Gastrointestinal Endoscopy Clinics RSS feed: Current Issue. Gastrointestinal Endoscopy Clinics of North America updates you on the latest trends in patient management; keeps you up to date on the newest advances; and provides a sound basis for choosing treatment options. Each issue focuses on a single topic in gastrointestinal endoscopy and is presented under the direction of an experienced guest editor.http://www.giendo.theclinics.com/?rss=yesElsevier Inc.en © 2009 Published by Elsevier Inc. All rights reserved. Gastrointestinal Endoscopy Clinics1052-5157194October 2009 © 2009 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.giendo.theclinics.com/article/PIIS1052515709001184/abstract?rss=yesContents10.1016/S1052-5157(09)00118-4Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-Xvviiihttp://www.giendo.theclinics.com/article/PIIS1052515709001196/abstract?rss=yesForthcoming issues10.1016/S1052-5157(09)00119-6Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-Xixixhttp://www.giendo.theclinics.com/article/PIIS1052515709001111/abstract?rss=yes Just when it seemed that all endoscopic frontiers had been crossed, intraductal biliary and pancreatic endoscopy or cholangiopancreatoscopy has emerged as a robust new area for exploration in gastrointestinal endoscopy. Although endoscopic retrograde cholangiopancreatography (ERCP) combines endoscopy with fluoroscopy and has resulted in remarkable progress in the management of diseases affecting the bile and pancreas ducts, it remains a hybrid procedure, providing indirect radiographic images. With the development of ever-thinner endoscopes, first fiberoptic and now tiny, powerful charge-coupled device chip video, real-time, high-quality visual imaging of the ducts via oral intubation of the papilla of Vater has become a reality.ForewordCharles J. Lightdale10.1016/j.giec.2009.09.002Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-Xxixiihttp://www.giendo.theclinics.com/article/PIIS1052515709001123/abstract?rss=yes Contrast radiography has given way to endoscopy for the evaluation of the upper gastrointestinal tract, the small bowel, and the colon. The pancreaticobiliary ductal system has remained the one area in which gastroenterologists depend heavily on contrast-enhanced fluoroscopy. The concept of entering the ducts with an endoscope is certainly not new; peroral cholangiopancreatoscopy has been possible for decades. The discipline has been enjoying a resurgence of interest, however, as the equipment has become increasingly miniaturized, maneuverable, and manageable. Furthermore, new diagnostic technologies and therapeutic accessories have been developed for intraductal applications that have widely expanded capabilities. This issue of Gastrointestinal Endoscopy Clinics of North America focuses on these advances in intraductal endoscopy that are allowing exploration of one of the last endoscopic frontiers.PrefacePeter D. Stevens10.1016/j.giec.2009.09.003Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-Xxiiixivhttp://www.giendo.theclinics.com/article/PIIS1052515709000762/abstract?rss=yesCholangiopancreatoscopy (CP) is a well-established modality for the direct visualization of intrahepatic biliary, extrahepatic biliary, and pancreatic ductal systems. The use of CP in the treatment of difficult biliary stones has become paramount when standard endoscopic retrograde cholangiopancreatography is ineffective. This article describes the available cholangioscopic devices and technical and clinical applications of cholangiopancreatoscopy. The efficacy and limitations of CP, as well as published comparative studies, are briefly reviewed.Cholangiopancreatoscopy: A Comprehensive ReviewSam Nourani, Gregory Haber10.1016/j.giec.2009.07.003Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-X527543http://www.giendo.theclinics.com/article/PIIS1052515709000683/abstract?rss=yesThe SpyGlass Direct Visualization System is a significant step forward in bringing optical visualization to the pancreatobiliary system by providing dedicated irrigation and therapeutic channels and 4-way steerability. Peroral cholangioscopy using the SpyGlass System may be safely performed by a single operator and provides reliable access to target sites for visual inspection and stone therapy using electrohydraulic lithotripsy or holmium laser lithotripsy. In addition, the SpyBite Biopsy Forceps has been shown to obtain adequate histologic tissue specimens reliably.New Kid on the Block: Development of a Partially Disposable System for CholangioscopyKrishnavel V. Chathadi, Yang K. Chen10.1016/j.giec.2009.06.001Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-X545555http://www.giendo.theclinics.com/article/PIIS1052515709000695/abstract?rss=yesWe