Enteroscopy-assisted ERCP Research Articles

Transanastomotic Forward-Viewing EUS-Guided Pancreatic Duct Drainage via Afferent Loop for Pancreaticojejunostomy Anastomotic Stricture After Pancreaticoduodenectomy.

Although balloon enteroscopy-assisted ERCP and transgastric EUS-guided pancreatic duct drainage (EUS-PD) are treatment option for pancreaticojejunostomy anastomotic stricture (PJAS), they are often challenging with several limitations. This study aimed to examine the feasibility of transanastomotic forward-viewing EUS-PD (FVEUS-PD) via the afferent loop for PJAS after pancreaticoduodenectomy. Ten consecutive patients with symptomatic PJAS who underwent FVEUS-PD between 2015 and 2021 were retrospectively evaluated. Study outcomes included technical and clinical success, adverse events, and recurrence rates associated with FVEUS-PD. A short dumbbell-shaped, fully covered metal stent was deployed in all cases, and the stent was removed 3month after placement, after which it became stent-free. The technical success rate was 80% (8/10), and the scope could not reach the PJAS in two patients. Clinical success was achieved in all technically successful patients. No procedure-related adverse events observed. All patients were followed up for over three years after metal stent removal and becoming stent-free; the median follow-up period was 63month. One patient developed symptomatic stricture recurrence 36month after removal, with a stricture recurrence rate of 13% (1/8). The remaining patients did not experience any recurrence or late adverse events during the study period. This study is the first to investigate FVEUS-PD, demonstrating promising technical feasibility with low adverse event and recurrence rates, potentially becoming a useful treatment option for PJAS.

Endoscopic Management of Biliary and Pancreatic Pathologies in Roux-en-Y Gastric Bypass Patients: Development of a Treatment Algorithm Based on 9-Year Experience.

Management of biliopancreatic pathology in Roux-en-Y gastric bypass (RYGB) patients is challenging despite the availability of multiple approaches like single-balloon enteroscopy-assisted ERCP (SBE-ERCP), laparoscopy-assisted ERCP (LA-ERCP), and EUS-directed transgastric intervention (EDGI). We evaluated the outcomes of the interchangeable combination of endoscopic procedures to treat biliopancreatic pathology in RYGB patients. This is a monocentric retrospective study of consecutive RYGB patients with biliopancreatic pathology between June 2014 and September 2023. Primary endpoints were technical success, adverse events (AE), and parameters of endoscopic procedures according to etiology. A clinically useful management algorithm was developed. A total of 102 patients with RYGB (73 women; mean age 55 ± 10years) were included. A total of 113 SBE-ERCP (in 90 patients), 26 EDGI (in 23 patients), and 2 LA-ERCP (in 2 patients) were performed. Technical success of SBE-ERCP was lower compared to EDGI (74.4% vs 95.1%, p = 0.002). The AE rate was lower using SBE-ERCP compared to EDGI (12.4% vs 38.5%, p = 0.003). Two sub-groups based on etiology were identified as "common bile duct stone" (CBDS) and "Other." In the CBDS group, the mean number and time of procedures were lower in SBE-ERCP as the first-line technique compared to first-line EDGI (1.1 vs 2.7, p < 0.00 and 91 ± 20.7min vs 161 ± 61.3min, p < 0.00). A combination of endoscopic procedures can achieve high technical success in managing biliopancreatic pathology in RYGB patients with an acceptable AE rate. In the case of CBDS, SBE-ERCP appeared to be a good first-line single-step option. For other indications, EDGI should be proposed as the first line.

A novel dedicated nonslip short-length balloon catheter for treating hepaticojejunostomy anastomotic stricture in balloon enteroscopy-assisted ERCP.

A novel dedicated nonslip short-length balloon catheter for treating hepaticojejunostomy anastomotic stricture in balloon enteroscopy-assisted ERCP.

Balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography for asymptomatic common bile duct stones on surgically altered anatomy: A high risk factor for post-endoscopic retrograde cholangiopancreatography pancreatitis.

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is more common in patients with asymptomatic common bile duct stones (CBDSs) and normal anatomy than in those with symptomatic CBDS; however, studies on the effect of surgically altered anatomy are lacking. We aimed to investigate whether asymptomatic CBDS in balloon enteroscopy-assisted ERCP cases for surgically altered anatomy also has a high incidence of PEP and analyze the risk factors for PEP. We retrospectively analyzed 108 consecutive patients who underwent initial ERCP for CBDS with surgically altered anatomies and with naive papilla at Kitasato University Hospital from April 2015 to December 2022. Study participants were as follows: 92 (85%) patients with symptomatic CBDS and 16 (15%) patients asymptomatic CBDS. The overall bile duct cannulation success rate was 89.8%, with PEP occurring in 7.4% of patients (symptomatic CBDS: 3.3%, asymptomatic CBDS: 31.3%). PEP incidence was significantly higher for asymptomatic CBDS (p = .0017). Multivariate analysis identified asymptomatic CBDS and precut sphincterotomy as significant risk factors for PEP. Asymptomatic CBDS may be a risk factor for PEP onset in balloon enteroscopy-assisted ERCP with surgically altered anatomy. Therefore, the procedure should be performed after obtaining sufficient informed consent and adequate preparation.

S1272 Comparing Endoscopic Ultrasound-Directed Transgastric ERCP, Enteroscopy-Assisted ERCP, and Laparoscopic-Assisted ERCP in Roux-en-Y Gastric Bypass: A Network Meta-Analysis

S1272 Comparing Endoscopic Ultrasound-Directed Transgastric ERCP, Enteroscopy-Assisted ERCP, and Laparoscopic-Assisted ERCP in Roux-en-Y Gastric Bypass: A Network Meta-Analysis

Long-term outcomes after EUS-guided antegrade intervention for benign bilioenteric anastomotic stricture

Background and aimsBilioenteric anastomotic stricture (BES) is a well-known adverse event after bilioenterostomy. Recently, endoscopic ultrasound-guided antegrade intervention (EUS-AI) has been developed for cases that are difficult to treat by balloon enteroscopy-assisted ERCP. However, there have been no data on the long-term outcomes after EUS-AI. The main goal of the present study was to clarify the long-term outcomes of EUS-AI in such patients. Methods and patientsBetween November 2013 and November 2021, 34 patients who were followed for more than 1 year after EUS-AI for BES were identified. The primary endpoint was the rate of stricture resolution. The secondary endpoints were factors associated with stricture resolution, the rate of BES recurrence, the rate of conversion to surgery, and the rate of hepatic fibrosis progression during follow-up. ResultsThe median follow-up period was 56.7 months. Stricture resolution was achieved in 17 of 34 cases (50%). A multivariate analysis confirmed that the presence of bile duct stones (odds ratio: 9.473; 95% confidence interval (CI): 1.66–53.98; P=0.01) was significantly associated with stricture resolution. The stricture recurrence rate was 33%, and the median time from stent removal to recurrence was 31.2 months. A total of 4 patients underwent surgery due to recurrent cholangitis. During the median follow-up period of 56.7 months, 25% progressed to hepatic fibrosis based on the Fib4 grade. Interestingly, the cases without cholangitis during follow-up did not show progression of hepatic fibrosis. ConclusionEUS-AI has achieved acceptable long-term clinical outcomes. EUS-AI can be a viable alternative treatment of choice before surgical treatment in patients who are difficult to treat by conventional approaches.

