The development of a new cholangioscope, the SpyGlass™ Discover (Boston Scientific), has allowed the laparoscopic transcystic common bile duct exploration and stone clearance. The possibility of simultaneous treatment of choledocholithiasis during early laparoscopic cholecystectomy offers the opportunity to enormously reduce the time between acute cholecystitis diagnosis and the execution of cholecystectomy with better outcomes for patients. Furthermore, an altered anatomy of the gastrointestinal tract is not an obstacle to this technique. The aim of the study was to determine whether this new procedure is feasible, safe, and effective.
The investigation employs a retrospective case series study including all consecutive patients with a diagnosis of common bile duct stones undergoing cholecystectomy and intraoperative laparoscopic common bile duct clearance using SpyGlass™ Discover at IRCCS Policlinico San Matteo in Pavia (Italy). Eighteen patients were included from May 2022 to May 2023.
A complete clearance of the common bile duct was obtained in 88.9% of patients. The mean postoperative length of stay was 3 days. No major complications occurred. After a median follow-up of 8 months, no recurrence of biliary events or readmissions occurred.
This procedure has proven to be feasible, safe, and effective.

BACKGROUND: Intrahepatic and extrahepatic lithiasis, a condition characterized by the presence of stones in the liver and bile ducts, is a common disease in Asia, particularly in East and Southeast Asia. We report a case with laparoscopic exploration of the common bile duct using a flexible cholangioscope and modified trans-common bile duct tunnel for hepatolithiasis combined with the dilated common bile duct.
METHODS: A 35-year-old male patient has had chronic epigastric and right upper quadrant pain. The common bile duct was 11 mm dilated, and hepatolithiasis was also present, according to an upper abdomen MRI. The largest stone measured between 14 and 21 mm. A modified trans-common bile duct tunnel from the abdominal wall into the common bile duct was used in a laparoscopic procedure to examine the common bile duct. Complications during the procedure or following it were not present. The procedure took 120 min, and the blood loss was about 50 ml. The patient was discharged on the sixth postoperative day, and a follow-up visit one month later revealed that single-session stone clearance had been accomplished.
CONCLUSIONS: Laparoscopic exploration of the common bile duct using a cholangioscope and modified trans-choledochal tube is applicable in selected patients and can be effectively and safely used to treat hepatolithiasis combined with the dilated common bile duct.
CONCLUSIONS: In this case, we present an innovative approach for hepatolithiasis when combined with dilated common bile duct.

Hemobilia is described as bleeding from the intra- or extrahepatic biliary tree expressed through the major duodenal papilla into the duodenum, with angiodysplasia of the major biliary duct as a rare etiological factor with few cases reported in the literature. Cholangioscopy plays a pivotal role in diagnosing and making therapeutic decisions regarding biliary tract lesions. We report a case of the diagnosis and treatment of hemobilia secondary to bleeding from angiodysplasia of the major biliary duct, which was resolved after the placement of a fully covered metallic stent, with a review of the literature.

Intrahepatic lithiasis, or hepatolithiasis, is an endemic disease in southeast Asia, although, with immigration from Eastern countries, the incidence of this pathology is rising worldwide. The Latin American experience demonstrates morbidity and mortality compatible with other Western countries, but minimally invasive procedures are lacking. We demonstrate a case of a combined surgical and endoscopic approach for stone clearance. We present a case of a 47-year-old female patient with biliary enteric anastomosis to treat recurrent pyogenic cholangitis resulting from intrahepatic lithiasis. The patient was admitted to the emergency room, presented with a new episode of cholangitis, and submitted to transcutaneous hepatobiliary drainage. The multidisciplinary approach, including the endoscopic and surgical teams, successfully performed the stone clearance with laser lithotripsy and stone removal by open access. The postoperative period was uneventful, and the patient did not present any sign of recurrence after one year. A combined surgical and endoscopic approach achieved short-term clinical and technical success in this novel case. Moreover, individualizing cases requiring open surgical access is feasible, which allows a combined endoscopic approach with safety.

Biliary cystadenoma is a type of rare liver cystic tumor. Intrahepatic biliary cystadenomas are the most common, while extrahepatic biliary cystadenomas are rarely seen. Biliary cystadenoma tends to occur in middle-aged to older women and there is a lack of specific preoperative diagnostic markers. Recent advancements in technology and the development of the SpyGlass system have led to an increased use of cholangioscopy. Herein, we report a patient in whom a space-occupying lesion was found in the bile duct by SpyGlass, and who later underwent radical surgery. The pathology report indicated that the final diagnosis was biliary cystadenoma. SpyGlass cholangioscopy may be a novel and effective diagnostic method for biliary cystadenoma.

