Clinical Endoscopy

Original Article

Feasibility of primary precut sphincterotomy in endoscopic retrograde cholangiopancreatography for patients with large oral protrusions of the duodenal papilla; prospective observation study in Japan: Masafumi Watanabe, Kosuke Okuwaki, Mitsuhiro Kida, Hiroshi Imaizumi, Kai Adachi, Akihiro Tamaki, Taro Hanaoka, Chika Kusano; Received August 9, 2025 Accepted September 17, 2025 Published online February 13, 2026; DOI: https://doi.org/10.5946/ce.2025.271 [Epub ahead of print]

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: Large oral protrusions may increase the difficulty of biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) and often require precut sphincterotomy. Precut sphincterotomy is a risk factor for post-ERCP pancreatitis (PEP). However, this may be reduced by a primary precut sphincterotomy. This study aimed to evaluate the results of biliary cannulation after primary precut sphincterotomy in patients with large oral protrusions identified during ERCP.
Methods
In this prospective observation study, we included 38 patients with naïve papillae who underwent ERCPs between January 2021 and December 2022 that revealed large oral protrusions and who underwent primary precut sphincterotomies as the biliary cannulation method. Primary precut sphincterotomy was performed by an experienced endoscopist in all cases.
Results
The biliary cannulation success rate for primary precut sphincterotomies was 100% (38/38 patients). There were seven cases (18.4%) of ERCP-related adverse events, specifically bleeding. Of these, six (15.8%) were mild and one (2.6%) was moderate. No cases of PEP were observed.
Conclusions
Primary precut sphincterotomy for large oral protrusions performed by an experienced endoscopist had a high biliary cannulation success rate without the occurrence of PEP. This procedure can be used for biliary cannulation in patients with large oral protrusions (University Hospital Medical Information Network-Clinical Trials Registry number: UMIN000042805).

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Review

Peroral cholangioscopy: past, present and future: Yuki Tanisaka, Robert Hawes; Clin Endosc 2025;58(3):360-369. Published online May 19, 2025; DOI: https://doi.org/10.5946/ce.2024.306

Abstract PDF PubReader ePub

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the evaluation of biliary strictures and the management of bile duct stones. However, standard ERCP techniques sometimes fail for both indications. In such situations, peroral cholangioscopy (POCS), which allows direct visualization of the bile duct, can play a significant role in diagnosis and treatment. Direct visualization using POCS can help differentiate between malignant and benign conditions and is more accurate in defining the extent of cholangiocarcinoma. Furthermore, POCS enables visually guided biopsies. Certain types of difficult bile duct stones, such as impacted and intrahepatic stones, require POCS for visually guided lithotripsy. Recent advancements in POCS will broaden its applicability and improve its diagnostic utility. In this review, we provide perspectives on the past, present, and future of POCS.

Citations

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Clinical Application of Ultra‐Slim Peroral Cholangioscopy for a Giant Common Bile Duct Stone: An Initial Experience
Yuta Kanazawa, Kazumasa Nagai, Noriyuki Hirakawa, Reina Tanaka, Ryosuke Tonozuka, Shuntaro Mukai, Yukitoshi Matsunami, Takao Itoi
Journal of Hepato-Biliary-Pancreatic Sciences.2026;[Epub] CrossRef
Research Progress in the Diagnosis and Treatment of Intrahepatic Bile Duct Stones
道文熊
Advances in Clinical Medicine.2025; 15(09): 783. CrossRef
A novel sheath system to improve target access for preoperative mapping biopsy: A randomized trial to inform surgical planning
Hironori Aoi, Kentaro Yamao, Takuya Ishikawa, Yasuyuki Mizutani, Tadashi Iida, Kota Uetsuki, Yoshihisa Takada, Takeshi Yamamura, Kazuhiro Furukawa, Masanao Nakamura, Hiroki Kawashima
Surgical Endoscopy.2025;[Epub] CrossRef

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Original Articles

Puncture angle on an endoscopic ultrasound image is independently associated with unsuccessful guidewire manipulation of endoscopic ultrasound-guided hepaticogastrostomy: a retrospective study in Japan: Akihisa Ohno, Nao Fujimori, Toyoma Kaku, Kazuhide Matsumoto, Masatoshi Murakami, Katsuhito Teramatsu, Keijiro Ueda, Masayuki Hijioka, Akira Aso, Yoshihiro Ogawa; Clin Endosc 2024;57(5):656-665. Published online July 26, 2024; DOI: https://doi.org/10.5946/ce.2023.244