Endoscopic treatment of biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants: Lessons learned from single-balloon enteroscopy-assisted ERCP

BackgroundEndoscopic treatment of biliopancreatic pathology is challenging due to surgically altered anatomy after Whipple's pancreaticoduodenectomy. This study aimed to evaluate the feasibility and safety of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (SBE-ERCP) to treat biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants. MethodsWe retrospectively analyzed 106 SBE-ERCP procedures in 46 patients with Whipple's variants. Technical and clinical success rates and adverse events were evaluated. ResultsBiliary SBE-ERCP was performed in 34 patients and pancreatic SBE-ERCP in 17, including 5 with both indications. From a total of 106 SBE-ERCP procedures, 76 were biliary indication with technical success rate of 68/76 (90%) procedures and clinical success rate of 30/34 (88%) patients. Mild adverse event rate was 8/76 (11%), without serious adverse events. From a total of 106 SBE-ERCP procedures, 30 were pancreatic indication with technical success rate of 24/30 (80%) procedures (P = 0.194 vs. biliary SBE-ERCP) and clinical success rate of 11/17 (65%) patients (P = 0.016 vs. biliary SBE-ERCP). Mild adverse event rate was 6/30 (20%) (P = 0.194 vs. biliary SBE-ERCP), without serious adverse events. After SBE-ERCP failure, endoscopic ultrasound-guided drainage, percutaneous drainage and redo surgery were alternative therapeutic options. ConclusionsBiliopancreatic pathology after Whipple's pancreaticoduodenectomy variants can be treated using SBE-ERCP without serious adverse events. Technical and clinical success rates are high for biliary indications, whereas clinical success rate of pancreatic indications is significantly lower. SBE-ERCP can be considered as first-line treatment option in this patient group with surgically altered anatomy.

Motorized spiral enteroscopy: effectiveness when used for new indications.

Motorized spiral enteroscopy is proven to be effective in antegrade and retrograde enteroscopy. Nevertheless, little is known about its use in less common indications. The aim of this study was to identify new indications for the motorized spiral enteroscope. Monocentric retrospective analysis of 115 patients who underwent enteroscopy using PSF-1 motorized spiral enteroscope between January 2020 and December 2022. A total of 115 patients underwent PSF-1 enteroscopy. 44 (38%) were antegrade procedures and 24 (21%) were retrograde procedures in patients with normal gastrointestinal anatomy with conventional enteroscopy indications. The remaining 47 (41%) patients underwent PSF-1 procedures for secondary less conventional indications: n=25 (22%) enteroscopy-assisted ERCP, n=8 (7%) endoscopy of the excluded stomach after Roux-en-Y gastric bypass, n=7 (6%) retrograde enteroscopy after previous incomplete conventional colonoscopy and n=7 (6%) antegrade panenteroscopy of the entire small bowel. In this group of secondary indications, technical success rate was significantly lower (72.5%) as compared to technical success rates in the conventional groups (98-100%, p<0.001 Chi-square). Minor adverse events occurred in 17/115 patients (15%), all treated conservatively (AGREE I and II). This study demonstrates the capabilities of PSF-1 motorized spiral enteroscope for secondary indications. PSF-1 is useful to complete colonoscopy in case of long redundant colon, to reach the excluded stomach after Roux-en-Y gastric bypass, to perform unidirectional pan-enteroscopy and to perform ERCP in patients with surgically altered anatomy. However, technical success rates are lower as compared to conventional antegrade and retrograde enteroscopy procedures, with only minor adverse events.

Efficacy & safety of EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in Roux-en-Y gastric bypass anatomy: a systematic review & meta-analysis.

