Endoscopy has replaced many radiological studies for the GI tract. However, ERCP remains a hybrid endoscopic-fluoroscopic procedure, which limits its portable delivery, creates delays due to fluoroscopy room unavailability and exposes patients/providers to radiation. We evaluated fluoroscopy/radiation-free management of patients with non-complex choledocholithiasis using direct solitary cholangioscopy (DSC).
Patients underwent fluoroscopy-free biliary cannulation, sphincterotomy then cholangioscopy to establish location, number/size of stones and document distance from ampulla to bifurcation to guide balloon advancement. Stones were extracted using a marked balloon catheter advanced to the bifurcation and inflated to the bile duct diameter, documented on prior imaging. Repeat cholangioscopy was performed to confirm stone clearance.
Fluoroscopy-free biliary cannulation was successful in all 40 patients (100%). Advanced cannulation techniques were required in 5 patients. Papillary balloon dilation was performed in 8 patients and electro-hydraulic lithotripsy in 3 patients. Discrete stones were visualized in 31 patients and stone debris/sludge in 8 patients. Fluoroscopy-free stone/debris/sludge extraction was successful in all these patients. Brief fluoroscopy was used in 2 patients (5%) to confirm stone clearance. No stone/debris/sludge was noted in 1 patient. Mild pancreatitis was noted in 2 patients (5%) and bleeding in 1 (2.5%).
This study establishes the feasibility of fluoroscopy/radiation-free, cholangioscopic management of non-complex choledocholithiasis, with, success and adverse event rates similar to standard ERCP. DSC represents a significant procedural advance in the management of biliary disorders, which need not be confined to the fluoroscopy suite, and can be reimagined as bedside procedures in emergency department or intensive care unit settings.