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub

Background
/Aims: Although endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is performed globally, the procedure remains challenging. Guidewire manipulation is the most difficult step, and there are few reports on the factors associated with unsuccessful guidewire manipulation. This study aimed to assess the significance of the puncture angle on EUS images and identify the most effective guidewire rescue method for patients with unsuccessful guidewire manipulation.
Methods
We retrospectively enrolled 115 patients who underwent EUS-HGS between May 2016 and April 2022 at two centers. The puncture angle between the needle and the intrahepatic bile duct was measured through EUS movie records.
Results
Guidewire manipulation was unsuccessful in 28 patients. Receiver operating characteristic (ROC) curves identified an optimal puncture angle cutoff value of 85° (cutoff value, 85°; area under the ROC curve, 0.826; sensitivity, 85.7%; specificity, 81.6%). Multivariate analysis demonstrated that a puncture angle <85° was a significant risk factor for unsuccessful guidewire manipulation (odds ratio, 19.8; 95% confidence interval, 6.42–61.5; p<0.001). Among the 28 unsuccessful cases, 24 patients (85.7%) achieved successful guidewire manipulation using various rescue methods.
Conclusions
The puncture angle observed on EUS is crucial for guidewire manipulation. A puncture angle of <85° was associated with unsuccessful guidewire manipulation.

Citations

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Backward leap technique using a novel 0.018-inch guidewire
Kosuke Takahashi, Eisuke Ozawa, Yasuhiko Nakao, Masanori Fukushima, Hisamitsu Miyaaki, Kazuhiko Nakao
Endoscopy.2025; 57(S 01): E90. CrossRef
The Role and Appropriate Selection of Guidewires in Biliopancreatic Endoscopy
Daniele Alfieri, Claudia Delogu, Stefano Mazza, Aurelio Mauro, Erica Bartolotta, Alessandro Cappellini, Davide Scalvini, Francesca Torello Viera, Marco Bardone, Andrea Anderloni
Medicina.2025; 61(5): 913. CrossRef
Consensus document for the transcystic approach to choledocholithiasis with ultrathin flexible choledochoscope
Alejandra García-Botella, Juan Pablo Arjona Trujillo, Sofía de la Serna, Pedro José Gil Vázquez, Santos Jiménez-Galanes Marchán, Erik Llàcer-Millán, Ana Belén Martín Arnau, David Martínez-Cecilia, Alba Zárate Pinedo, Alberto Martínez-Isla
Cirugía Española (English Edition).2025; : 800259. CrossRef

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Safety and efficacy of novel oblique-viewing scope for B2-endoscopic ultrasound-guided hepaticogastrostomy: Sho Ishikawa, Kazuo Hara, Nozomi Okuno, Nobumasa Mizuno, Shin Haba, Takamichi Kuwahara, Yasuhiro Kuraishi, Takafumi Yanaidani, Masanori Yamada, Tsukasa Yasuda, Toshitaka Fukui, Teru Kumagi, Yoichi Hiasa; Clin Endosc 2024;57(4):527-533. Published online March 29, 2024; DOI: https://doi.org/10.5946/ce.2023.129

Graphical Abstract Abstract PDF PubReader ePub

Background
/Aims: Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) performed at the intrahepatic bile duct segment 3 (B3) is widely used for biliary drainage. Although performing post-puncture procedures is easier in the intrahepatic bile duct segment 2 (B2) when using a conventional oblique-viewing (OV) EUS scope, this method may cause transesophageal puncture and severe adverse events. We evaluated the safety and efficacy of B2 puncture using a novel OV-EUS scope.
Methods
In this single-center retrospective study, we prospectively enrolled and collected data from 45 patients who consecutively underwent EUS-HGS procedures with a novel OV-EUS scope between September 2021 and December 2022 at our cancer center.
Results
The technical success rates of B2-EUS-HGS and EUS-HGS were 93.3% (42/45) and 97.8% (44/45), respectively. The early adverse event rate was 8.9% (4/45) with no cases of scope changes or transesophageal punctures. The median procedure time was 13 minutes (range, 5–30).
Conclusions
B2-EUS-HGS can be performed safely with the novel EG-740UT (Fujifilm) OV-scope without transesophageal puncture and with a high success rate. B2-EUS-HGS using this novel OV scope may be the preferred strategy for EUS-HGS.