A 76-year-old man presented with liver dysfunction and intrahepatic bile duct dilatation. Imaging studies showed two large stones that had become impacted in the common hepatic duct, which was fused with the gallbladder. The patient was diagnosed with Mirizzi syndrome type IV. Hepaticojejunostomy and stone removal failed due to dense gallbladder adhesions involving the right hepatic artery. The bile flow was temporarily restored; however, the patient experienced cholangitis 16 months later. The stones were extracted via peroral single-operator cholangioscopy (SOC)-guided electrohydraulic lithotripsy. This is the first case in which stones were completely removed by SOC-guided treatment in a patient with Mirizzi syndrome type IV.

Castleman disease (CD) rarely presents with obstructive jaundice, which poses a diagnostic and therapeutic challenge to the management of the disease. A 40-year-old man was referred to our hospital for emergent management of upper abdominal pain. An abdominal mass was removed, and the postoperative pathology showed retroperitoneum CD, which was subsequently managed by adjuvant therapy of combination chemotherapy and steroids. One month later, a biliary metal stent was placed due to the presentation of obstructive jaundice. After ~3 months, the patient experienced another episode of obstructive jaundice, and SpyGlass DS cholangioscopy was performed via the biliary tract for biopsy, which pathologically showed biliary malignancies. Radiofrequency ablation was performed with a probe, and another uncovered metal stent was placed within the existing metal stent. No stent occlusion occurred during a 6-month follow-up period. In conclusion, CD rarely presents with obstructive jaundice, and a combination of radiofrequency ablation with metal stent implantation under cholangioscopy can prolong the stent patency time and the survival time of patients.

Treatments for hepatolithiasis include peroral endoscopy, percutaneous cholangioscopy, and surgery. Balloon-assisted endoscopic retrograde cholangiopancreatography (BAERCP) has been widely performed in recent years for patients with hepatolithiasis after biliary reconstruction. However, accidental bowel perforation caused by BAERCP may need emergency surgery. Here, we describe a 77-year-old Japanese woman diagnosed with acute cholangitis due to hepatolithiasis after biliary reconstruction (a biliary diversion operation for pancreaticobiliary maljunction). She underwent BAERCP for treatment of hepatolithiasis, however, a small-bowel perforation occurred. She underwent an emergency operation to suture the perforation and add a catheter jejunostomy. She had no postoperative complications after surgery and was discharged 11 days after surgery. One month later, she was readmitted and underwent percutaneous transjejunal cholangioscopy-guided lithotripsy with complete removal of the calculi. Although endoscopists should be careful to avoid small-bowel perforation during BAERCP, if perforation occurs, addition of a catheter jejunostomy during emergency surgery can be easily transitioned to subsequent treatment of the hepatolithiasis.

BACKGROUND: Intraductal papillary neoplasm of the bile duct (IPNB) is a rare variant of bile duct tumors, characterized by an exophytic growth exhibiting a papillary mass within the bile duct lumen and it can be localized anywhere along the biliary tree, with morphological variations and occasional invasion.
METHODS: We present a patient with obstructive jaundice who was diagnosed with IPNB using cholangioscopy during endoscopic retrograde cholangio-pancreatography. Using the SpyGlass DS II technology, we were able to define tumor extension and obtain targeted Spy-byte biopsies. After multidisciplinary evaluation, the patient was scheduled for surgical resection of the tumor, which was radically removed.
CONCLUSIONS: Cholangioscopy appears to be crucial for the rapid and clear diagnosis of lesions in the bile duct to achieve radical surgical resection.

BACKGROUND: Careful evaluation of intrahepatic injury of biliary tract diseases is crucial to assure proper management and estimate disease prognosis. Hepatholithiasis is a rare condition that can be associated to cholestatic liver diseases. Additional tools to improve diagnosis and patient care are of great interest specially if associated to decreased morbidity. Recently the spread of single-operator platforms of cholangioscopy brought this procedure back to scene. Our aim was to identify safety, feasibility and utility of SpyGlass cholangioscopy of biliary tract during laparoscopic hepaticojejunostomy.
METHODS: A 53 years-old man with hepatolithiasis associated to choledolithiasis under treatment with ursodeoxycholic acid and fenofibrate for 8 months, was submitted to laparoscopic hepaticojejunostomy with cholangioscopy for biliary duct evaluation. Spyscope was inserted through a right lateral laparoscopic trocar entering the common bile duct. Examination of intra-hepatic bile ducts showed injury of right biliary. Few microcalculi were visualized. Left biliary ducts presented normal mucosa. Histopathological examination showed a chronic inflammatory process. During the procedure contrasted radiologic images were performed to assure Spyscope location. Following cholangioscopy evaluation, a Roux-en-Y hepaticojejunostomy was performed. To enlarge hepatic duct, a small longitudinal incision was made, and a PDS-5.0 running suture was used for bilioenteric anastomosis. Patient was discharged on postoperative day 6, with drain removal on day 20.
CONCLUSIONS: SpyGlass cholangioscopy during laparoscopic hepaticojejunostomy is feasible leading to minimal additional invasion of the surgical. In this case the method was performed safely, providing detailed examination of injured biliary ducts, adding elements to determine disease prognosis and patient care.