The interventional direct peroral cholangioscopy toolbox for endoscopic snare resection of a high-grade biliary intraductal neoplasia

Post written by Jerry Yung-Lun Chin, MBBS, FRACP, from the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA, and the Department of Gastroenterology and Hepatology, Waikato Hospital, Te Whatu Ora, Hamilton, New Zealand.


Direct peroral cholangioscopy (DPOC) is a valuable diagnostic and therapeutic tool for various biliary disorders. It also is economically favorable compared with its single-use counterpart.

However, it is seldom performed because of its associated technical challenges. This video article describes the techniques for performing DPOC and biliary polypectomy while highlighting the tools and accessories available for use.

In this case, we were able to achieve deep biliary cannulation and successfully perform endoscopic resection of large biliary intraductal neoplasia. Several technical factors should be considered to achieve the desired outcome. Prior ERCP with sphincterotomy and often balloon sphincteroplasty are prerequisites to permit passage of the ultra-slim pediatric endoscope into the biliary tree.

The “hook and pull” free-hand technique described in our video with careful maneuvers, including patient positioning and applying abdominal pressure, often allows for adequate biliary intubation.

The commercially available pediatric occlusion balloon catheter also can be used over a guidewire to provide an anchoring effect to gain deeper access. A custom-made clear distal cap offered further stability during biliary intubation.

It is important to note that excessive CO2 insufflation should be minimized because of risk of barotrauma. Air insufflation in the biliary tree is actively discouraged because of concerns about embolization.

In our article, we also highlight numerous dedicated endoscopic tools that can be passed through the 2-mm accessory channel of the ultra-slim pediatric endoscope to perform a wide range of diagnostics and interventions such as direct mucosal biopsies, snare resection, argon plasma coagulation, foreign body retrieval, and lithotripsy.

In conclusion, DPOC is an important part of advanced endoscopists’ armamentarium and highly effective when applied to the appropriate clinical setting.

Chin_figureCommercially available equipment to perform interventional direct peroral cholangioscopy through pediatric gastroscope.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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