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Biliary intervention using SpyGlass DS cholangioscopy through a cap-attached variable-stiffness colonoscope in a patient following Billroth II gastrectomy
Arab Journal of Gastroenterology xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Arab Journal of Gastroenterology journal homepage: www.elsevier.com/locate/ajg
Case report
Biliary intervention using SpyGlass DS cholangioscopy through a cap-attached variable-stiffness colonoscope in a patient following Billroth II gastrectomy Tesshin Ban, Hiroshi Kawakami , Yoshimasa Kubota a b
Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Japan Center for Digestive Disease, University of Miyazaki Hospital, Japan
a r t i c l e
i n f o
Article history: Received 4 July 2017 Accepted 27 July 2017 Available online xxxx Keywords: Cholangioscopy Altered anatomy Bile duct biopsy SpyGlass DS Colonoscope
a b s t r a c t The SpyGlass DS system is currently used as a direct video cholangioscope for biliary diagnostic and therapeutic procedures. In general, the SpyGlass DS cholangioscope is passed through the working channel of a duodenoscope and inserted into a bile duct via duodenal papilla. However, the procedure has been challenging in patients with altered gastrointestinal anatomy due to the retrograde route through a potentially tortuous afferent limb. A therapeutic colonoscope with variable stiffness can offer alternative guidance for SpyGlass DS cholangioscope in patients with surgically altered gastrointestinal anatomy. Ó 2017 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.
Introduction Tissue acquisition in a biliary tract under transpapillary direct visualization in patients with a surgically altered gastrointestinal anatomy has been challenging. Balloon-enteroscope-assisted, peroral direct cholangioscopy using an ultra-slim gastroscope has been previously described as a novel technique for patients with anatomical complications [1,2]. Herein, we present a successful case of biliary intervention using a direct video cholangioscope through a peroral colonoscope in a patient with Billroth II reconstruction.
Case report An 85-year-old man with a history of distal gastrectomy and Billroth II reconstruction for gastric cancer, 30 years prior, was admitted for detailed evaluation of asymptomatic elevation of hepatobiliary enzymes. Liver function test results were as follows: total and direct bilirubin levels of 0.6 mg/dL and 0.1 mg/dL, respectively; aspartate transaminase level of 67 U/L; alanine transaminase level of 52 U/L; and alkaline phosphatase level of 1220 U/L. Corresponding author at: 5200 Kihara, Kiyotake, Miyazaki, Miyazaki 889-9602, Japan. E-mail address: [email protected] (H. Kawakami).
Computed tomography and magnetic resonance cholangiography revealed perihilar bile duct stricture. A distal cap attached variable-stiffness colonoscope (CF-H260AI; Olympus Corp. Tokyo, Japan) was carefully advanced to the afferent limb with adjustment of colonoscope shaft flexibility. A distal cap is useful both for viewing the ampulla of Vater from the front and for fixing the ampulla. The technique of pancreatic guidewire-assisted biliary cannulation overcame the selective biliary cannulation and contrast medium was injected into the bile duct. Endoscopic retrograde cholangiogram (ERC) demonstrated a perihilar biliary stricture. Intraductal ultrasound revealed circumferential wall thickness (Fig. 1). Subsequently, a video cholangioscope (SpyGlass DS system, Boston Scientific Corp., MA, United States) was advanced into the stricture through the colonoscope after endoscopic papillary large balloon dilation. Direct peroral video cholangioscopy revealed irregular, reddish, highly vascular biliary mucosa (Fig. 1). Multiple biopsies using 3-Fr SpyBite forceps (Boston Scientific) were conducted (Fig. 2). All specimens exhibited mild atypia of the epithelial tissue with edematous fibrotic interstitium and inflammatory cell infiltration in the sub-epithelial tissue. When counting the number of IgG4-positive plasma cells, we found up to 2 cells in the high-power fields. The finding of obliterative phlebitis could not be supported (Fig. 3). These findings suggested inflammatory stenosis of the bile duct. The patient received follow-up examination after discharge from our institution, with no worsening of perihilar bile duct stricture.
https://doi.org/10.1016/j.ajg.2017.07.001 1687-1979/Ó 2017 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Ban T et al. Biliary intervention using SpyGlass DS cholangioscopy through a cap-attached variable-stiffness colonoscope in a patient following Billroth II gastrectomy. Arab J Gastroenterol (2017), https://doi.org/10.1016/j.ajg.2017.07.001
2
T. Ban et al. / Arab Journal of Gastroenterology xxx (2017) xxx–xxx
Fig. 1. Radiograph showing a 20 MHz intraductal ultrasound (IDUS) probe at the stricture of the perihilar bile duct. Top inset: IDUS image showing the circumferential wall thickness at the perihilar stricture. Bottom inset: Endoscopic image showing irregular, reddish, and highly vascular mucosa.
