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expanded the horizons of interventional endoscopy [1]. Starting with rigid optical endoscopes that could access only either end of the digestive system, endoscopy evolved to enable visualization of the en− tire gastrointestinal tract with the devel− opment of capsule endoscopy and dou− ble−balloon enteroscopy [2]. However, the biliary−pancreatic system still re− mained a side track. The available bili− ary−pancreatic endoscopes are expensive, suboptimal, and not widely available [3, 4]. Optimal visualization of the bile duct lumen enabling direct interventions through an adequate working channel re− mains a dream. Working under the odds of third−world realities, we recently adapted the diagnostic double−balloon enteroscope to serve as a peroral choledo− choscope, without the need for an expen− sive mother±baby system. A 65−year−old man presented with a 6− week history of painless progressive jaundice and fever. There was evidence of severe extrahepatic distal biliary ob− struction on abdominal CT. Endoscopic retrograde cholangiopancreatography showed a large intraluminal filling defect in the dilated common bile duct and a suspected stricture at the hilar region (l" Fig. 1). Proximal biliary access failed despite a sphincterotomy and multiple attempts with different accessories. With negative biliary brush cytology and noninforma− tive magnetic resonance cholangiopan− creatography, a percutaneous biliary ac− cess seemed inevitable due to the lack of a choledochoscope. Encouraged by prior extensive experience with double−bal− loon enteroscopy, cholangioscopy was performed using the 8.5 mm diagnostic Fujinon double−balloon enteroscope after balloon dilation of the proximal biliary stricture (l" Video 1). Successful endoscopic biliary drainage was accomplished under direct vision, after biopsy of the large papillary projec− tions observed in the proximal common bile duct near the hilum (l" Fig. 2 a, b). Histopathology confirmed papillary cyst− adenocarcinoma that was subsequently operated on (l" Fig. 2 c). To conclude, thinking outside the box, we describe an alternative approach for chol− angioscopy with a 2.8 mm working chan− nel that would enable most endoscopic interventions in the dilated biliary tree. Development of a dedicated peroral cho− ledochoscope to extend therapeutic op− tions seems long overdue.

Peroral cholangioscopy: new approach with a balloon enteroscope