Post written by In Rae Cho, MD, and Sang Hyub Lee, MD, PhD, from the Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea.

Anastomotic biliary strictures (ABSs) are a major adverse event after living donor liver transplantation (LDLT) and often difficult to treat with standard ERCP alone. The SPYPASS-2 study evaluated whether digital single-operator cholangioscopy (SOC; SpyGlass DS II; Boston Scientific Corp, Natick, Mass, USA) could safely and effectively manage ABSs when conventional ERCP fails by directly visualizing and navigating the stricture site.

LDLT-related strictures tend to be tight, twisted, and resistant to standard guidewire passage. Failure of ERCP often leaves patients with no choice but invasive procedures such as percutaneous drainage or surgery, both associated with higher morbidity and prolonged recovery. SpyGlass technology offers real-time imaging and 4-way steering, making it ideal for these challenging cases. We needed solid clinical data to confirm its role as a salvage strategy after ERCP failure.

Among 40 patients, SOC-assisted guidewire passage and therapy achieved a 92.5% technical success rate and an 82.5% clinical success rate. Adverse events were mild (cholangitis 10%, pancreatitis 15%, and no perforations), and no serious adverse events occurred. Compared with historical ERCP-only cases, SOC significantly improved success, particularly in pouched-type strictures, where traditional fluoroscopic guidance struggles. SpyGlass procedures took only about 7 minutes on average, although total ERCP times were longer.

These findings suggest SOC could shift treatment paradigms, not just as rescue therapy but potentially as an earlier intervention in difficult ABS cases. Next steps should include multicenter trials comparing early SOC use versus conventional ERCP, as well as cost-effectiveness studies.

SPYPASS-2 highlights how direct visualization with SpyGlass can transform management of biliary strictures after LDLT. By offering a minimally invasive rescue option, we can reduce patient suffering, avoid percutaneous drainage, and improve transplant outcomes. Wider adoption of SOC—with trained endoscopists and proper patient selection — could set a new standard for post-transplant biliary care.

Fluoroscopic (A-C) and cholangioscopic (D-F) findings of successful cases of single-operator cholangioscopy–assisted guidewire placement. A and D, Pouched type; B and E, intermediate type; C and F, triangular type.

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