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1. Cholangioscopy
• Allows direct and optical contrast based (NBI)
visualization of the biliary tree
• Particularly useful for assessing strictures and
treating large stones and confirming their
complete removal
• Role in assessing post-OLT biliary
strictures???
• Can perform biopsies, laser or
electrohydraulic lithotripsy, and even ablation

2. Cholangioscopy
• First done in 1974 (percutaneously)
• Mother-daughter scope
– Fiber Optic (1976)
– Video
• Probe based cholangioscopy (2005)
• Direct endoscope based cholangioscopy
(1977)

3. Comparison of
Cholangioscopy Options
Fiber Optic
Baby Scope
Electronic
Video Baby
Scope
Spyglass
Probe
System
Ultraslim
“Per oral”
Electronic
Gastroscope
Number of
operators
2 2 1 1
Tip Deflection 2-way (U-D) 2-way(U-D)
4-way
(U-D, L-R)
4 way
(U-D, L-R)
Separate
Irrigation
Channel
No No Yes No
Exchangeable
optics
No No Yes No
Image Quality Moderate Good-excellent Moderate Excellent
Fragility Yes Yes Somewhat No
Monga et al, J Interv Gastro 1:2, 2011, p. 70-77

4. Mother Daughter Cholangioscopy
• Requires 2 operators
• Fragile “Daughter”
endoscope
• Only 1 degree of
freedom
• Small working channel
• Some versions without
working channels or
are fiber optic

5. Probe-based Cholangioscopy

6. Probe-based Imaging: Biliary
Stricture in PSC
Courtesy A. Sliva MD, Univ. of Pittsburgh

7. “Spyglass” Data
• Single center study in India
• 36 pts (22 M) with
indeterminate biliary strictures
• All received cholangioscopy
with directed biopsies
• 22 patients with cancer
– Cholangioscopy + : 21/22
(95%)
• 14 patients with benign lesions
– Cholangioscopy - : 11/14
(79%)
• Overall accuracy: 89% (32/36)
Ramchandani et al, GIE, 2011, 74:3, p. 511-519.
77% (23/30) yield in patients with negative ERCP with brushings
and EUS-FNA and no mass on imaging – Siddiqui et al CGH, 2012

8. Per Oral Cholangioscopy
• Start with ERCP
• Perform sphincterotomy
• Use ultra-stiff wire
• May require anchoring
balloon in bile ducts
• Advantages
– Better optics
– Larger working channel
• May benefit from CO2
rather than water
insufflation
– Better visualization
– Less risk of air embolism
Duodenal View
Intra-CBD View

9. Per Oral Cholangioscopy

10. Per Oral Cholangioscopy with
NBI: Videos

11. CLE Devices: Endoscope &
Probe-Based
CellVizio
Pentax
Resolution: 1, 3.5 µm
FOV: 240 µm, 600 µm
Depth of observation: 55-65 µm, 70-
130 µm
Comp. Op. Channel: 2.8 mm

12. Multiple CLE probes available

13. CLE of the Normal Biliary Tree

14. CLE of Cholangiocarcinoma

15. CLE Videos from the Biliary
Tree
Normal Cancer

17. Study Specifics
• Prospective observational multicenter
registry
• 5 centers, 102 patients screened
• Indications for ERCP
– 70% had indeterminate PBD stricture
– 17% with mass on imaging
– 5% with jaundice
– 5% with prior nondiagnostic ERCP
– 3% with dilated CBD or PD
– 1% PSC

18. pCLE to Evaluate Indeterminate
Bile Duct Strictures
Of note, pCLE had 16 false positives Slivka, ASGE Plenary, DDW 2011