summarized past and present results concerning the observation capability of cholangiopancratoscopy using chromoendoscopy, autofluorescence imaging (AFI), and narrow-band imaging (NBI). New generation peroral and percutaneous transhepatic video cholangiopancreatoscopes provide superior quality images. Pilot studies suggest that chromoendocholangioscopy using methylene blue or cholangioscopy using AFI can distinguish benign from malignant bile duct lesions. On the other hand, the NBI system enhances the imaging of certain features such as mucosal structures and microvessels in pancreatobiliary lesions. In patients with main-duct–type intraductal papillary mucinous neoplasm, peroral pancreatoscopy can be used to determine extent of tumor involvement. Although many technical hurdles still need to be overcome, image-enhanced cholangiopancratoscopy appears to be a promising modality to improve diagnostic accuracy of pancreatobiliary diseases, particularly in distinguishing benign from malignant lesions.Diagnostic Value of Image-Enhanced Video CholangiopancreatoscopyTakao Itoi, Horst Neuhaus, Yang K. Chen10.1016/j.giec.2009.06.002Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-X557566http://www.giendo.theclinics.com/article/PIIS1052515709000725/abstract?rss=yesEstablishing a tissue diagnosis in patients with suspected pancreaticobiliary malignancies remains challenging. Endoscopic retrograde cholangiopancreatography (ERCP)-based sampling methods have been reviewed in a previous issue of this journal but, unfortunately, the diagnostic yield continues to be inadequate in a significant minority of patients. The availability and image quality of cholangioscopy and pancreatoscopy have advanced in the last few years and our ability to make a diagnosis on imaging alone is improving. However, a definitive diagnosis requires tissue; cholangiopancreatoscopy allows targeted biopsies of the epithelium of the biliary and pancreatic ducts. This article reviews the evidence that cholangioscopy- and pancreatoscopy-guided biopsies improves diagnostic yield over ERCP-based tissue sampling techniques.Cholangiopancreatoscopy for Targeted Biopsies of the Bile and Pancreatic DuctsShahzad Iqbal, Peter D. Stevens10.1016/j.giec.2009.06.005Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-X567577http://www.giendo.theclinics.com/article/PIIS1052515709000701/abstract?rss=yesCholangioscopy is gaining renewed interest and gradually expanded use as a result of recent technical improvements in endoscopes and accessories, coupled with shortcomings in the accuracy of currently available techniques for biliary sampling and diagnosis. Challenging clinical dilemmas that may benefit from its application include early diagnosis of cholangiocarcinoma in the setting of primary sclerosing cholangitis, early identification of biliary infection or ischemia following orthotopic liver transplantation, and selective duct access with wires and other devices during therapeutic endoscopic retrograde cholangiopancreatography. Preliminary data suggest that cholangioscopy has significant utility in assessment and management of primary sclerosing cholangitis. Applications in posttransplant patients and for selective duct access remain minimally defined and used.Cholangioscopy for Special Applications: Primary Sclerosing Cholangitis, Liver Transplant, and Selective Duct AccessBret T. Petersen10.1016/j.giec.2009.06.003Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-X579586http://www.giendo.theclinics.com/article/PIIS1052515709000774/abstract?rss=yesIn more than 90% of choledocholithiasis cases, endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction are successful therapeutic options for clearance of the bile duct with the use of a stone retrieval balloon or basket. However, these techniques fail in a small percentage of patients with biliary stones, and advanced techniques for fragmentation must be used. Intraductal shock wave lithotripsy offers the endoscopist a therapeutic option that may be effective despite the difficulties of a large, impacted stone that cannot be captured by a basket, or a stricture that prohibits delivery of a stone beyond it. This article reviews the use of electrohydraulic lithotripsy and laser lithotripsy in the clinical setting.Choledochoscopy-Assisted Intraductal Shock Wave LithotripsyJason Bratcher, Franklin Kasmin10.1016/j.giec.2009.07.004Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-X587595http://www.giendo.theclinics.com/article/PIIS1052515709000749/abstract?rss=yesThere is little information in the literature on endoscopic tumor treatment