In patients with Roux-en-Y gastric bypass (RYGB) anatomy, laparoscopic endoscopic retrograde cholangiopancreatography (LA-ERCP) and enteroscopy-assisted ERCP (E-ERCP) have been utilized to achieve pancreaticobiliary access. Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) has recently emerged as an alternate and efficient approach. As data regarding EDGE continues to evolve, concerns about safety and efficacy remain, limiting wide adoptability. We performed a systematic review and meta-analysis to assess the safety and efficacy of EDGE and compare it to the current standard of care. A comprehensive search of major databases (inception to Nov 2022) identified published studies on EDGE. A random-effects model was used to calculate the pooled rates and heterogeneity (I2). Risk ratio (RR) and standardized difference in means (SMD) were utilized for head-to-head comparison analysis between EDGE vs. LA-ERCP and EDGE vs. E-ERCP. Primary outcomes assessed pooled EDGE safety (adverse events) and efficacy (technical/clinical success). Secondary outcomes assessed efficacy and safety profiles via a comparative analysis of EDGE vs. LA-ERCP and EDGE vs. E-ERCP. A total of 16 studies (470 patients) were included. EDGE pooled technical success (TS) rate was 96%(95% CI 92-97.6, I2 = 0), and clinical success was 91% (85-95, I2 = 0). Pooled rate of all adverse events with EDGE was 17% (14-24.6, I2 = 32%). On sub-group analysis, these included failure of fistula closure 17% (10-25.5, I2 = 48%), stent migration 7% (4-12, I2 = 51%), bleeding 5% (3.2-7.9, I2 = 0), post-EDGE weight gain 4% (2-9, I2 = 0), perforation 4% (2.1-5.8, I2 = 0), and post-ERCP pancreatitis 2% (1-5, I2 = 0). EDGE TS was comparable to LA-ERCP (97% vs. 98%; RR, 1.00; CI, 0.85-1.17,p = 0.95)and E-ERCP (100%vs. 66%; RR, 1.26; CI, 0.99-1.6,p = 0.06).No statistical difference was noted in adverse events between EDGE and LA-ERCP (13% vs. 17.6%; RR, 0.61; CI, 0.28-1.35,p = 0.52) and E-ERCP (9.6%vs. 16%; RR, 0.61; CI, 0.28-1.35,p = 0.22). EDGE procedure time and hospital stay were shorter than LA-ERCP and E-ERCP (p < 0.001). Our analysis shows that EDGE is safe and efficacious to the current standard of care. Further head-to-head comparative trials are needed to validate our findings.

Efficacy of short-bending sphincterotome for difficult biliary cannulation in double-balloon enteroscopy-assisted ERCP.

Efficacy of short-bending sphincterotome for difficult biliary cannulation in double-balloon enteroscopy-assisted ERCP.

Outcomes of patients with hepaticojejunostomy anastomotic strictures undergoing endoscopic and percutaneous treatment

Background and study aims The increase in hepaticojejunostomies has led to an increase in benign strictures of the anastomosis. Double balloon enteroscopy-assisted ERCP (DBE-ERCP) and percutaneous transhepatic biliary drainage (PTBD) are treatment options; however, there is lack of long-term outcomes, with no consensus on management. We performed a retrospective study assessing the outcomes of patients referred for endoscopic management of hepaticojejunostomy anastomotic strictures (HJAS). Patients and methods All consecutive patients at a tertiary institution underwent endoscopic intervention for suspected HJAS between 2009 and 2021 were enrolled. Results Eighty-two subjects underwent DBE-ERCP for suspected HJAS. The technical success rate was 77 % (63/82). HJAS was confirmed in 41 patients. The clinical success rate for DBE-ERCP ± PTBD was 71 % (29/41). DBE-ERCP alone achieved clinical success in 49 % of patients (20/41). PTBD was required in 49 % (20/41). Dual therapy was required in 22 % (9/41). Those with liver transplant had less technical success compared to other surgeries (72.1 % vs 82.1 % P = 0.29), less clinical success with DBE-ERCP alone (40 % vs 62.5 % P = 0.16) and required more PTBD (56 % vs 37.5 % P = 0.25). All those with ischemic biliopathy (n = 9) required PTBD for clinical success, required more DBE-ERCP (4.4 vs 2.0, P = 0.004), more PTBD (4.7 vs 0.3, P < 0.0001), longer treatment duration (181.6 vs 99.5 days P = 0.12), and had higher rates of recurrence (55.6 % vs 30.3 % P = 0.18) compared to those with HJAS alone. Liver transplant was the leading cause of ischemic biliopathy (89 %). The overall adverse event rate was 7 %. Conclusions DBE-ERCP is an effective diagnostic and therapeutic tool in those with altered gastrointestinal anatomy and is associated with low complication rates.