Fig. 3. Representative microscopic images of the same specimen in 200 X magnification (top: Hematoxylin-Eosin stain; bottom: IgG4 stain). Mild atypia of the epithelial tissue with an edematous fibrotic interstitium and inflammatory cell infiltration in the subepithelial tissue. A small number of IgG4-positive plasma cells were also detected.
Fig. 2. Radiograph and inset endoscopic image showing a representative session of forceps biopsy in the common bile duct using 3-Fr SpyBite forceps.
Discussion In the meta-analysis by Navaneethan et al., we found that the diagnostic yield of single-operator cholangioscopy and targeted biopsies in the diagnosis of indeterminate biliary strictures was acceptable. Pooled sensitivity and specificity for the diagnosis of malignant biliary strictures was 74.7% (95% confidence interval
[CI], 63.384.0%) and 93.3% (95% CI, 85.197.8%), respectively [6]. However, biliary targeted biopsy using the cholangioscope in patients with surgically altered anatomy is still challenging. Conceivable biliary access routes for direct cholangioscopy in such patient includes a percutaneous route, a transhepaticogastrostomy route [7], and a transpapillary route. Regarding the percutaneous route or the trans-hepaticogastrostomy route, it is invasive and time-consuming to create the transhepatic fistula. Furthermore, creating the fistula for direct cholangioscopy is time consuming and needle tract seeding is a problematic issue in a case with a biliary malignant tumour. The transhepaticogastrostomy route is not a well-established method so far [7]. We consider that the acceptable route for a patient with the anatomically issue is transpapillary route via afferent limb. A balloon enteroscope assisted peroral direct cholangioscopy using an ultra-slim gastroscope was described as a novel technique for this anatomical problem [1,2]. However, it is a complicated methodology that leaves an accessory over tube formation as guidance of an ultra-slim gastroscope as a cholangioscope. According to the previous reports, the use of SpyGlass through the large working channel of forward-viewing endoscopes facilitates ERC in a patient with an altered gastrointestinal anatomy [8 10] (Table 1). It is also reported that use of a variable-stiffness colonoscope significantly improves the cecal intubation rate [3] and that cap-assisted colonoscopy reduces the time required for cecal intubation [4,5]. In this case, the cap-assisted variable-
Please cite this article in press as: Ban T et al. Biliary intervention using SpyGlass DS cholangioscopy through a cap-attached variable-stiffness colonoscope in a patient following Billroth II gastrectomy. Arab J Gastroenterol (2017), https://doi.org/10.1016/j.ajg.2017.07.001
3
T. Ban et al. / Arab Journal of Gastroenterology xxx (2017) xxx–xxx Table 1 Previous reports including combination of SpyGlass, SpyGlass DS and colonoscope for surgically altered gastrointestinal anatomy. Author
Surgical procedure
Recontruction
Entry of CBD
Mother colonoscope
Distal attachment
Baby cholangioscope
Biliary intervention
Working channel of mother colonoscope
Mou [8] Baron [9]
PD HJ
Roux-en-Y Roux-en-Y
Anastomotic site Anastomotic site
CF-H 180AL/I* CF-Q160AL*
N.D. N.D.
