calculated. Survival time from HCC diagnosis was recorded.

Results

Among 30 screened patients, 5 were excluded due to missing imaging. In the final cohort of 25 patients, the prevalence of sarcopenia was 52%. Compared to non-sarcopenic patients, sarcopenic patients were older (67.6 vs 56 years) and more often male. The most frequent etiology in sarcopenic patients was hepatitis C (46.2%), while hepatitis B was predominant in non-sarcopenic patients (58.3%). Cirrhosis was mostly compensated in both groups. HCC was typically unifocal, infiltrative, and multilobar in both groups. The mean time from HCC diagnosis to death was shorter in sarcopenic patients (13.4 vs 33.9 months). Male sex and older age were significantly associated with sarcopenia (p < 0.05), whereas tumor characteristics, Child-Pugh class, and biological tests were not. Kaplan-Meier analysis showed a tendency toward worse survival in patients with higher MELD-sarcopenia scores, although the difference was not statistically significant (p > 0.05).

Table : Comparison of clinical and survival characteristics between sarcopenic and non-sarcopenic patients with hepatocellular carcinoma

Conclusion

Sarcopenia is highly prevalent among patients with HCC and is independently associated with male sex and older age. The MELD-sarcopenia score appears to be a promising tool for mortality risk stratification and may aid clinical decision-making.

References

https://pubmed.ncbi.nlm.nih.gov/21893129/

Disclosure

There were no conflicts of interest.

Introduction

Digital single-operator cholangioscopy (DSOC) allows an accurate diagnosis of biliary strictures. Two DSOC-based artificial intelligence (AI) models trained to identify neoplasia were proposed. DSOC-guided pCLE biliary strictures direct visualization, using the Miami and Paris classifications has demonstrated high diagnostic accuracy for neoplasia (higher than expert endoscopists at times). To date, there are no head-to-head studies comparing DSOC-AI vs DSOC-pCLE.

Aims & Methods

We aim to compare the diagnostic accuracy for identifying neoplasia in indeterminate biliary lesions using a novel DSOC-AI model against DSOC-pCLE. Historic cohort-based diagnostic accuracy study in agreement with STARD initiative including patients ≥18 years old who underwent DSOC-pCLE (06/2014 to 11/2021). Patients without available DSOC videos, biopsy, or impossibility for 12-month follow-up were excluded. For DSOC direct visualization, neovasculature constituted neoplasia. For DSOC-pCLE, a higher presence of the Miami classification’s malignancy criteria (thick white and dark bands, dark clumps, epithelium) than the Paris classification’s inflammatory criteria (vascular congestion, roughness aspect, increased inter-glandular space, and thickened reticular structure) constituted neoplasia. For DSOC and pCLE-guided biopsy, corresponding histological findings constituted neoplasia. An offline DSOC-based AI model analysis was performed using the DSOC recorded videos from the selected cases. The DSOC-AI model considered neovasculature as the criterion for neoplasia. The gold standard for neoplasia was based on further clinical evolution, imaging, or surgical specimen findings during a 12-month follow-up. Accuracy of DSOC direct visualization, DSOC-pCLE, DSOC and pCLE-guided biopsy, and DSOC-AI model was calculated in terms of sensitivity, specificity, positive and negative predictive values (PPV and NPV), observed agreement, and area under the curve (AUC). Comparison of obtained diagnostic accuracies were defined through DeLong’s test for two ROC curves.

Results

Ninety patients were selected, median age was 66.4 ± 13.7 years, 56.7% female. Tumour suspicion was the most common indication (55.6%) (Table 1). DSOC-AI reached a 97.7% sensitivity, 75% specificity, 98.8% PPV, 60% NPV and 96.7% observed agreement; whereas, DSOC-pCLE had a 94.2% sensitivity, a 100% specificity, 100% PPV, 44.4% NPV, and 94.4% observed agreement (Table 2). AUC for DSOC-AI was 0.79; for DSOC direct visualization (0.74; P=.763), DSOC-pCLE (0.72; P=.634), and DSOC and pCLE-guided biopsy (0.83; P=.809).