Citations

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Enhanced Endoscope is Associated With Success Rates in B2‐ Endoscopic Ultrasound‐Guided Hepaticogastrostomy
Yoshitaro Yamamoto, Kazuo Hara, Nozomi Okuno, Shin Haba, Takamichi Kuwahara, Hiroki Koda, Minako Urata, Takashi Kondo, Keigo Oshiro, Tomoki Ogata, Ren Kuwabara
DEN Open.2026;[Epub] CrossRef
Clinical evaluation of a novel fluoroscopic mode for improving visibility during interventional endoscopic ultrasound (with video)
Naoto Aoyama, Takeshi Ogura, Saori Ueno, Atsushi Okuda, Nobu Nishioka, Jun Sakamoto, Yuki Uba, Mitsuki Tomita, Nobuhiro Hattori, Junichi Nakamura, Kimi Bessho, Takafumi Kanadani, Hiroki Nishikawa
Therapeutic Advances in Gastroenterology.2025;[Epub] CrossRef
Scope withdrawal technique to prevent transesophageal puncture during endoscopic ultrasound-guided hepaticogastrostomy
Kazuki Endo, Haruo Miwa, Ritsuko Oishi, Hiromi Tsuchiya, Yuichi Suzuki, Kazushi Numata, Shin Maeda
Endoscopy.2025; 57(S 01): E705. CrossRef
Primary endoscopic ultrasound-guided hepaticogastrostomy for biliary drainage prior to pancreatoduodenectomy: a retrospective study in Japan
Nozomi Okuno, Kazuo Hara, Seiji Natsume, Masataka Okuno, Shin Haba, Tomonari Asano, Takamichi Kuwahara, Hiroki Koda, Yasuhiro Shimizu
Clinical Endoscopy.2025; 58(4): 604. CrossRef
Dedicated Echoendoscope for Interventional Endoscopic Ultrasound: Comparison with a Conventional Echoendoscope
Toshio Fujisawa, Shigeto Ishii, Yousuke Nakai, Hirofumi Kogure, Ko Tomishima, Yusuke Takasaki, Koichi Ito, Sho Takahashi, Akinori Suzuki, Hiroyuki Isayama
Journal of Clinical Medicine.2024; 13(10): 2840. CrossRef

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Double-guidewire technique for selective biliary cannulation does not increase the rate of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with naïve papilla: Han Taek Jeong, June Hwa Bae, Ho Gak Kim, Jimin Han; Clin Endosc 2024;57(2):226-236. Published online January 26, 2024; DOI: https://doi.org/10.5946/ce.2023.128

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: This study aimed to compare the safety of the double-guidewire technique (DGT) with that of the conventional single-guidewire technique (SGT) in real-world situations.
Methods
A total of 240 patients with naïve papilla who underwent endoscopic retrograde cholangiopancreatography (ERCP) at Daegu Catholic University Medical Center between January 2021 and December 2021 were included. The primary outcome was the rate of post-ERCP pancreatitis (PEP) in the SGT and DGT groups.
Results
A total of 163 patients (67.9%) belonged to the SGT group, and 77 (32.1%) belonged to the DGT group. The rates of successful biliary cannulation were 95.7% and 83.1% in the SGT and DGT groups, respectively (p=0.002). In the study group, PEP occurred in 14 patients (5.8%). The PEP rates were not significantly different between the SGT and DGT groups (4.3% vs. 9.1%, p=0.150). In the multivariate analysis, the age of <50 years (odds ratio [OR], 9.305; 95% confidence interval [CI], 1.367–63.358; p=0.023) and hyperlipidemia (OR, 7.384; 95% CI, 1.103–49.424; p=0.039) were significant risk factors for PEP in the DGT group.
Conclusions
DGT did not increase the PEP rate in patients with naïve papilla. In addition, the age of <50 years and hyperlipidemia were significant risk factors for PEP in the DGT group.

