Completely obstructed bile duct? Let cholangioscopy guide the way

Cholangioscopy involves the use of a small-caliber, flexible endoscope to directly inspect the biliary epithelium, perform sight-directed tissue sampling, and enable therapeutic procedures within the bile ducts. Technical improvements including improved imaging and wider-diameter working channels have led to increased clinical success and utility of cholangioscopy. Currently, the primary applications of cholangioscopy are indeterminate biliary strictures and treatment of difficult bile duct stones. Here we describe a case of a completely obstructed bile duct in a patient with duodenal adenocarcinoma with previously placed metallic biliary and duodenal stents. During ERCP, the biliary tree proximal to the stricture did not opacify (Fig. 1), and the wire could not be advanced proximal to the obstruction. The use of direct intraductal visualization afforded by cholangioscopy aided in the visualization of bile staining and subsequent deep biliary cannulation. This clinical scenario would otherwise have resulted in percutaneous transhepatic biliary drainage, EUS-guided hepaticogastrostomy, or EUS-guided biliary access, the latter of which would not have been possible because of the previously placed metal biliary and enteral stents. Further novel uses of cholangioscopy, like cholangioscopic-assisted deep biliary cannulation as described here (Video 1, available online at www.giejournal.org), are likely to be developed with further refinement of this technique.