Conclusion

The DSOC-AI model demonstrated an offline diagnostic accuracy similar to DSOC-pCLE. Larger multicentric head-to-head trials with a proportional sample among neoplastic and non-neoplastic cases are advisable for best estimation of obtained results.

References

1. Koda H, Hara K, Nozomi O, Kuwahara T, Nobumasa M, Haba S, et al. High-Resolution Probe-Based Confocal Laser Endomicroscopy for Diagnosing Biliary Diseases. Clin Endosc. 2021;54(6):924–9.
2. Pilonis ND, Januszewicz W, di Pietro M. Confocal laser endomicroscopy in gastro-intestinal endoscopy: Technical aspects and clinical applications. Transl Gastroenterol Hepatol. 2022;7:1–20.
3. Kahaleh M, Raijman I, Gaidhane M, Tyberg A, Sethi A, Slivka A, et al. Digital Cholangioscopic Interpretation: When North Meets the South. Digestive Diseases and Sciences. 2021;67(4):1345–51.
4. Robles-Medranda C, Oleas R, Sánchez-Carriel M, Olmos JI, Alcívar-Vásquez J, Puga-Tejada M, et al. Vascularity can distinguish neoplastic from non-neoplastic bile duct lesions during digital single-operator cholangioscopy. Gastrointestinal Endoscopy. 2021;93(4):935–41.
5. Robles-Medranda C, Valero M, Soria-Alcivar M, Puga-Tejada M, Oleas R, Ospina-Arboleda J, et al. Reliability and accuracy of a novel classification system using peroral cholangioscopy for the diagnosis of bile duct lesions. Endoscopy. 2018;50(11):1059–70.
6. Sethi A, Tyberg A, Slivka A, Adler DG, Desai AP, Sejpal D v., et al. Digital Single-operator Cholangioscopy (DSOC) Improves Interobserver Agreement (IOA) and Accuracy for Evaluation of Indeterminate Biliary Strictures: The Monaco Classification. Journal of Clinical Gastroenterology. 2022;56(2).

Disclosure

Carlos Robles-Medranda is a key opinion leader and consultant for Pentax Medical, Steris, Medtronic, Motus, Micro-tech, G-Tech Medical Supply, CREO Medical, EndoSound, and mdconsgroup. The other authors declare no conflicts of interest.

Introduction

Percutaneous liver biopsy (PC-LB) is the gold standard for the study of chronic liver disease. However, it is limited to patients with appropriate clinical and hematological conditions. Transjugular liver biopsy (TJ-LB) represents a less invasive yet less available technique. Endoscopic ultrasound-guided liver biopsy (EUS-LB) has emerged as a minimally invasive readily available technique. To the best of our knowledge, no network meta-analysis has compared LB quality and related adverse events among these techniques.

Aims & Methods

A systematic search was run in PubMed, Embase, Web of Science and Cochrane. The search included studies from inception to November 2023, in adult patients, which compared at least two of the following techniques: EUS-LB, PC-LB or TJ-LB. The analyzed endpoints were mean total sample length (TSL), mean number of complete portal triads (CPT), rate of appropriate sample for diagnosis, sample fragmentation and major adverse events (hematomas, bleeding, perforation, death). There was no distinction regarding study design, biopsy needle type or assistance with additional imaging methods. The studies with insufficient data, without any reported endpoint, or case series were excluded. The PC-LB was the reference. Data was analyzed in Rv4.0.

Results

Over the last thirty years (1993 to 2023), 21 original studies were analyzed being: 18/21 full manuscripts; 15/21 retrospective, 3/21 prospective, 3/21 randomized clinical trials (RCT); 11/21 EUS-LB, 21/21 PC-LB and 16/21 TJ-LB; 5/21 EUS-LB vs PC-LB, 10/21 PC-LB vs TJ-LB, and 6/21 compared the three techniques. We scrutinized 620 EUS-LB patients, 3347 PC-LB, and 1901 TJ-LB. TSL pooled mean for EUS-LB, PC-LB, and TJ-LB was 28.6 ± 10.6 mm, 23.3 ± 13.5 mm, and 15.7 ± 9.0 mm, respectively. Pooled rate of appropriate sample for diagnosis was 96.6%, 89.2%, and 85.4%, with a major adverse events pooled rate of 4%, 2.9%, and 3.5%, respectively. Between 14 studies and 24 pairwise comparisons, TSL EUS-LB mean was 0.17 mm longer (p=.932), but TJ-LB 4.93 mm shorter (p=.0025) (I²=95%). Between 3 studies and 5 pairwise comparisons, relative risk (RR) of sample fragmentation was significantly higher for EUS-LB (RR 4.55; 95% CI 2.72 – 7.61; p<.001) and TJ-LB (RR 2.72; 95% CI 1.54 - 4.80; p<.001) (I²=0%). There was not significant difference among mean number of CPT (I²=97.3%), rate of appropriate sample for diagnosis (I²=48.7%) or major adverse events (I²=10.5%).