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Review

Endoscopic Evaluation of Biliary Strictures: Current and Emerging Techniques: Roy Huynh, Corinne Owers, Christopher Pinto, Thuy-My Nguyen, Titus Kwok; Clin Endosc 2021;54(6):825-832. Published online May 27, 2021; DOI: https://doi.org/10.5946/ce.2021.048

Abstract PDF PubReader ePub

The diagnosis of biliary strictures in clinical practice can be challenging. Discriminating between benign and malignant biliary strictures is important to prevent the morbidity and mortality associated with incorrect diagnoses. Missing a malignant biliary stricture may delay surgery, resulting in poor prognostic outcomes. Conversely, it has been demonstrated that approximately 20% of patients who undergo surgery for suspected biliary malignancies have a benign etiology on histopathology. Traditional tissue sampling using endoscopic retrograde cholangiography does not always produce a definitive diagnosis, with a considerable proportion of cases remaining as indeterminate biliary strictures. Recent advances in endoscopic techniques have the potential to improve the diagnostic and prognostic accuracy of biliary strictures.

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Diagnostic value of new biliary biopsy cannulae for malignant bile duct strictures via endoscopic retrograde cholangiopancreatography pathway
Meng-Qi Zhuang, Cheng Zheng, Wei-Wei Xie, Lin Xu, Jia-Li Wu, Dao-Quan Zhang, Yuan-Gan Chen, Sen-Sen Niu, Xiang Zhan, Yu-Bao Zhou
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Yun Chae Lee, Shayan Irani, Hyung Ku Chon
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Chunyan Meng, Jing Wang, Peipei Zhang, Bo Wang
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Eszter Bényei, Antonio Molinaro, Per Hedenström, Riadh Sadik
Scandinavian Journal of Gastroenterology.2024; 59(8): 980. CrossRef
The Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound Connection: Unity Is Strength, or the Endoscopic Ultrasonography Retrograde Cholangiopancreatography Concept
Claudio Giovanni De Angelis, Eleonora Dall’Amico, Maria Teresa Staiano, Marcantonio Gesualdo, Mauro Bruno, Silvia Gaia, Marco Sacco, Federica Fimiano, Anna Mauriello, Simone Dibitetto, Chiara Canalis, Rosa Claudia Stasio, Alessandro Caneglias, Federica Me
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Matteo Ghisa, Angelo Bellumat, Manuela De Bona, Flavio Valiante, Marco Tollardo, Gaia Riguccio, Angelo Iacobellis, Edoardo Savarino, Andrea Buda
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Special Issue Article of IDEN 2013

Functional Self-Expandable Metal Stents in Biliary Obstruction: Chang-Il Kwon, Kwang Hyun Ko, Ki Baik Hahm, Dae Hwan Kang; Clin Endosc 2013;46(5):515-521. Published online September 30, 2013; DOI: https://doi.org/10.5946/ce.2013.46.5.515

Abstract PDF PubReader ePub

Biliary stents are widely used not only for palliative treatment of malignant biliary obstruction but also for benign biliary diseases. Each plastic stent or self-expandable metal stent (SEMS) has its own advantages, and a proper stent should be selected carefully for individual condition. To compensate and overcome several drawbacks of SEMS, functional self-expandable metal stent (FSEMS) has been developed with much progress so far. This article looks into the outcomes and defects of each stent type for benign biliary stricture and describes newly introduced FSEMSs according to their functional categories.

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Tae Young Kim, Won-Jong Lee, Yurim Lee, Seo Jung Kim, Sungjin Min, Seyong Chung, Soo A Kim, Keun-Young Yook, Chang-Hwan Moon, Yeontaek Lee, Kijun Park, Dae-Hyun Kim, Jungmok Seo
Bioactive Materials.2026; 61: 210. CrossRef
Anti-fibrotic and anti-stricture effects of biodegradable biliary stents braided with dexamethasone-impregnated sheath/core structured monofilaments
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Gastrointestinal Endoscopy.2024; 100(4): 679. CrossRef
A machine learning-based predictive model for biliary stricture attributable to malignant tumors: a dual-center retrospective study
Qifan Yang, Lu Nie, Jian Xu, Hua Li, Xin Zhu, Mingwei Wei, Jun Yao
Frontiers in Oncology.2024;[Epub] CrossRef
Recent research progresses of bioengineered biliary stents
Jianing Yan, Zhichao Ye, Xiaofeng Wang, Danyang Zhong, Ziyuan Wang, Tingting Yan, Tianyu Li, Yuyang Yuan, Yu Liu, Yifan Wang, Xiujun Cai
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Surgical Endoscopy.2022; 36(7): 4932. CrossRef
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Caitlin E. Jackson, Liam S. J. Johnson, Dominic A. Williams, Hans-Ulrich Laasch, Derek W. Edwards, Alison G. Harvey
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Special Issue Articles of IDEN 2012