SpyGlass** SpyGlass**
3.7 mm 3.7 mm
Kawakubo [10] Present report
Gastrectomy Gastrectomy
Billroth II Billroth II
Papilla Papilla (naÿve)
N.D. CF-H260AI*
N.D. (+)
SpyGlass** SpyGlass DS**
Biliary biopsy EHL for Choledocholithiasis Biliary biopsy Biliary biopsy
N.D. 3.7 mm
CBD, common bile duct; HJ, hepaticojejunostomy; EHL, electronic hydraulic lithotripsy; PD, pancreaticoduodenectomy. N.D., not described. * Olympus, Tokyo, Japan. ** Boston Scientific Corp., MA, United States.
stiffness colonoscope facilitated intubation into the afferent limb as well as biliary intervention for surgically altered gastrointestinal anatomy. Notably, several colonoscopes with a large working channel have sufficient length and adjustable stiffness to reach the duodenal papilla through the afferent limb of the Billroth II during gastrectomy. However, there are some drawbacks to performing this procedure with a variable-stiffness colonoscope. Successful delivery of the colonoscope to the duodenal papilla depends on the length of the afferent limb. ERC is difficult enough, but the large diameter of the tip of the colonoscope is an obstacle to selective bile duct cannulation, especially in the naÿve duodenal papilla. In conclusion, cap-attached variable-stiffness colonoscopes involving large working channels and SpyGlass DS system, in combination, facilitate successful biliary intervention in patients with surgically altered anatomy.
Conflicts of interest The authors declare that they have no conflicts of interest regarding this article.
Acknowledgement The authors would like to thank Dr. Hayashi K, affiliated with the Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences.
References [1] Itoi T, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T, Ishii K, et al. Diagnostic and therapeutic peroral direct cholangioscopy in patients with altered GI anatomy (with videos). Gastrointest Endosc 2012;75(2):441–9. [2] Matsushita M, Shimatani M, Takaoka M, Okazaki K. Effective peroral direct cholangioscopy with an ultraslim gastroscope in combination with a short double-balloon enteroscope for altered GI anatomy. Gastrointest Endosc 2012;76(5):1075. [3] Xie Q, Chen B, Liu L, Gan H. Does the variable-stiffness colonoscope makes colonoscopy easier? A meta-analysis of the efficacy of the variable stiffness colonoscope compared with the standard adult colonoscope. BMC Gastroenterol 2012;12:151. [4] Park SY, Kim HS, Yoon KW, Cho SB, Lee WS, Park CH, et al. Usefulness of capassisted colonoscopy during colonoscopic EMR: a randomized, controlled trial. Gastrointest Endosc 2011;74(4):869–75. [5] Harada Y, Hirasawa D, Fujita N, Noda Y, Kobayashi G, Ishida K, et al. Impact of a transparent hood on the performance of total colonoscopy: a randomized controlled trial. Gastrointest Endosc 2009;69(3 Pt 2):637–44. [6] Navaneethan U, Hasan MK, Lourdusamy V, Njei B, Varadarajulu S, Hawes RH. Single-operator cholangioscopy and targeted biopsies in the diagnosis of indeterminate biliary strictures: a systematic review. Gastrointest Endosc 2015;82(4):608–14. e2. [7] Kawakami H, Kubota Y, Kawahata S, Kubo K, Okabayashi S, Tatsumi R, et al. Peroral transhepatic cholangioscopy-guided electrohydraulic lithotripsy via an endoscopic ultrasonography-guided hepaticogastrostomy route for bile duct stones in a patient with Roux-en-Y anatomy. Endoscopy 2016;48(Suppl. 1). E146-147. [8] Mou S, Waxman I, Chennat J. Peroral cholangioscopy in Roux-en-Y hepaticojejunostomy anatomy by using the SpyGlass Direct Visualization System (with video). Gastrointest Endosc 2010;72(2):458–60. [9] Baron TH, Saleem A. Intraductal electrohydraulic lithotripsy by using SpyGlass cholangioscopy through a colonoscope in a patient with Roux-en-Y hepaticojejunostomy. Gastrointest Endosc 2010;71(3):650–1. [10] Kawakubo K, Isayama H, Tsujino T, Nakai Y, Sasahira N, Kogure H, et al. Peroral cholangioscopy in a patient with a Billroth II gastrectomy using the SpyGlass Direct Visualization System. Endoscopy 2011;43(Suppl. 2). UCTN:E241-242.
Please cite this article in press as: Ban T et al. Biliary intervention using SpyGlass DS cholangioscopy through a cap-attached variable-stiffness colonoscope in a patient following Billroth II gastrectomy. Arab J Gastroenterol (2017), https://doi.org/10.1016/j.ajg.2017.07.001
Contents lists available at ScienceDirect
Arab Journal of Gastroenterology journal homepage: www.elsevier.com/locate/ajg
Case report
Biliary intervention using SpyGlass DS cholangioscopy through a cap-attached variable-stiffness colonoscope in a patient following Billroth II gastrectomy Tesshin Ban, Hiroshi Kawakami , Yoshimasa Kubota a b
Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Japan Center for Digestive Disease, University of Miyazaki Hospital, Japan
a r t i c l e
i n f o
Article history: Received 4 July 2017 Accepted 27 July 2017 Available online xxxx Keywords: Cholangioscopy Altered anatomy Bile duct biopsy SpyGlass DS Colonoscope
a b s t r a c t The SpyGlass DS system is currently used as a direct video cholangioscope for biliary diagnostic and therapeutic procedures. In general, the SpyGlass DS cholangioscope is passed through the working channel of a duodenoscope and inserted into a bile duct via duodenal papilla. However, the procedure has been challenging in patients with altered gastrointestinal anatomy due to the retrograde route through a potentially tortuous afferent limb. A therapeutic colonoscope with variable stiffness can offer alternative guidance for SpyGlass DS cholangioscope in patients with surgically altered gastrointestinal anatomy. Ó 2017 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.
Introduction Tissue acquisition in a biliary tract under transpapillary direct visualization in patients with a surgically altered gastrointestinal anatomy has been challenging. Balloon-enteroscope-assisted, peroral direct cholangioscopy using an ultra-slim gastroscope has been previously described as a novel technique for patients with anatomical complications [1,2]. Herein, we present a successful case of biliary intervention using a direct video cholangioscope through a peroral colonoscope in a patient with Billroth II reconstruction.
Case report An 85-year-old man with a history of distal gastrectomy and Billroth II reconstruction for gastric cancer, 30 years prior, was admitted for detailed evaluation of asymptomatic elevation of hepatobiliary enzymes. Liver function test results were as follows: total and direct bilirubin levels of 0.6 mg/dL and 0.1 mg/dL, respectively; aspartate transaminase level of 67 U/L; alanine transaminase level of 52 U/L; and alkaline phosphatase level of 1220 U/L. Corresponding author at: 5200 Kihara, Kiyotake, Miyazaki, Miyazaki 889-9602, Japan. E-mail address: [email protected] (H. Kawakami).
Computed tomography and magnetic resonance cholangiography revealed perihilar bile duct stricture. A distal cap attached variable-stiffness colonoscope (CF-H260AI; Olympus Corp. Tokyo, Japan) was carefully advanced to the afferent limb with adjustment of colonoscope shaft flexibility. A distal cap is useful both for viewing the ampulla of Vater from the front and for fixing the ampulla. The technique of pancreatic guidewire-assisted biliary cannulation overcame the selective biliary cannulation and contrast medium was injected into the bile duct. Endoscopic retrograde cholangiogram (ERC) demonstrated a perihilar biliary stricture. Intraductal ultrasound revealed circumferential wall thickness (Fig. 1). Subsequently, a video cholangioscope (SpyGlass DS system, Boston Scientific Corp., MA, United States) was advanced into the stricture through the colonoscope after endoscopic papillary large balloon dilation. Direct peroral video cholangioscopy revealed irregular, reddish, highly vascular biliary mucosa (Fig. 1). Multiple biopsies using 3-Fr SpyBite forceps (Boston Scientific) were conducted (Fig. 2). All specimens exhibited mild atypia of the epithelial tissue with edematous fibrotic interstitium and inflammatory cell infiltration in the sub-epithelial tissue. When counting the number of IgG4-positive plasma cells, we found up to 2 cells in the high-power fields. The finding of obliterative phlebitis could not be supported (Fig. 3). These findings suggested inflammatory stenosis of the bile duct. The patient received follow-up examination after discharge from our institution, with no worsening of perihilar bile duct stricture.
https://doi.org/10.1016/j.ajg.2017.07.001 1687-1979/Ó 2017 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Ban T et al. Biliary intervention using SpyGlass DS cholangioscopy through a cap-attached variable-stiffness colonoscope in a patient following Billroth II gastrectomy. Arab J Gastroenterol (2017), https://doi.org/10.1016/j.ajg.2017.07.001
2
T. Ban et al. / Arab Journal of Gastroenterology xxx (2017) xxx–xxx
Fig. 1. Radiograph showing a 20 MHz intraductal ultrasound (IDUS) probe at the stricture of the perihilar bile duct. Top inset: IDUS image showing the circumferential wall thickness at the perihilar stricture. Bottom inset: Endoscopic image showing irregular, reddish, and highly vascular mucosa.
Fig. 3. Representative microscopic images of the same specimen in 200 X magnification (top: Hematoxylin-Eosin stain; bottom: IgG4 stain). Mild atypia of the epithelial tissue with an edematous fibrotic interstitium and inflammatory cell infiltration in the subepithelial tissue. A small number of IgG4-positive plasma cells were also detected.
Fig. 2. Radiograph and inset endoscopic image showing a representative session of forceps biopsy in the common bile duct using 3-Fr SpyBite forceps.
Discussion In the meta-analysis by Navaneethan et al., we found that the diagnostic yield of single-operator cholangioscopy and targeted biopsies in the diagnosis of indeterminate biliary strictures was acceptable. Pooled sensitivity and specificity for the diagnosis of malignant biliary strictures was 74.7% (95% confidence interval
[CI], 63.384.0%) and 93.3% (95% CI, 85.197.8%), respectively [6]. However, biliary targeted biopsy using the cholangioscope in patients with surgically altered anatomy is still challenging. Conceivable biliary access routes for direct cholangioscopy in such patient includes a percutaneous route, a transhepaticogastrostomy route [7], and a transpapillary route. Regarding the percutaneous route or the trans-hepaticogastrostomy route, it is invasive and time-consuming to create the transhepatic fistula. Furthermore, creating the fistula for direct cholangioscopy is time consuming and needle tract seeding is a problematic issue in a case with a biliary malignant tumour. The transhepaticogastrostomy route is not a well-established method so far [7]. We consider that the acceptable route for a patient with the anatomically issue is transpapillary route via afferent limb. A balloon enteroscope assisted peroral direct cholangioscopy using an ultra-slim gastroscope was described as a novel technique for this anatomical problem [1,2]. However, it is a complicated methodology that leaves an accessory over tube formation as guidance of an ultra-slim gastroscope as a cholangioscope. According to the previous reports, the use of SpyGlass through the large working channel of forward-viewing endoscopes facilitates ERC in a patient with an altered gastrointestinal anatomy [8 10] (Table 1). It is also reported that use of a variable-stiffness colonoscope significantly improves the cecal intubation rate [3] and that cap-assisted colonoscopy reduces the time required for cecal intubation [4,5]. In this case, the cap-assisted variable-
Please cite this article in press as: Ban T et al. Biliary intervention using SpyGlass DS cholangioscopy through a cap-attached variable-stiffness colonoscope in a patient following Billroth II gastrectomy. Arab J Gastroenterol (2017), https://doi.org/10.1016/j.ajg.2017.07.001
3
T. Ban et al. / Arab Journal of Gastroenterology xxx (2017) xxx–xxx Table 1 Previous reports including combination of SpyGlass, SpyGlass DS and colonoscope for surgically altered gastrointestinal anatomy. Author
Surgical procedure
Recontruction
Entry of CBD
Mother colonoscope
Distal attachment
Baby cholangioscope
Biliary intervention
Working channel of mother colonoscope
Mou [8] Baron [9]
PD HJ
Roux-en-Y Roux-en-Y
Anastomotic site Anastomotic site
CF-H 180AL/I* CF-Q160AL*
N.D. N.D.
SpyGlass** SpyGlass**
3.7 mm 3.7 mm
Kawakubo [10] Present report
Gastrectomy Gastrectomy
Billroth II Billroth II
Papilla Papilla (naÿve)
N.D. CF-H260AI*
N.D. (+)
SpyGlass** SpyGlass DS**
Biliary biopsy EHL for Choledocholithiasis Biliary biopsy Biliary biopsy
N.D. 3.7 mm
CBD, common bile duct; HJ, hepaticojejunostomy; EHL, electronic hydraulic lithotripsy; PD, pancreaticoduodenectomy. N.D., not described. * Olympus, Tokyo, Japan. ** Boston Scientific Corp., MA, United States.
stiffness colonoscope facilitated intubation into the afferent limb as well as biliary intervention for surgically altered gastrointestinal anatomy. Notably, several colonoscopes with a large working channel have sufficient length and adjustable stiffness to reach the duodenal papilla through the afferent limb of the Billroth II during gastrectomy. However, there are some drawbacks to performing this procedure with a variable-stiffness colonoscope. Successful delivery of the colonoscope to the duodenal papilla depends on the length of the afferent limb. ERC is difficult enough, but the large diameter of the tip of the colonoscope is an obstacle to selective bile duct cannulation, especially in the naÿve duodenal papilla. In conclusion, cap-attached variable-stiffness colonoscopes involving large working channels and SpyGlass DS system, in combination, facilitate successful biliary intervention in patients with surgically altered anatomy.
Conflicts of interest The authors declare that they have no conflicts of interest regarding this article.
Acknowledgement The authors would like to thank Dr. Hayashi K, affiliated with the Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences.
References [1] Itoi T, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T, Ishii K, et al. Diagnostic and therapeutic peroral direct cholangioscopy in patients with altered GI anatomy (with videos). Gastrointest Endosc 2012;75(2):441–9. [2] Matsushita M, Shimatani M, Takaoka M, Okazaki K. Effective peroral direct cholangioscopy with an ultraslim gastroscope in combination with a short double-balloon enteroscope for altered GI anatomy. Gastrointest Endosc 2012;76(5):1075. [3] Xie Q, Chen B, Liu L, Gan H. Does the variable-stiffness colonoscope makes colonoscopy easier? A meta-analysis of the efficacy of the variable stiffness colonoscope compared with the standard adult colonoscope. BMC Gastroenterol 2012;12:151. [4] Park SY, Kim HS, Yoon KW, Cho SB, Lee WS, Park CH, et al. Usefulness of capassisted colonoscopy during colonoscopic EMR: a randomized, controlled trial. Gastrointest Endosc 2011;74(4):869–75. [5] Harada Y, Hirasawa D, Fujita N, Noda Y, Kobayashi G, Ishida K, et al. Impact of a transparent hood on the performance of total colonoscopy: a randomized controlled trial. Gastrointest Endosc 2009;69(3 Pt 2):637–44. [6] Navaneethan U, Hasan MK, Lourdusamy V, Njei B, Varadarajulu S, Hawes RH. Single-operator cholangioscopy and targeted biopsies in the diagnosis of indeterminate biliary strictures: a systematic review. Gastrointest Endosc 2015;82(4):608–14. e2. [7] Kawakami H, Kubota Y, Kawahata S, Kubo K, Okabayashi S, Tatsumi R, et al. Peroral transhepatic cholangioscopy-guided electrohydraulic lithotripsy via an endoscopic ultrasonography-guided hepaticogastrostomy route for bile duct stones in a patient with Roux-en-Y anatomy. Endoscopy 2016;48(Suppl. 1). E146-147. [8] Mou S, Waxman I, Chennat J. Peroral cholangioscopy in Roux-en-Y hepaticojejunostomy anatomy by using the SpyGlass Direct Visualization System (with video). Gastrointest Endosc 2010;72(2):458–60. [9] Baron TH, Saleem A. Intraductal electrohydraulic lithotripsy by using SpyGlass cholangioscopy through a colonoscope in a patient with Roux-en-Y hepaticojejunostomy. Gastrointest Endosc 2010;71(3):650–1. [10] Kawakubo K, Isayama H, Tsujino T, Nakai Y, Sasahira N, Kogure H, et al. Peroral cholangioscopy in a patient with a Billroth II gastrectomy using the SpyGlass Direct Visualization System. Endoscopy 2011;43(Suppl. 2). UCTN:E241-242.
Please cite this article in press as: Ban T et al. Biliary intervention using SpyGlass DS cholangioscopy through a cap-attached variable-stiffness colonoscope in a patient following Billroth II gastrectomy. Arab J Gastroenterol (2017), https://doi.org/10.1016/j.ajg.2017.07.001