diagnosis of stone obstruction had to be revised III

favor of tumor obstruction.

DISCUSSION

Our preliminary results demonstrate that cholan­gioscopy with the improved mother-baby-scope pro­totype is an easy and safe technique with a highsuccess rate. Additional procedures such as directbiopsy, brush cytology, and guided cholangiographyare possible due to the size of the cholangioscope'schannel. Problems of visualization by viscous juicemay be circumvented by installation of sterile wateror normal saline. Endoscopic papillotomy (EPT), butnot dilation of the common bile duct, is mandatory.Our success rate therefore is in contrast to findings ofother groups who did not perform EPT prior to cho­langioscopy.4

The percutaneous transhepatic approach requiresmore time and skill compared with the transpapillaryroute,5 although operative endoscopy is also possiblevia this route.6 The increase in diagnostic accuracy incases with no definite diagnosis on ERCP is due tothe visualization of lesions which can be approachedwith guided biopsy or cytology. In complete obstruc­tion, guided cholangiography remains possible in somecases despite a negative approach on routine ERCP.

Cholangioscopy is not suitable for prepapillary le­sions because immediately after intubation of the com­mon bile duct the tip of the scope has to be sharplyangled in order not to slip out again. At this point thetip of the scope is against the duct wall and a goodview of the prepapillary area cannot be obtained.

In our opinion, ERCP and peroral cholangioscopyare complementary procedures. Our findings are ingood accordance with Kozarek,7 who states that radio-

A new pediatric duodenoscope:successful cannulation without a cannulaelevator

Kenneth Mauer, MDJerome D. Wave, MD

ERCP in the unoperated patient requires a cannulaelevator mechanism in addition to the up-down andright-left tip deflection controls. We report the use ofa prototype small caliber pediatric duodenoscope with­out a cannula elevator.

Received March 14, 1989. For revision April 3, 1989. Accepted April29,1989.

From the Department of Medicine, Division of Gastroenterology, Mt.Sinai Medical Center, New York, New York. Reprint requests:Jerome D. Waye, MD, Department of Medicine, Division of Gastro­enterology, Mt. Sinai Medical Center (CUNY), New York, New York10021.

VOLUME 35, NO.5, 1989

graphic studies alone may some times be misleadingor nondiagnostic.

In the future, therapeutic approaches such as laserlithotripsy of common bile duct stones8 and recanali­zation of tumor stenoses by means of intraductalradiation therapy may be possible.9

Peroral cholangioscopy is going to play a limited,but definite role in diagnostic and therapeutic biliaryendoscopy. In our first group of patients the cholan­gioscope durability was quite good; however, due tothe intensive demands which the procedure makes onthe flexibility of the endoscope it is to be expectedthat it will not function as long as standardendoscopes.

REFERENCES1. Kawai K, Nakajima M, Akasaka Y, Shimamoto K, Murakami

K. Eine neue endoskopische Technik: die perorale Choledoch­opankreatikoskopie. Leber Magen Darm 1976;6:121-4.

2. ROsch W, Koch W, Demling L. Peroral cholangioscopy. Endos­copy 1976;6:172-5.

3. Riemann JF, Kohler B, Harloff M, Weber J. Peroral cholan­gioscopy-an improved method in the diagnosis of common bileduct diseases [Abstract). Gastroenterology 1988;94:377.

4. Bar Meir S, Rotmensch S. A comparison between peroral cho­ledochoscopy and endoscopic retrograde cholangiopancreatog­raphy. Gastrointest Endosc 1987;33:13-4.

5. Brams JH, Leser HG, Salm R, et al. Perkutan-transhepatischeCholangioskopie. Dtsch. Med. Wochenschr 1987;112:1943-6.

6. Cheu MF, Ja YY. Percutaneous transhepatic removal of com­mon bile duct and intrahepatic duct stones with a fiberopticcholedochoscope. Gastrointest Endosc 1986;32:347-9.

7. Kozarek RA. Direct cholangioscopy and pancreatoscopy at timeof endoscopic retrograde cholangiopancreaticography. Am JGastroenteroI1987;83:55-7.

8. Lux G, Ell Ch, Hochberger J, MUlIer D, Delming L. The firstsuccessful endoscopic retrograde laser lithotripsy of commonbile duct stones in man using a pulsed neodymium-YAG-Iaser.Endoscopy 1986;18:144-5.

9. Kozarek RA. The future of invasive pancreatico-biliary endos­copy. J Clin GastroenteroI1988;10:253-7.

INSTRUMENT

The Olympus prototype pediatric duodenoscope PJF-7.5(Fig. 1) has a total length of 1350 mm and a working lengthof 1030 mm. The insertion diameter is 7.5 mm, with a distaltip length of 7.8 mm. The field of view is 80 degrees, depthof field 5 to 60 mm, and deflection capability of 120 degreesup, 90 degrees right, left and down. The accessory channelis 2 mm in diameter without a cannula elevator (Fig. 2).