Endoscopic Ultrasonography in the Evaluation of Indeterminate Biliary Strictures: Mark Topazian; Clin Endosc 2012;45(3):328-330. Published online August 22, 2012; DOI: https://doi.org/10.5946/ce.2012.45.3.328

Abstract PDF PubReader ePub

Biliary strictures may be due to a variety of benign and malignant processes. Imaging with endoscopic ultrasonography (EUS) often suggests the diagnosis, but is usually not definitive. EUS-guided fine needle aspiration (FNA) facilitates the diagnosis of extrahepatic biliary strictures, although peritioneal metastases due to needle tract seeding may occur after EUS-FNA of cholangiocarcinoma. In addition to diagnosis of strictures, EUS may play an important role in staging of cholangiocarcinoma.

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Endoscopy.2024; 56(S 02): S356. CrossRef
Advanced endoscopy meets molecular diagnosis of cholangiocarcinoma
Massimiliano Cadamuro, Ahmad Al-Taee, Tamas A. Gonda
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David J. Restrepo, Chris Moreau, Cyrus V. Edelson, Ameesh Dev, Shreyas Saligram, Hari Sayana, Sandeep N. Patel
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증례 : 담도 췌장 ; 담도의 다발성 유두종 1예 ( Case Reports : Biliary Tract & Pancreas ; A Case of Biliary Papillomatosis which Underwent Curative Resection ): Korean J Gastrointest Endosc 1998;18(1):111-115. Published online November 30, 1997

Abstract PDF: Biliary Papillomatosis is an extremely rare pathologic entity. Only about 40 cases of intrahepatic or diffuse intra- and extrahepatic papillomatosis have been described since the first report in 1959 by Caroli. Although this is a histologically benign lesion, its course is unfavaurable because of its tendency to extend to the entire biliary tract, high recurrence rate following local excision and the probability of progression to malignancy. We described herein a case of biliary papillomatosis associated with diffuse bile duct dilatation. The patient, a 59-year-old male, was admitted to our hospital because of right upper abdominal pain and weight loss. Cholangiogram revealed multiple round filling defects in common hepatic duct with intrahepatic bile duct dilatation. The patient underwent Whipple's operation with right lobectomy. Grossly, multiple small pin-head sized polypoid masses were seen in common bile duct, common hepatic duct and right intrahepatic duct. Microscapically, papillary epithelial hyperplasia with moderate cellular atypia was seen and there was no evidence of stromal invasion. He is healthy with a follow-up for 7 months. (Korean J Gastrointest Endosc 18: 111-114, 1998)

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증례 : 담도 췌장 ; 결석을 동반한 간외담관 기형 1예 ( Case Reports : Biliary Tract & Pancreas ; A Rare Case of Extrahepatic Bile Duct Anomaly Associated with Multiple Stones ): Korean J Gastrointest Endosc 1996;16(6):1023-1028. Published online November 30, 1995

Abstract PDF: Congenital anomaly of the extrahepatic biliary system is relatively common, especially vascular variations are much more frequent than anatomic variations. The normal anatomical structure is encountered in only 35 percent of individuals, many of these variations have little or no clinical improtance, but some cases induce symptoms and signs or may lead to incorrect diagnosis and inappropriate management. These are very important to correct diagnosis of biliary variations observed during ultrasonography, cholangiography and endoscopic retrograde cholangiopancreatography(ERCP) and to accurate management by surgeon or endoscopist since accidental section or ligation of aberrant structures can lead to serious complications. We experienced a very rare case of extrahepatic bile duct anomaly confirmed by ERCP. The right and left extrahepatic ducts were connected at the level of the pancreatic segment of the common bile duct and the cystic duct drains to the right extrahepatic duct. There were several stones in the distal portion of the left extrahepatic duct and gallbladder. (Korean J Gastrointeet Endosc 16: 1023-1028, 1996)

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