Cholangioscopy.

Direct visualization of the bile ducts and gall bladder via cholangioscopy is very useful both in treatment of complex stone cases and the assessment of indeterminate strictures or masses. It allows use of instruments that cannot be used safely with fluoroscopic guidance alone. It also increases procedural efficiency and decreases radiation doses. Careful selection of access routes is critical to ensuring successful cholangioscopy. Tract dilation to accommodate the access sheath should be deferred for several weeks after the initial drainage procedure. This allows clearance of infected material plus allows the tract to mature. Allowing time for tract maturation decreases the chances of bleeding complications. Overall complications occur in about 20% of cases, with major complications occurring in around 8%. Most complications are bleeding or infectious and the majority relate to tract dilation, with a minority being due to the cholangioscopy itself. Successful stone removal can be achieved in about 90 to 95% of cases. Successful diagnosis of indeterminate stricture can be accomplished through a combination of visual inspection and endoscopic-guided biopsy. For intraluminal masses the accuracy of endoscopic biopsy is close to 100% but for periductal metastatic lesions or mural strictures (as with primary sclerosing cholangitis) diagnostic accuracy is significantly lower.