Tomohiro Ishii

Biliary cannulation has been reported to be difficult using traction techniques [1] [2] or a rotatable sphincterotome [3]; only few studies have attempted the combined use of these methods. Here, we report a case wherein biliary cannulation was successfully achieved using a rotatable sphincterotome after adjusting the papillary position via a two-step traction technique using a multi-ring traction device. A 75-year-old woman underwent laparoscopic cholecystectomy for pericholecystic abscess and acute cholecystitis ([Fig. 1]). Endoscopic retrograde cholangiopancreatography (ERCP) was performed to treat the common bile duct stone identified preoperatively using magnetic resonance cholangiopancreatography ([Fig. 2]). During the initial ERCP, the presence of a papillary diverticulum necessitated multiple techniques; however, only pancreatic duct cannulation was achieved. Pancreatic stenting was performed after endoscopic pancreatic sphincterotomy. A second ERCP was attempted 2 days later. Despite attempting multiple techniques, biliary cannulation was unsuccessful. Therefore, we attempted biliary cannulation using both a seven-ring traction device (Adachi, Osaka, Japan; [Fig. 3]) and a rotatable sphincterotome (Engetsu; Kaneka Medix, Osaka, Japan). First, the papilla was pulled toward the 7 o’clock position. To visualise the bile duct opening from the front, the loop between the first and second clips was pulled further toward the 4 o’clock position. As the papillary diverticulum did not allow the axis of a standard catheter to align in the bile duct direction, the sphincterotome was rotated to 2 o’clock, enabling successful bile duct cannulation ([Video 1]). The bile duct stones were successfully removed using endoscopic papillary balloon dilation and the sphincterotome was freely rotated to facilitate loop resection. The traction device used in this case featured seven rings, allowing two-step traction by pulling any ring to secure a better field of view. Thus, the combined use of the device and a rotatable sphincterotome could be an effective approach to achieve bile duct cannulation. Endoscopy_UCTN_Code_TTT_1AR_2AK Article published online: 19 December 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Anastomotic stenosis of the hepaticojejunostomy is a major complication following pancreaticoduodenectomy [1]. In cases of complete anastomotic obstruction, drainage has been attempted using a cholangioscope via the percutaneous transhepatic biliary drainage route or a forward-viewing echoendoscope [2] [3]. However, reports of direct puncture of the anastomotic site remain scarce [4]. Here, we present a case of complete hepaticojejunostomy obstruction successfully managed with direct needle puncture drainage using a radial miniature probe (UM-2R; Olympus, Tokyo, Japan). A 72-year-old woman was under postoperative surveillance following surgery for pancreatic tail cancer when an iatrogenic recurrence of pancreatic head cancer was detected. She subsequently underwent residual pancreatectomy. Postoperatively, she developed obstructive jaundice ([Fig. 1] and [Fig. 2]) and was referred to our department. Single-balloon enteroscopy (SIF-H290S; Olympus, Tokyo, Japan) was performed to evaluate the hepaticojejunostomy anastomosis; however, complete occlusion precluded biliary drainage. The endoscope was then switched to a therapeutic video gastroscope (GIF-H290T; Olympus, Tokyo, Japan) to access the anastomotic site. Water was slowly injected through the auxiliary water channel, and the water-filled area surrounding the hepaticojejunostomy was visualized using the UM-2R. The right hepatic artery and portal vein were clearly identified, confirming a safe trajectory for puncturing the anastomosis and accessing the bile duct. A 19-G needle was used to directly puncture the hepaticojejunostomy anastomosis, allowing successful cholangiography. Following guidewire placement, the anastomotic stenosis was dilated with a biliary balloon catheter, and 7-Fr biliary stents were placed in the right and left hepatic ducts, achieving effective drainage ([Video 1]). Direct needle puncture of the hepaticojejunostomy anastomosis carries potential risks, including small intestinal perforation, bile leakage, and vascular injury leading to hemorrhage. However, the use of the UM-2R enabled safe bile duct access and drainage while mitigating complications, thus broadening the scope of endoscopic management for anastomotic stenosis. Endoscopy_UCTN_Code_TTT_1AS_2AH Article published online: 12 March 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Background: Peroral cholangioscopy (POCS) is valuable for assessing malignant biliary strictures; however, biliary drainage prior to POCS often hinders accurate diagnosis. Objectives: This retrospective study aimed to investigate the feasibility of POCS using a newly developed cholangioscope, CHF-B290, during initial endoscopic retrograde cholangiopancreatography (ERCP) for malignant biliary strictures. Methods: This multicenter retrospective study included patients who underwent initial ERCP for malignant biliary strictures at two institutions between January 2018 and March 2022. Patients who underwent initial ERCP with POCS were classified into the POCS group, and those without POCS were classified into the non-POCS group. To prevent post-POCS cholangitis, the original irrigation system for CHF-B290 was used in all POCS examinations. The primary endpoint was the rate of post-ERCP biliary infections, and the secondary endpoints were other ERCP-related complications, including pancreatitis, bleeding, and perforation. Results: Overall, 53 and 94 patients were included in the POCS and non-POCS groups, respectively. For the primary endpoint, the rate of post-ERCP biliary infection was not significantly different between the two groups (1.9% vs. 5.3%, p = 0.42). For the secondary endpoints, no significant differences were observed in the rates of post-ERCP pancreatitis (5.7% vs. 6.4%, p = 1.00) and other ERCP-related complications. The overall complication rate was 9.4% in the POCS group and 13% in the non-POCS group (p = 0.60). Conclusions: POCS during the initial ERCP for malignant biliary strictures is feasible.