A 3lfz-month-old boy with a history of Tetrology ofFallot and Waterson shunt at 2 weeks of age wasadmitted for evaluation of neonatal jaundice noted onthe third day of life. Evaluation with sonogram hadshown normal bile ducts and gallbladder and DESIDAscans revealed normal hepatic uptake without intes­tinal excretion. Liver biopsy at 2 months showedsinusoidal bile collection, no proliferation of intrahe-

437

Figure 1. Olympus prototype pediatric duodenoscope PJF­7.5.

6\I-~. --- ----. --_.

Figure 2. Tapered tip cannula (5 F) inserted through acces­sory channel without a cannula elevator.

patic ductules, and scant inflammatory cells. ERCPwas performed to assess extrahepatic ducts. Usingchloral hydrate for sedation, the duodenoscope wasinserted into the second portion of the duodenum with

438

the infant in the prone position. The papilla of Vaterwas located and cannulation achieved using the up­down, right-left controls and torque on the shaft ofthe lateral-viewing instrument. A tapered tip (5 F)catheter was used to cannulate and inject contrast.Visualization of the biliary tree demonstrated thinintrahepatic bile ducts and normal extrahepatic ducts(Fig. 3).

Hyperdistension of the gallbladder (Fig. 4) resultedfrom repeated attempts to opacify the intrahepaticradicals which were narrowed to the extent that theycould not be seen on the fluoroscopic monitor screen.The "balloon effect" resolved within 4 hours postpro­cedure. The infant was discharged with the diagnosisof biliary atresia. The same instrument was used tosuccessfully cannulate the bile ducts and pancreas ina normal size 82-kg male with a suspicion of pancreaticcancer.

There is a current trend toward larger caliber in­struments for ERCP as the therapeutic potential ofthe procedure has expanded. ERCP of the infantrequires a thinner endoscope, although the first re­ported infant ERCP was performed with a standardadult-type duodenoscope.1,2 Although the adult duo­denoscope can be used in the infant, recent series havereported on use of the Olympus PJF duodenoscope forevaluating infants with neonatal jaundice.3

-5 The ma­

jor differences between the PJF and the PJF-7.5 arethe smaller diameter and the lack of a cannula elevatorin the latter (Table 1). We found that selective can­nulation was readily accomplished both in this caseand in an adult patient without a mechanism for

Figure 3. Cholangiogram visualizing gallbladder, common bileduct, and thin intrahepatic bile ducts.

GASTROINTESTINAL ENDOSCOPY

l=igure4. Distend&! gallbladder and atretic intrahepatic ducts.

Table 1.Specifications of PJF and PJF-7.5

deflection of the catheter beyond that achieved usingstandard dial controls. In both the adult and infant,the PJF-7.5 was easily positioned in the duodenalsweep and readily responded to adjustments of thecontrols. There is no difference in the ability forselective cannulation with the PJF-7.5 as comparedwith the PJF duodenoscope, and it appears that, withthe small radius of tip deflection in the PJF-7.5 in­strument, the cannula elevator is not needed.

Overdistension of the gallbladder in the infantraised concern as to the possibility of an ERCP­induced perforation. Although this complication hasnot been reported, it appears to be a potential hazardin the infant. Care should be used while injectingcontrast to avoid high injection pressures and overdis­tension.

We conclude that successful selective cannulationis possible with the Olympus PJF-7.5 side-viewingduodenoscope without a cannula elevator. Althoughthe small accessory channel limits its use to diagnosticstudies, it may prove valuable for evaluation of neo­natal jaundice in adults when a narrow caliber instru­ment is desired and can also be successfully used innormal adults. It is doubtful that an instrument with­out a cannula elevator can be built for therapeuticbiliary tract manipulation, since the tight deflectionradius required for successful cannulation would prob­ably interfere with passage of a stent or ancilliarydevice. It would be interesting to perform a feasibilitystudy on a range of instrument sizes without thecannula elevator mechanism since there will be somespace economy within the instrument by deletion ofthe elevator guide wire.

PJF PJF-7.5

Field of view (degree)Depth of fieldDistal tip, outside diameter (mm)Angulation (degree)

Insertion tube, outside diameter (mm)Channel size (mm)ElevatorControl sectionWorking length (mm)Total length (mm)

VOLUME 35, NO.5, 1989

805-608.8Up 120Down 90Left 90Right 908.52YesPre-OES11301310

805-607.8Up 120Down 90Left 90Right 907.52NoOES10301350

REFERENCES1. Waye JD. Endoscopic retrograde cholangiopancreatography in

the infant. Am J GastroenteroI1976;65:461-3.2. Lebwohl 0, Waye JD. Endoscopic retrograde cholangiopancrea·

tography in the diagnosis of extrahepatic biliary atresia. Am JDis Child 1979;133:647-9.

3. Drakami D, Seki H, Kishi S. Endoscopic retrograde cholangio·pancreatography (ERCP) performed in children. Endoscopy1977;9:86-9.

4. Guelrud M, Jaen D, Torres P, et al. Endoscopic cholangiopan­creatography in the infant: evaluation of a new prototype pe­diatric duodenoscope. Gastrointest Endosc 1987;33:4-8.

5. Heyman MB, Shapiro HA, Thaler MM. Endoscopic retrogradecholangiography in the diagnosis of biliary malformations ininfants. Gastrointest Endosc 1988;34:449-53.

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