in the bile duct with a curative intention. This article reports on the few cases published and on the authors' own experience with endoscopic retrograde and percutaneous transhepatic cholangioscopic treatment of tumors in the biliary system.Endoscopic Tumor Treatment in the Bile DuctJuergen Hochberger, Giovanni d'Addazio10.1016/j.giec.2009.07.001Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-X597600http://www.giendo.theclinics.com/article/PIIS1052515709000750/abstract?rss=yesPeroral pancreatoscopy (POP) is an exciting modality for the evaluation of pancreatic diseases. It has proved efficacy in the evaluation of suspected intraductal papillary mucinous neoplasia and allows for a determination of the presence and extent of pancreatic duct involvement. When other imaging modalities are inconclusive, POP seems a useful adjunct in the evaluation of indeterminate pancreatic duct strictures and permits tissue sampling under direct vision. Despite recent advances, refinements in endoscope caliber, tip deflection, and optics are still required for more routine application in pancreatic diseases.Peroral Pancreatoscopy in the Diagnosis and Management of Intraductal Papillary Mucinous Neoplasia and Indeterminate Pancreatic Duct PathologyDaniel A. Ringold, Raj J. Shah10.1016/j.giec.2009.07.002Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-X601613http://www.giendo.theclinics.com/article/PIIS1052515709000713/abstract?rss=yesIntraductal ultrasound (IDUS) used during endoscopic retrograde cholangiopancreatography (ERCP) can facilitate reliable evaluation of biliary and pancreatic disorders. The smaller diameter, flexibility, and the image quality offered by IDUS devices makes them ideal for evaluating a variety of difficult biliary and pancreatic diseases, especially in undefined strictures, luminal filling defects, and ampullary neoplasms. This article examines the numerous possible roles for IDUS in the evaluation of biliary and pancreatic conditions, as well as in ampullary neoplasms. IDUS is a simple, easy to learn, and safe technique that should be considered an integral tool in the therapeutic endoscopist's armamentarium.Clinical Application of Intraductal Ultrasound During Endoscopic Retrograde CholangiopancreatographyRabi Kundu, Douglas Pleskow10.1016/j.giec.2009.06.004Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-X615628http://www.giendo.theclinics.com/article/PIIS1052515709000786/abstract?rss=yesThe preoperative diagnosis of biliary neoplasms is associated with a low sensitivity. To overcome this limitation, probe-based confocal laser endomicroscopy was further developed to enable in vivo microscopic imaging, with confocal miniprobes further miniaturized to such an extent to enable their use even via the instrumentation channel of cholangioscopes. The current data available suggest that this new technology represents a promising approach for further differentiation of strictures and stenosis in the biliary, and perhaps also pancreatic system. Nevertheless, those results are based on a limited number of patients; further studies involving more patients examined at various centers are necessary and already under way to prove the true clinical importance of this new imaging modality.Confocal EndomicroscopyAlexander Meining10.1016/j.giec.2009.07.005Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-X629635http://www.giendo.theclinics.com/article/PIIS1052515709000737/abstract?rss=yesOptical coherence tomography (OCT) is an optical imaging modality introduced in 1991 that performs high-resolution, cross-sectional, subsurface tomographic imaging of the microstructure in materials and biologic systems by measuring backscattered or backreflected infrared light. OCT has been used for biomedical applications where many factors affect the feasibility and effectiveness of any imaging technique. The highly scattering and absorbing living tissues greatly limit the application of optical imaging modalities. In the last decade, OCT technology has evolved from an experimental laboratory tool to a new diagnostic imaging modality with a wide spectrum of clinical applications in medical practice, including the gastrointestinal (GI) tract and pancreaticobiliary ductal system.Optical Coherence Tomography for Bile and Pancreatic Duct ImagingPier Alberto Testoni, Benedetto Mangiavillano10.1016/j.giec.2009.06.006Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-X637653http://www.giendo.theclinics.com/article/PIIS1052515709001202/abstract?rss=yesIndex10.1016/S1052-5157(09)00120-2Gastrointestinal Endoscopy Clinics 19, 4 (2009)2009-10-01Gastrointestinal Endoscopy Clinics2009-10-01194S1052-5157(09)X0005-X655660