Technical Tips and Tricks in ERCP: Fully Covered Metallic Stent-Assisted Direct Cholangioscopy

Experienced teaching points

Clinical Pearls

Direct cholangioscopy (DC) using ultraslim gastroscopes can be technically challenging and carries a failure rate up to 15%, primarily due to difficult scope positioning and the inability to cannulate a stenotic or fibrosed biliary sphincter.
Deploying a fully covered self-expanding metal stent (fcSEMS) into the bile duct effectively dilates the papilla and provides a stable, wide-caliber conduit that drastically simplifies subsequent biliary cannulation.
Once the fcSEMS is in place, an ultraslim gastroscope can be advanced transnasally through the stomach, directly into the stent lumen, enabling seamless stent-assisted direct cholangioscopy for complex stone extraction or targeted biopsies.

Klaus Mönkemüller, MD, PhD, FASGE (USA), FJGES (Japan), FESGE (Europe) Professor of Medicine, Department of Gastroenterology, Ameos Klinikum Halberstadt, Germany and Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

Direct cholangioscopy using ultra slims endoscopes (i. e. pediatric gastroscopes or transnasal gastroscopes) enables diagnostic and therapeutic interventions of the biliary tract. However, DC is not always feasible with failure rates up to 15%, mainly due to cannulaton failure. Entering the bile duct may be hampered by a stenotic bile duct and difficult scope position. Herein we present the novel concept of stent-assisted direct cholangioscopy.

A 76-year-old female patient was referred to our institution with obstructive jaundice due to complex biliary tract lithiasis, which could not be removed during the initial ERCP. At our hospital cholangiography revealed a very dilated, tortuous bile duct with filling defects in the common hepatic and right intrahepatic duct. At the referring hositlal the stone could not be retrieved, and thus dual biliary stent insertion (7fr 15cm and 10Fr 5cm) was done. At our hospital ERCP performed 12 weeks later revealed a narrowed and fibrosed papilla. After removing the plastic stents and performing biliary sphincterotomy (panel A) an extraction balloon was used to sweep significant amount of debris out of the severely dilated bile ducts. Given the previous concern for stones and the severely dilated biliary tree, a fully covered metal stent (10Fr 8cm) (Cook Medical, USA) was placed in the bile duct (B). A 4.9 mm ultraslim scope was passed nasally into the stomach and duodenum and then the bile duct was cannulated through the fc SEMS, thus achieving a direct stent-assisted cholangiosopy (C). The remaining stones were removed using DOC with basket. No stones were left behind intraductally (C).

This case shows how inserting a fully covered self-expanding metal stent allowed for direct biliary access using an ultraslim transnasal gastroscope, thus performing direct cholangioscopy.

None of the authors (ASK, KM) has any conflicts of interest with any of the products or devices mentioned in this article.

About the author

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Editor-in-Chief, The Practicing Endoscopist

Professor of Medicine, Carilion Memorial Hospital / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE, is the editor-in-chief of The Practicing Endoscopist and the founder of EndoCollab. He is Professor of Medicine at Virginia Tech Carilion School of Medicine and a practicing endoscopist at Carilion Memorial Hospital in Roanoke, Virginia.

Dr. Mönkemüller has published extensively on endoscopic techniques and devices, with a particular focus on therapeutic endoscopy, foreign body removal, GI bleeding, and the use of caps and accessories in everyday practice. He lectures internationally and has contributed to multiple GI endoscopy textbooks and atlases.

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