Conclusion

EUS-LB quality is comparable to PC-LB and superior to TJ-LB in terms of TSL. These techniques are comparable in terms of the mean number of CPT, rate of appropriate sample for diagnosis, and major adverse events. Further original studies are needed to define the sample fragmentation rate of the aforementioned.

References

McCarty TR, Bazarbashi AN, Njei B, Ryou M, Aslanian HR, Muniraj T. Endoscopic Ultrasound-Guided, Percutaneous, and Transjugular Liver Biopsy: A Comparative Systematic Review and Meta-Analysis. Clin Endosc. 2020 Sep;53(5):583-593. doi: 10.5946/ce.2019.211. Epub 2020 Sep 29. PMID: 33027584; PMCID: PMC7548145.
Chandan S, Deliwala S, Khan SR, Mohan BP, Dhindsa BS, Bapaye J, Goyal H, Kassab LL, Kamal F, Sayles HR, Kochhar GS, Adler DG. EUS-guided versus percutaneous liver biopsy: A comprehensive review and meta-analysis of outcomes. Endosc Ultrasound. 2023 Mar-Apr;12(2):171-180. doi: 10.4103/EUS-D-21-00268. PMID: 36204798; PMCID: PMC10237604.

Introduction

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the most commonly used therapeutic procedure for pancreaticobiliary disorders. Despite the central role of bile duct cannulation in procedural success and safety, data on influencing factors remain limited. Cannulation outcomes can be affected by periampullary diverticula (PAD), anatomical variations, and the experience of the endoscopist. Our previous meta-analysis and systematic review identified papilla morphology as a significant contributing factor. Further research suggests that different papilla types may influence technical success and complication rates, including post-ERCP pancreatitis (PEP). Moreover, papilla morphology appears to impact both the need for and choice of rescue cannulation techniques, making its evaluation particularly relevant in clinical practice.

Aims & Methods

This study aims to evaluate how papilla morphology affects ERCP outcomes, including cannulation success, rescue techniques, and complications like post-ERCP pancreatitis (PEP). We conducted a retrospective cohort study at a tertiary care center, reviewing patients with native papilla scheduled for ERCP between September 2022 and August 2024. Papillae were classified according to the Haraldsson system into four types. Demographic, clinical, and procedural outcome data were collected, including complications such as PEP. Rescue techniques included transpancreatic sphincterotomy (TPS), needle-knife papillotomy (NKP), needle-knife fistulotomy (NKF), and double guidewire technique (DGT). Descriptive statistics were used to analyze the data.

Results

A total of 409 patients with native papilla were included in the study. Cannulation failure rates varied across papilla types, being highest in type II papilla (15.6%), followed by type I (9.1%), type IV (8.1%), and type III (4.4%). The rate of PAD was highest in type IV papillae (13.5%) and lowest in type III (4.4%). Biliary etiology was the leading indication for ERCP across all papilla types, with rates of 60.6% for type I, 59.4% for type II, 66.7% for type III, and 56.8% for type IV. PEP occurred most frequently in type IV papillae (10.8%), followed by type III (6.7%), type I (6.5%), and type II (4.2%). Other complications, including cholangitis, perforation, and bleeding, were rare, with rates of 1.73% for type I and 2.08% for type II papillae, while none occurred in type III or IV papillae. Rescue cannulation techniques were most frequently required in type III papillae (46.7%), where the most common methods included transpancreatic sphincterotomy and needle-knife papillotomy, both of which were used in 20% of cases. The double guidewire technique was employed in 15.6% of type III cases, while needle-knife fistulotomy was used in 6.7%. Type I and type IV papillae also had significant rates of rescue cannulation (40.7% and 40.5%, respectively), with needle-knife papillotomy being the most commonly used method in both types (19.9% for type I and 24.3% for type IV). For type I papillae, TPS was used in 16% of cases, while the DGT was the preferred method for type IV papillae in 13.5% of cases. Rescue techniques were less frequently needed for type II papillae (29.2%), with DGT being the most commonly applied (10.4%), followed by TPS (9.4%) and NKP (8.3%).