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Stent retriever dilation (Soehendra stent retriever, SSR-7; Cook, Tokyo, Japan) has demonstrated effectiveness in treating main pancreatic duct stenosis in chronic pancreatitis [1] [2]. However, there have been few reports on stent retriever tip breakage [3]. In this study, we describe a case of dislodgment of the stent retriever tip during main pancreatic duct stenosis owing to chronic pancreatitis, including the removal method. A 56-year-old man was referred to our hospital for obstructive pancreatitis because of chronic pancreatitis-associated pancreatic stones. Initial endoscopic retrograde cholangiopancreatography (ERCP) demonstrated stenosis of the main pancreatic duct in the pancreatic body. A 5-Fr pancreatic stent was placed in the pancreatic head because it failed to pass through the body stenosis. Subsequently, contrast-enhanced abdominal computed tomography (CT) demonstrated persistent inflammation around the pancreatic body and tail ([Fig. 1]). Another ERCP was performed to place a pancreatic stent for body stenosis. Pancreatography demonstrated pancreatic body stenosis and extrapancreatic leakage of contrast agent at the stenosis site. Initially, the stenosis was partially dilated using a thin-tipped balloon catheter. Further caudal dilation was attempted; however, the catheter and another bougie dilator failed to pass through the stenosis. Subsequently, we dilated the stenosis using the SSR-7. When the SSR-7 was removed following dilatation, the tip was dislodged midway through the stenosis and remained in the pancreatic duct ([Video 1]). An attempt to remove the tip using biopsy forceps failed because it could not pass through the stenosis. Subsequently, a wire-guided single-opening biopsy forceps (E634044, 2.2-mm channel; Olympus, Tokyo, Japan) was used to successfully grasp and remove the dislodged tip through the stenosis ([Fig. 2]). The stenosis was dilated again using a thin-tipped balloon catheter, followed by the successful placement of a 5-Fr pancreatic stent at the stenosis site. Endoscopy_UCTN_Code_CPL_1AK_2AZ Article published online: 08 October 2024 © 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Background/Purpose: Endoscopic treatment of common bile duct (CBD) stones involves the use of basket or balloon catheters; however, what is the appropriate device remains controversial. In this study we aimed to prospectively evaluate the usefulness of a novel 8‐wire helical basket (8WB) catheter made of Nitinol for the removal of CBD stones ≤10 mm.Methods: We conducted a multicenter prospective trial. Patients with CBD stones ≤10 mm were enrolled. The primary endpoint was the rate of complete stone removal within 10 min using the 8WB. The number of cases was determined using a previous study of stone removal by a conventional basket catheter as a historical control.Results: A total of 155 patients were enrolled and 139 were ultimately included in the analysis. Patients with a single stone were the most common (84 cases, 60.4%), with a median maximum stone diameter of 5 mm. The median stone removal time using the 8WB was 6 min. The complete stone removal rate was 95.0% (132/139). Adverse events were observed in 14 patients (10.1%).Conclusions: The novel 8WB catheter is useful in the treatment of CBD stones ≤10 mm, presenting a high complete stone removal rate in this study.Trial registration number: jRCT1032200324.

