Overtube-balloon–assisted direct peroral cholangioscopy by using an ultra-slim upper endoscope (with videos)

BackgroundThe “mother–baby” endoscope system currently used for peroral cholangioscopy (POC) has several limitations. Endoscopic direct cholangioscopy when using an ultra-slim upper endoscope with a guidewire to maintain access has been reported, but appropriate accessories are required to increase the success rate. Herein, we describe a novel method, overtube-balloon–assisted endoscopy, for direct POC.ObjectiveTo evaluate the feasibility and usefulness of direct POC when using an ultra-slim upper endoscope with an overtube balloon to maintain access.SettingA single center.DesignCase series.PatientsTwelve patients with biliary disease.InterventionsDirect POC by using an ultra-slim upper endoscope and diagnostic and/or therapeutic procedures.Main Outcome MeasurementsSuccess rate of this technique, diagnostic or therapeutic feasibility, and complications.ResultsOvertube-balloon–assisted direct POC was performed successfully in 10 of 12 patients (83.3%). The procedure revealed 4 common bile duct (CBD) stones, 4 benign biliary strictures, 1 polypoid tumor, and 1 cholangiocarcinoma. Five patients underwent forceps biopsy under direct visualization of the intraductal lesion. Laser lithotripsy was successfully performed in 1 patient. No procedure-related complication occurred.LimitationsA small number of patients and no comparison with conventional cholangioscopy.ConclusionsThe overtube balloon appears to be a useful accessory in direct POC when using an ultra-slim upper endoscope. However, further development of a slim overtube or other accessories is necessary to improve the success rate of direct POC.