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IntroductionSingle operator cholangioscopy (SOC) has an important role in the diagnosis and management of biliary strictures and complex biliary stones. The evidence base is evolving, but with small numbers in reported studies. The majority of published literature discusses SOC under general anaesthetic;typically propofol. We compared successful stone clearance, stricture assessment and safety under conscious sedation and propofol.MethodsA single centre retrospective analysis was performed of consecutive SOCs over 8 years at Bristol Royal Infirmary (tertiary referral centre for SW England and South Wales). Parameters included sedation/propofol usage, stone clearance, electrohydraulic lithotripsy (EHL), histology, final diagnosis and complications.ResultsBetween Jan 2013 – Nov 2020, 471 SOCs were performed on 352 patients (175f, 177m);mean age 65.7years (17-92), referred from 18 centres. 15 SOCs were performed in 2013 compared to 99 in 2019 before restrictions from the COVID19 pandemic.228 therapeutic SOCs + EHL were performed for stone clearance, 79.8% (n=182/228) under conscious sedation (median fentanyl dose 150mcg;midazolam 7mg;comfort score 2). Complete stone clearance rose from 79.7% in the conscious sedation group to 89.2% in with propofol sedation, although the difference was not significant (p=0.19).243 diagnostic SOCs were performed, 88.9% under conscious sedation. Similar to therapeutic SOCs, median fentanyl dose 150mcg;midazolam 7mg;and comfort score 2. Overall macroscopic assessment of strictures correlating with malignancy had a sensitivity, specificity and diagnostic accuracy of 90.2% (95%CI 82.7-95.2), 92.6% (95%CI 86.3-96.5) and 91.5% (87.0-94.8%) respectively. Diagnostic accuracy with macroscopic assessment was comparable between patients receiving conscious sedation (91.4%;95%CI 86.6-94.9) vs propofol sedation (92%;95%CI 74.0-99.0). Diagnostic accuracy with histological assessment appeared greater in patients receiving propofol sedation (95%;95%CI 75.1-99.9) compared to conscious sedation (84.7%;95%CI 78.5-89.6)28 adverse events were recorded (5.9%), with post ERCP cholangitis (2.3%) and pancreatitis (2.1%) the commonest causes. Complications were marginally higher in patients receiving propofol sedation (6.8%;n=5/73) vs those receiving conscious sedation (5.8%;n=23/398) but the difference was not significant (p=0.72).ConclusionsThis is the largest single centre retrospective analysis of SOCs. Successful stone clearance is similar to results found in literature from smaller studies. There was a trend to greater successful stone clearance with propofol. Conscious sedation has previously been described as a risk factor for inadequate visualisation, but we found very similar high levels of diagnostic accuracy in both groups. Both were generally well tolerated with low rates of adverse events. |