A new method to identify the afferent limb in balloon enteroscopy-assisted ERCP: Retention of gel mixed with contrast medium under fluoroscopy.

A new method to identify the afferent limb in balloon enteroscopy-assisted ERCP: Retention of gel mixed with contrast medium under fluoroscopy.

Scissor-type knife precut in balloon enteroscopy–assisted ERCP for patients with difficult biliary cannulation and surgically altered anatomy (with video)

Balloon enteroscopy-assisted ERCP (BE-ERCP) is useful for treating pancreatobiliary disease in patients with surgically altered anatomy (SAA); however, biliary cannulation, including the precut technique, is often challenging. This study aimed to examine the feasibility of scissor-type knife precutting (SKP) during BE-ERCP in patients with SAA. This retrospective study investigated consecutive patients who underwent BE-ERCP and SKP for difficult biliary cannulation between 2016 and 2021. The study outcomes included the technical success and adverse event rates associated with SKP during BE-ERCP. During the study period, 125 patients with native duodenal papillae underwent BE-ERCP, and the papilla was reached in 116 patients. The success rate of biliary cannulation with the standard cannulation approach alone was 67.2% (78/116), which increased to 77.6% (90/116) with the inclusion of advanced cannulation techniques besides precutting and further improved to 87.9% (102/116) with the addition of needlife precutting. SKP was attempted in 12 patients in whom all other cannulation approaches were difficult or resulted in failure. The technical success rate of SKP was 66.7% (8/12); thus, SKP increased the final success rate of biliary cannulation to 94.8% (110/116). The rate of adverse events associated with SKP was 8.3% (1/12). This is the first study to report the use of the SKP technique for difficult biliary cannulation in patients with SAA, which may serve as a useful option for salvage cannulation during BE-ERCP.

Through-the-stent ERCP in Roux-en-Y gastrectomy via EUS-guided jejunoduodenostomy with EUS-guided cholangiography for duodenal mapping

An 85-year-old with total gastrectomy and Roux-en-Y esophagojejunostomy experienced cholangitis. Transabdominal US revealed choledocholithiasis. Looping prevented the insertion of a pediatric colonoscope to the papilla for ERCP. EUS-guided antegrade stone removal was deemed more efficient than enteroscopy-assisted ERCP.

Enteroscopy-assisted ERCP with needle-knife stricturoplasty of a strictured hepaticojejunostomy

A 66-year-old woman with a history of T3N2 pancreatic adenocarcinoma who had been previously treated with a Whipple procedure and adjuvant chemotherapy presented with jaundice and pruritus. A CT scan demonstrated marked intrahepatic biliary ductal dilation with a transition point at the level of the hepaticojejunostomy; marked nodular enhancement was concerning for a stricture, and findings were suggestive of cholangitis. She was referred for an attempt at ERCP (Video 1, available online at www.giejournal.org).

Success of single-balloon enteroscope-assisted endoscopic retrograde colangiopancreatography in patients with a modified anatomy.

We would like to congratulate Drs. Espinel and Pinedo for their excellent results in single-ballon enteroscopy-assisted ERCP recently published in REED(1).We also want to share our experience. Between 2015 and 2021 we have performed 31 procedures in 26 patients. Half of the procedures (45.16%) were performed in patients with Roux-en-Y hepatic jejunostomy. Eight of these (22.80%) had prior primary bile duct surgery and six (19.35%) had prior Whipple surgery. The other half of the procedures (54.8%) presented native papilla: 10 (32.25%) subtotal gastrectomy and seven (22.58%) gastric bypass surgery.

