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©The Author(s) 2015.
World J Gastroenterol. Apr 21, 2015; 21(15): 4722-4734
Published online Apr 21, 2015. doi: 10.3748/wjg.v21.i15.4722
Published online Apr 21, 2015. doi: 10.3748/wjg.v21.i15.4722
Table 1 Detailed evidence levels of respective references are provided for each consensus statement
Consensus statement | Evidence level distribution | Recommendation grade | |||||||
1 ++ | 1 + | 1 - | 2 ++ | 2 + | 2 - | 3 | 4 | ||
1 | 0 | 0 | 0 | 1 | 8 | 1 | 7 | 16 | B |
2 | 0 | 0 | 0 | 4 | 15 | 1 | 7 | 9 | B |
3 | 0 | 1 | 0 | 1 | 13 | 1 | 5 | 10 | A |
4 | 0 | 0 | 0 | 0 | 3 | 2 | 3 | 11 | C |
5 | 0 | 0 | 0 | 0 | 2 | 1 | 1 | 7 | C |
6 | 0 | 0 | 0 | 0 | 4 | 0 | 3 | 8 | C |
Table 2 Consensus statement 1
POCPS is now an important additional tool during ERCP |
Recommendation Grade B |
Quality of evidence: 2++ |
Direct visualization and the ability to sample and treat lesions aids in the care of patients by providing the correct diagnosis and allowing definitive treatment of lesions |
Cholangiopancreatoscopy through an ERCP catheter is a simple, safe and effective procedure for diagnosing pancreatobiliary diseases |
Intraductal peroral cholangioscopy and pancreatoscopy-sampling techniques appear to offer an advantage over fluoscopy-guided ERCP sampling techniques for the diagnosis of pancreatobiliary lesions |
Table 3 Consensus statement 2
In patients with indeterminate biliary strictures, POCS and POCS-guided targeted biopsy is useful for establishing a definitive diagnosis |
Recommendation Grade B |
Quality of evidence: 2++ |
Technical success: Technical success for POCS with or without POCS-guided biopsy is reported to be 66% to 95% when defined as ability to reach the targeted lesion and, if desired, obtain a biopsy adequate for histopathology |
Diagnostic accuracy: Diagnostic measures of POCS with or without POCS-guided biopsy for malignancy were explicitly reported for a total of 980 cases in 11 studies. Reported sensitivity ranged from 49% to 100% and specificity ranged from 77% to 100%. In three prospective trials reporting separately on POCS alone and on POCS-guided biopsy and representing 297 patients, the weighted average sensitivity and specificity were 83% and 96% for POCS alone and were lower at 56% and 81% for POCS-guided biopsy |
Intrinsic vs extrinsic strictures: POCS-guided biopsy is significantly higher for intrinsic than extrinsic tumors, and may be particularly useful in PSC patients prior to liver transplantation |
POCS findings in indeterminate strictures: Findings of POCS such as tortuous and irregularly dilated vessels, intraductal nodules or masses, infiltrative or ulcerated strictures, and papillary or villous mucosal projections are reported to be associated with malignancy. Generally POCS is reported to improve yield of associated ERCP-guided biopsy. POCS with NBI was reported to significantly improve diagnostic accuracy over white light POCS |
Altered patient management: Changed patient management following POCS is reported in as many as 2/3 of patients when measured. Impact of POCS on pre-operative diagnosis may impact a surgical decision. POCS combined with IDUS was reported useful in guiding patient management in portal biliopathy. POCS was also reported useful for assessment of anastomotic strictures after liver transplantation |
Complications: Reported overall complication rates range from 6.6% to 9%. The most common complication is cholangitis, reported in approximately 5% of cases. There is one report of fatal cholangitis |
Table 4 Summary of diagnostic accuracy parameters reported in relevant references
Ref. | Grading | Article type | Sensitivity | Specificity | Positive predictive value | Negative predictive value |
[34] | 4 | Review | 92% | 93% | 89% | 95% |
[12] | 2+ | Prospective | 78% | 82% | 49% | 98% |
[13] | 2+ | Prospective | 95% | 79% | 82% | 82% |
[21] | 2++ | Prospective | 100% | 77% | 71% | 100% |
[35] | 2+ | Prospective | NR | NR | 88% | 94% |
[14] | 2+ | Prospective | NR | NR | 89% | 96% |
[15] | 4 | Retrospective | 66% | 98% | NR | NR |
[26] | 2+ | Retrospective | 98% | 90% | NR | NR |
[32] | 2+ | Retrospective | 57% | 100% | NR | NR |
[36] | 2+ | Retrospective | 77% | NR | NR | NR |
[37] | 2++ | Prospective | 99% | 96% | 99% | 95.8% |
