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Endoscopy is the first-line therapy for most post-liver transplantation anastomotic biliary strictures. Passage of a guidewire through the stricture is done under fluoroscopic guidance. Although anastomotic biliary strictures are usually short, they can be tight, fibrotic, and angulated, sometimes not allowing guidewire passage. Additional interventions (percutaneous transhepatic cholangiography [PTC], or endoscopic ultrasoundguided biliary drainage [EUS-BD]) can be necessary to avoid re-operation. The successful use of direct cholangioscopy to assist guidewire placement has been reported for strictures following liver transplantation from deceased and living donors [1, 2], and for post-surgical [3] and malignant [4] strictures. However, no cost analysis has been conducted. We present a video involving five postliver transplantation patients with anastomotic biliary stricture which could not be traversed by the guidewire, despite the use of different guidewires (▶Fig. 1), occlusion balloons, and rotatable sphincterotome. Eventually, direct cholangioscopy (SpyGlass DS direct visualization system; Boston Scientific) was used. The stricture (▶Fig. 2) and orifices (▶Fig. 3, ▶Fig. 4 a) were clearly identified using the SpyScope. The guidewire was placed under direct visual guidance (▶Fig. 4b, ▶Video1), allowing endoscopic retrograde therapy. There were no complications. PTC and EUS-BD were avoided in all cases. Based on procedure and device costs at our institution, the cholangioscopy increased the median individual expense by US$ 3545. The costs of uneventful EUS-BD and PTC are estimated at US$ 4065 and US$ 9090, respectively. Considering that 100 liver transplants are performed yearly at our hospital, the incidence of anastomotic biliary stricture is 12% [5], and failure to traverse the stenosis occurs in 9% of patients with anastomotic biliary stricture, use of cholangioscopy would save from U$ 6240 up to US$ 66540 per year. These savings E-Videos

Cholangioscopy-assisted guidewire placement in post-liver transplant anastomotic biliary stricture: efficient and potentially also cost-effective