Conclusion

Papilla morphology affects ERCP outcomes and the choice of rescue cannulation techniques. Types III and IV were associated with higher use of advanced techniques and complication rates. Identifying papilla type may support individualized procedural planning and improve success and safety.

Introduction

Primary sclerosing cholangitis (PSC) is a progressive disease leading to inflammation and fibrosis of the bile ducts with biliary strictures. New strictures or symptoms should trigger the suspicion of cholangiocarcinoma which may develop in more than 20% of patients. Endoscopic retrograde cholangiopancreaticography (ERCP) is useful in stricture management, but standard tissue acquisition with brush cytology provides poor diagnostic accuracy. Cholangioscopy can aid stricture assessment and stone clearance. This study investigated the technical success, diagnostic yield and complication rate of cholangioscopy in PSC patients in two large tertiary European hospitals.

Aims & Methods

This retrospective cohort included all consecutive PSC patients who underwent ERCP with cholangioscopy between 2014 and 2024. Exclusion criteria were liver transplantation or confirmed cholangiocarcinoma. Charts were reviewed for patient characteristics, procedure characteristics and outcomes.

Results

A total of 84 cholangioscopies were performed in 55 PSC patients (55% male, mean age 63 years). Most patients were of Caucasian ethnicity (68%). Cirrhosis was present in 29% of patients with 54% also having concurrent inflammatory bowel disease.
Most patients (88%) were discussed in a multidisciplinary meeting prior to ERCP. The primary indications for ERCP were stricture assessment (38%), dominant stricture (21%), cholangitis (19%), suspicion of malignancy (11%), stones (10%). The mean serum alkaline phosphatase and bilirubin were 508 IU/Land 60 umol/L, respectively. Most patients received rectal diclofenac (98%) and antibiotics (96.5%). Fifteen patients (18%) had a native ampulla of whom 5 (33%) were considered as difficult cannulation (per ESGE). No precut was performed. All patients with native ampulla underwent sphincterotomy.
Cholangioscopy was successful in 98% of cases with two failures due to tight stricture and inadequate intraductal view. Electrohydraulic lithotripsy was successful in 76% of cases with a complete stone clearance rate of 82%.
Cholangioscopy-guided biopsies were taken in 44 cases which resulted in histological diagnosis of cholangiocarcinoma in four patients. One patient was diagnosed with cholangiocarcinoma on cholangioscopy-guided biopsies while the cytological brush was non-diagnostic and one patient had cholangiocarcinoma confirmed on both cholangioscopy-guided biopsies and cytological brush. The other two cholangiocarcinoma was diagnosed where only cholangioscopyguided biopsies were done. On the other hand, one patient with normal cholangioscopy-guided biopsies and cytological brush was diagnosed with cholangiocarcinoma on endoscopic ultrasound guided lymph node biopsy.
Seven patients developed a complication (8%): 1 peri-procedural bleeding, 1 hepatic decompensation, 1 gallbladder perforation and pancreatitis, 3 cholangitis and 1 abdominal pain requiring admission. Native papilla was not associated with an increased risk of complications (6.6% vs. 8.7%, p>0.05).

Conclusion

This is one of the largest cohort of cholangioscopies in PSC patients performed in two high volume centre. Cholangioscopy had a high technical success rate. Previous concern that strictures preclude technical success was not seen. Stone clearance using electrohydraulic lithotripsy was also effective. On the other hand, cholangioscopy-guided biopsies may inform clinical management but more data is needed on the clinical impact of cholangioscopy. Cholangioscopy did not appear to increase the established risk of ERCP in PSC patients.