Assessing the utility, findings, and outcomes of percutaneous transhepatic cholangioscopy with Spyglass Direct visualization system: a case series.

Bile duct stones, indeterminate biliary strictures and other biliary duct pathologies represent a significant surgical and endoscopic challenge in patients with altered luminal or biliary anatomy. Traditional endoscopic retrograde cholangiopancreatography (ERCP) is not feasible and alternative approach is usually required. A novel alternative approach of addressing these challenging cases is assessed by this case series. All patients who underwent percutaneous transhepatic cholangioscopy (PTCS) and Spyglass Direct visualization system (SDVS) between December 2016 and February 2018 were studied. The indications for procedure, interventions performed, outcomes and complications were reviewed for each case. Spyglass marketed by Boston Scientific Corporation, Marlborough, Massachusetts was utilized by interventional endoscopists and radiologists through a 12 French (Fr) percutaneous vascular sheath. Five patients had altered biliary and/or luminal anatomy: two with Roux-en-Y gastric bypass and three with Roux-en-Y hepaticojejunostomy. All patients had unsuccessful previous ERCP attempts. All PTCS with SDVS procedures were technically successful. Indications for this unusual approach were: ascending cholangitis, abnormal liver function tests and biliary dilation on imaging. SDVS was utilized to conduct electrohydraulic lithotripsy (EHL) for biliary stone management in four patients and intraductal biopsies for indeterminate strictures in two of them. PTCS with SDVS can be beneficial for multiple diagnostic and therapeutic indications in patients with altered biliary or luminal anatomy. SDVS allows direct evaluation and management of different biliary pathologies in challenging cases where traditional ERCP is not feasible. Some indications for PTCS with SDVS include evaluation of biliary strictures and biliary stasis, biliary tract biopsy and lithotripsy for management of biliary stones.