[38] | 2+ | Prospective | NR | NR | 100% visual | 92% visual |
38% biopsy | 100% biopsy |
Table 5 Consensus statement 3
POCS and POCS-guided lithotripsy is recommended for treatment of difficult CBD stones when standard techniques fail |
Recommendation Grade A |
Quality of evidence: 1+ |
Technical success: Technical success for POCS and POCS-guided lithotripsy for the treatment of difficult CBD stones when standard techniques fail range from 71%-100% |
Direct visualization advantage: One of the key therapeutic benefits of POCS is the capacity to directly visualize and treat large intraductal stones. Studies show that nearly all bile duct stones which failed conventional endoscopic removal (5%-10% of patients) could be removed non-surgically using POCS and POCS-guided lithotripsy |
Residual stone detection: The diagnosis of small bile duct stones can be difficult with an ERCP. In those cases, POCS is able to detect residual stones missed on routine ERCP. |
Complications: The most common complication reported is cholangitis (4.0%). Reported overall complications rates range from 3.8% to 13.3% |
The results support the non-surgical management of difficult bile duct stones, particularly in patients at high risk for surgery |
Table 6 Consensus statement 4
In patients with main duct IPMN POPS may be used to assess the extent of tumor to assist surgical resection |
Recommendation Grade C |
Quality of evidence: 2+ |
Technical success: Technical success for POPS in patients with IPMN is reported between 73% and 92% when defined as ability to reach and examine the targeted lesion |
Diagnostic accuracy: Diagnostic measures of POPS with or without POPS-guided biopsy for malignancy in IPMN are rarely reported in detail, and range from 50% to 68% sensitivity and from 87% to 100% specificity. Diagnostic accuracy seems better in main duct IPMN than in side branch IPMN |
POPS findings in IPMN: The most commonly reported POPS findings associated with malignancy in IPMN are villous patterns and vascular images Granular mucosa and fish-like patterns without vascularity were not associated with malignancy |
POPS and IDUS: Some studies document enhanced diagnostic accuracy when POPS is combined with endosonographic measures, particularly IDUS |
Pre-operative and intra-operative POPS: The role of POPS to pre-operatively provide diagnostic information on malignancy and to pre-operatively and/or intra-operatively document the location and extent of dysplastic IPMN is generally reported |
Table 7 Consensus statement 5
In difficult pancreatic ductal stones, POPS-guided lithotripsy may be useful in fragmentation and extraction of stones |
Recommendation Grade C |
Quality of evidence: 2+ |
POPS-guided EHL or laser lithotripsy: EHL was reported for 17 cases, with stone clearance reported in 71% (12/17). Laser lithotripsy was reported for 9 cases, with stone clearance reported in 100% (9/9). Stone clearance was reported in 70% (32/46) with EHL or laser lithotripsy in 39 of those cases |
POPS-guided EHL vs ESWL: POPS-guided EHL compared to ESWL for treatment of pancreatic duct stones is reported as difficult and as being only rarely indicated |
Table 8 Consensus statement 6
Additional indications for POCPS include selective guidewire placement, unexplained hemobilia, assessing intraductal biliary ablation therapy, and extraction of migrated stents |
Recommendation Grade C |
Quality of evidence: 2+ |
The primary indications of peroral cholangiopancreatoscopy are indeterminate stricture, indeterminate filling defect and stones, but the application of the technology is vast and is forever expanding. While not many cases are performed and documented, the indications extend to selective guidewire placement, unexplained hemobilia, assessment of intraductal biliary ablation therapy as well as the extraction of migrated stents |
These additional indications have been reported in clinical studies as well as comprehensive reviews of POCPS |
- Citation: Ramchandani M, Reddy DN, Lakhtakia S, Tandan M, Maydeo A, Chandrashekhar TS, Kumar A, Sud R, Rerknimitr R, Makmun D, Khor C. Per oral cholangiopancreatoscopy in pancreatico biliary diseases - Expert consensus statements. World J Gastroenterol 2015; 21(15): 4722-4734
- URL: https://www.wjgnet.com/1007-9327/full/v21/i15/4722.htm
- DOI: https://dx.doi.org/10.3748/wjg.v21.i15.4722