Post written by Yuki Tanisaka, MD, PhD, from the Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan.

A 79-year-old man was referred to our hospital because of jaundice. He had previously undergone Billroth-II gastrectomy for gastric cancer. ERCP was performed. At first, we used a SIF-H290S (Olympus Medical Systems, Tokyo, Japan) with a working length of 152 cm and channel diameter of 3.2 mm. However, the biopsy sample was insufficient to enable a conclusive diagnosis. ERCP was performed again 2 weeks later. With the aim of improving diagnostic ability, a CF-H260AI colonoscope (Olympus Medical Systems Corporation, Tokyo, Japan) with a working length of 133 cm and channel diameter of 3.7 mm was used to perform peroral cholangioscopy (POCS) guided by SpyGlass DS (Boston Scientific Corp, Marlborough, Mass, USA), fluorescein-dripping probe-based confocal laser endomicroscopy (pCLE) (CholangioFlex, Cellvizio; Mauna Kea Technologies, Inc, Paris, France), and POCS-guided biopsy. As a result, pCLE findings were possible with this method, and we were able to obtain a sufficiently large biopsy sample by POCS-guided biopsy, confirming pancreatic cancer.

In patients with Billroth-II gastrectomy, it is common to use a forward-viewing endoscope like the single-balloon enteroscope we used initially in this case. The absence of an elevator makes adjusting angles on devices difficult, and in the present case, this restriction resulted in an insufficient biopsy sample size. However, POCS-enabled angle adjustment of the cholangioscope itself inside the bile duct was highly effective for pCLE and biopsy. In fact, exact pCLE findings were possible with this method, and we were able to obtain a sufficiently large biopsy sample by POCS-guided biopsy. You can perform POCS-guided pCLE to diagnose cancer even if the patient has surgically altered anatomy.

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