Introduction Per-oral Cholangioscopy (POC) offers the facility for direct visualisation of bile ducts, targeted biopsy and interventional techniques including Electro Hydro lithotripsy (EHL). Procedure completion time is often longer than conventional Endoscopic Retrograde Cholangio-Pancreatography (ERCP), patients often require high doses of standard sedation or general anaesthesia. We present our data where POC is performed under conscious sedation.
Method Retrospective analysis was performed for all POC cases between January 2013 –December 2014. Definitions and endpoints were as used by Kalaitzakis et al .1Procedural success was defined as direct visualisation of the lesion enabling tissue sampling. Adequacy of tissue samples were analysed against the final Multidisciplinary meeting (MDM) decision-detailing both benign and malignant diagnosis.
Results 47 cases of POC were performed in 43 patients. Median age was 63 years (IQR 22–86 years). 31 cases were performed for non stone-related disease (28 for indeterminate lesions 3 for other reasons). 16 patients underwent POC for choledocholithiasis, 9 of which had EHL. All patients had conscious sedation during POC.
Median midazolam dose was 7 mg (IQR 5–11 mg), fentanyl 150 mcg (IQR 50–225 mcg). Buscopan was used in 42 cases (range 20–60 mg) and glucagon (1 mg) in 6 cases. Lowest oxygen saturations recorded were 95% (range 95–99%). Where a score of 1 represented maximum discomfort and 5 least, worst comfort score recorded was 3 for a single case. There were 4 failed procedures, 1 due to patient related factors and 3 due to equipment failure. Median procedure time was 86 min (IQR 34–114 min) for non-EHL and 92 min (IQR 76–132 min) for EHL cases. Procedural success was established in in 42 (89%) cases with positive visualisation of the target lesion. For non-stone related disease, 27 were successful (87%). For suspected malignancy, POC performance was again comparable with published data (sensitivity 70%, specificity 93%, positive predictive value 88%, negative predictive value 81%), when compared against the final MDT decision. Overall complication rate was comparable with other published data (6.3%). Over sedation requiring reversal was not encountered in the study.
Conclusion Diagnostic results and complication rates, in our study, were comparable with published UK outcomes. Our practice demonstrates that POC can be performed under conscious sedation without compromising patient safety, test tolerance or efficacy.
Disclosure of interest None Declared.
Kalaitzakis E, Webster GJ, Oppong KW, Kallis Y, Vlavianos P, Huggett M, et al. Diagnostic and therapeutic utility of single-operator peroral cholangioscopy for indeterminate biliary lesions and bile duct stones. Eur J Gastroenterol Hepatol. 2012;24(6):656–64