EUS-guided transanastomotic drainage for severe biliopancreatic anastomotic stricture using a forward-viewing echoendoscope in patients with surgically altered anatomy.

Background and Objectives: Balloon enteroscopy-assisted ERCP (BE-ERCP) has become the first-line therapy for biliopancreatic anastomotic strictures. However, it is not always successful, and salvage methods have not been established. This study aimed to evaluate the outcomes of EUS-guided transanastomotic drainage using a forward-viewing (FV) echoendoscope.Patients and Methods: Of eight cases wherein BE-ERCP treatment failed due to severe or complete benign anastomotic stricture, seven cases underwent EUS-guided choledochojejunostomy, and EUS-guided pancreaticojejunostomy was applied in one case after intubating an FV echoendoscope into the anastomotic site.Results: The success rate of reaching the target site was 100% (8/8) for patients after modified Child resection. The median time to reach the anastomosis was 5 min (range: 3–17 min), and the technical success rate for drainage was 75% (6/8). The median total procedure time was 33.5 min (range: 22–45 min) for six successful cases. Cautery dilatation catheters were necessary to dilate the puncture site in all cases, and no early complications were observed. During the follow-up period (median: 13.3 months [range: 6.5–60.3]), recurrence of the stricture occurred in one case, and a stent-free status was achieved after 6–12 months of stent placement in five cases.Conclusions: EUS-guided transanastomotic drainage using an FV echoendoscope is a feasible and safe rescue technique for the management of benign severe biliopancreatic anastomotic strictures.

Combined bridging and antegrade stent placement during transmural treatment for malignant hilar biliary obstruction in a patient with surgically altered anatomy.

Recently, bilateral biliary drainage has been considered as the recommended approach for malignant hilar biliary obstruction (MHBO).1 Patients with surgically altered anatomy (SAA) usually represent a challenge for enteroscopy-assisted ERCP (E-ERCP), with its demanding procedure and dedicated technique. This challenge is greatly increased if SAA is combined with MHBO, especially with the limited availability of suitable metal stents for E-ERCP. EUS-guided hepaticogastrostomy (EUS-HGS) has become a feasible alternative approach for this group of patients, allowing bilateral drainage through the bridging technique using an uncovered self-expandable metal stent (SEMS) across the hilar malignant stricture joining the right and left hepatic ducts (RHDs and LHDs, respectively).

S2367 Push Enteroscopy-Assisted ERCP for Treatment of Biliary Obstruction and Cholangitis in a Patient With Kasai Porto-Enterostomy

INTRODUCTION: Biliary obstruction and acute cholangitis are late complications in patients with Kasai porto-enterostomy performed for biliary atresia. Patients typically present with fevers and jaundice and can progress to liver failure. Only a few cases have reported successful endoscopic treatment for biliary obstruction in adults with a previous Kasai procedure. Here we describe the case of a 34-year-old female with Kasai porto-enterostomy with recurrent cholangitis. A successful enteroscopy-assisted ERCP was performed with resolution of symptoms. CASE DESCRIPTION/METHODS: A 34-year-old female with a history of biliary atresia status post Kasai procedure done shortly after birth presented with intermittent fevers, refractory pruritus, and recent hospitalization for acute cholangitis. Her workup revealed elevated liver tests and serum bile acids. MRCP showed right intrahepatic bile duct (RHD) dilatation with peribiliary cysts, trace left intrahepatic bile duct (LHD) dilatation and focal stricture at the porto-enterostomy anastomosis. We performed an enteroscopy-assisted ERCP with the patient in supine position. A pediatric colonoscope with a clear cap was used to access the biliary limb. After applying external abdominal pressure, the porto-enterostomy was reached and showed a severely stenosed opening of the bile ducts (Figure 1). The RHD was deeply cannulated using a 0.025” hydrophilic-tipped guidewire. Cholangiogram showed dilated RHD up to 10mm with severe stricture at the porto-enterostomy (Figure 2). The stricture was dilated with a balloon dilator first to 3mm then 4mm. A 5Fr x 4cm plastic stent with a single internal flange and single external pigtail was placed into the RHD. Cannulation of the LHD was unsuccessful due to complete obstruction of the ducts. A submucosal ink injection was used to mark the biliary limb. The patient was discharged home the same day. Both her fever and pruritus resolved and she has not had further episodes of cholangitis. Her liver tests improved markedly (Table 1). On repeat ERCP, the prior stent was exchanged for a 7Fr x 5cm stent. Liver enzymes normalized. No late complications occurred. DISCUSSION: Enteroscopy-assisted ERCP is a feasible treatment for biliary obstruction in patients with Kasai porto-enterostomy. Altered anatomy and limited choice of tools make interventions challenging. This procedure should be considered as an alternative to more invasive percutaneous and surgical techniques and as part of a multidisciplinary approach.Table 1.: Serum Bile Acids, Hepatic Panel, Complete blood count, C-reactive Protein prior to ERCP vs. 4 and 12 weeks post ERCP with stent placementFigure 1.: Severely stenosed bile ducts (black arrow).Figure 2.: Cholangiogram with dilated right intrahepatic bile duct.