Texture and color enhancement imaging (TXI) and red dichromatic imaging (RDI) modes are new image-enhancement options available on the EVIS X1 system (Olympus Corporation, Tokyo, Japan). TXI emphasizes slight differences in color tone and structural changes on the mucosal surface under normal light [1], whereas RDI may improve the visibility of deep blood vessels [2]. We previously reported the use of TXI- and RDI-mode cholangioscopy (CHF-B290, Olympus Corporation) in cholangiocarcinoma [3]. Here, we describe this technique in a patient with IgG4-related sclerosing cholangitis (IgG4-SC) and autoimmune pancreatitis (AIP). An 87-year-old woman presented with elevated liver enzymes and diffuse pancreatic enlargement ([Fig. 1], [Fig. 2]). Endoscopic retrograde cholangiopancreatography (ERCP) revealed segmental stenosis of the distal bile duct, preventing passage of the cholangioscope. A biliary stent was placed. Histopathology revealed no malignant findings; high IgG and IgG4 levels led to the diagnosis of AIP + IgG4-SC. Due to the patient’s age, stent replacement and stenosis reassessment were performed 2 months later without medication. The second ERCP showed slight improvement in stenosis, allowing passage of the cholangioscope. Cholangioscopy revealed partially dilated and slightly tortuous vessels without encasement or fusion [4] at the hilar bile duct. Dilated vessels were more clearly observed, and the fine surface structures of the thickened mucosa were more pronounced in TXI mode 1 than with white-light imaging. In RDI mode 3, the color of the bile disappeared and the dilated vessels were more strongly accentuated than with TXI. The mucosal surface was smooth, and no tumor vessels were observed at the stenosis ([Video 1]). The addition of TXI and RDI to cholangioscopy may therefore aid the diagnosis of IgG4-SC. A third ERCP 4 months later showed slight bile duct stenosis that did not require stenting; no adverse events or recurrence of symptoms were observed over the 10-month follow-up period. Video 1 Findings of the cholangioscopy using texture and color enhancement imaging mode 1 and red dichromatic imaging mode 3 in a patient with IgG4-related sclerosing cholangitis and autoimmune pancreatitis. Endoscopy_UCTN_Code_TTT_1AR_2AG Article published online: 30 August 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Texture and color enhancement imaging (TXI) and red dichromatic imaging (RDI) modes are new image-enhancement systems available on the EVIS X1 (Olympus, Tokyo, Japan). TXI emphasizes slight differences in color tone and structural changes on the mucosal surface under normal-light observation and is expected to improve the observation performance of lesions [1]. On the other hand, RDI emphasizes the contrast of deep tissue and is expected to improve the visibility of deep blood vessels [2]. Especially in RDI mode 3, the color of bile disappears, making visualization easier. TXI and RDI modes are gaining popularity in the diagnosis of gastrointestinal cancer. However, TXI and RDI mode cholangioscopy (CHF-B290, Olympus) has not been reported for cholangiocarcinoma [3]. We describe the findings and characteristics of TXI mode 1 and RDI mode 3 cholangioscopy for cholangiocarcinoma. An 81-year-old man was admitted to the hospital with obstructive jaundice and cholangitis ([Fig. 1], [Fig. 2]). Endoscopic retrograde cholangiopancreatography was performed, revealing stenosis of the distal bile duct. A biliary stent was placed, cholangitis was treated, and histopathology revealed a cholangiocarcinoma. Cholangioscopy was performed to confirm the extent of superficial spreading. TXI mode 1 more clearly depicted the meandering tumor vessels along with caliber changes and the roughness of the tumor surface when compared to white-light imaging. In RDI mode 3, the color of bile disappeared and the tumor vessels were more accentuated than those in TXI ([Video 1]). Narrow-band imaging demonstrated good delineation of superficial tumor vessels [4], but the presence of bile made it difficult to observe the bile duct. Biopsies from the hilar region of the bile duct showed no malignancy, and a pancreatoduodenectomy was performed. Postoperative histopathology showed an irregular papillary epithelium with irregularly dilated tumor vessels ([Fig. 3]). Image-enhanced cholangioscopy is useful in diagnosing cholangiocarcinomas. Video 1 Demonstration of new image-enhanced cholangioscopy for the diagnosis of cholangiocarcinoma. Endoscopy_UCTN_Code_CCL_1AZ_2AC Article published online: 28 October 2022 © 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany