LAUSR

Cholangioscopy-assisted guidewire placement is reported to be a useful method for endoscopic biliary drainage that is made difficult by complex strictures and obstructions [1–5]. However, the guidewire sometimes becomes misdirected because of the lack of contrastfilled images. With the aim of improving safety and certainty, we present two practical cases that employ a novel technique using an over-the-wire microcatheter through digital intraductal cholangioscopy (IDC) (SpyGlass DS; Boston Scientific, Natick, Massachusetts, USA). Case 1 involved a 72-year-old woman with hilar cholangiocarcinoma who underwent endoscopic biliary drainage for segmental cholangitis. The cholangiogram showed complete obstruction of the left hepatic duct (▶Fig. 1). Although direct visualization with IDC allowed advancing the 0.025-inch guidewire over the obstructing tumor in the left hepatic duct, the guidewire lost the pathway to the left intrahepatic bile duct. The 3-Fr outer sheath of a basket catheter (MicroCatch; MTW Endoskopie, Düsseldorf, Germany), which can be inserted into the SpyGlass DS, was introduced as a microcatheter in order to inject contrast medium and assist guidewire manipulation. The contrast-filled image of the left intrahepatic bile duct allowed successful negotiation (▶Fig. 2), followed by replacement of the endoscopic nasobiliary drainage tube (▶Video 1). Case 2 involved a 79-year-old man with acute cholecystitis. The cholangiogram showed complete obstruction of the cystic duct (▶Fig. 3), which prevented guidewire advancement under fluoroscopic imaging. The orifice of the cystic duct was visualized using the SpyGlass DS, then the guidewire with a 3-Fr endoscopic nasobiliary drainage tube (Daimon-PTCD set, Hanaco Medical, Saitama, Japan), another microcatheter that may be used through the SpyGlass DS, was advanced into the ▶ Fig. 1 Case 1: Endoscopic retrograde cholangiography shows complete obstruction with no flow of contrast into the left intrahepatic bile duct in a patient with hilar cholangiocarcinoma.