S1516 Malignant Biliary Obstruction Diagnosed by Percutaneous Transhepatic Cholangioscopy With Spyglass Direct Visualization System

INTRODUCTION: Malignant biliary obstruction associated with gastric cancer is uncommon. We report a patient with obstructive jaundice due to a new biliary stricture after gastrectomy and loop gastrojejunostomy. Conventionally, enteroscopy-assisted ERCP will be needed to biopsy the stricture which can be difficult and not widely available. Here we describe an easier approach using Percutaneous Transhepatic Cholangioscopy (PTCS) with SpyglassTM Direct visualization system (SDVS). CASE DESCRIPTION/METHODS: 51-year-old male with history of gastric adenocarcinoma status post distal gastrectomy with loop gastrojejunostomy presented 3 years later with painless jaundice. Initial imaging studies including US and CT scan showed severe biliary obstruction with pronounced intrahepatic and extrahepatic ductal dilatation. MRCP revealed a proximal common bile duct stricture with resultant severe intrahepatic ductal dilation spanning approximately 1.5 cm, highly suspicious for malignancy (Image1). ERCP was not attempted due to the altered anatomy and a percutaneous internal biliary drain was placed by Interventional radiology (IR). The drain was placed through the left biliary system into the common duct and into the duodenum. Cholangiogram showed two strictures in the proximal and mid bile duct. In order to obtain the diagnosis, the decision was made to proceed with a combined endoscopic and IR guided approach. A digital cholangioscope was passed through a 12Fr sheath catheter that was placed by IR. The stricture was endoscopically visualized and appeared erythematous, friable with whitish mucosa (Image 2). Multiple biopsies were obtained using a mini biopsy forceps. Pathology revealed poorly differentiated adenocarcinoma with associated fibrosis, inflammation and necrosis. DISCUSSION: Cholangioscopy through a percutaneous transhepatic route is an attractive alternative option when traditional ERCP is technically challenging or not feasible. SDVS provides direct visualization of the biliary system increasing the diagnostic yield, as in our case where it helped to diagnose a malignant biliary stricture in a patient who was in remission from primary gastric carcinoma. PTCS with SDVS also provides therapeutic potential for choledocholithiasis, biliary strictures and local tumor ablative therapy. Though it is an invasive procedure requiring collaboration between a gastroenterologist and an interventional radiologist, as demonstrated, it is a safe and technically easy procedure with unique diagnostic and therapeutic potentials.Figure 1.: blue arrow: Proximal common bile duct stricture causing severe intrahepatic ductal dilation.Figure 2.: Biliary stricture seen using direct visualization system.