Concurrent endoscopic ultrasound-guided biliary drainage and ultra-slim (6.5-French) cholangioscopy for malignant biliary obstruction: A one-procedure technical innovation

Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) and peroral cholangioscopy are conventionally staged procedures due to fistula maturation requirements.[ 1​ ] [ 2​ ] [ ​3​ ] We report a novel “single-session” approach using a 6.5Fr ultra-slim cholangioscope immediately during EUS-BD. This protocol not only enhances the success rate of EUS-BD and reduces bile leakage but also saves time by eliminating the waiting interval. A 58-year-old man with unresectable pancreatic head cancer presented with obstructive jaundice. Endoscopic retrograde cholangiopancreatography failed due to duodenal infiltration by tumors. EUS-BD was performed via a transgastric approach to B3 ([ Fig. 1 ]), creating a hepaticogastrostomy with 6 mm balloon dilation. Immediately thereafter, a 6.5Fr digital single-operator cholangioscope (eyeMAX; Micro-Tech, Nanjing, China) with a 0.75-mm working channel and 220-cm length was advanced through the fresh fistula without fluoroscopic guidance. Direct visualization confirmed a malignant stricture at the distal bile duct. Under cholangioscopic guidance, the guidewire was successfully advanced across the stricture segment and antegrade into the duodenal lumen ([ Fig. 2 ]). Following the direct visual confirmation of no distal obstruction in the duodenal cavity, we subsequently performed EUS-guided antegrade stenting combined with EUS-guided hepaticogastrostomy to achieve combined biliary drainage ([ Fig. 3 ]). The total procedure time was 35 minutes. No bile leakage, bleeding, or perforation occurred. Bilirubin normalized within 9 days ([ Video 1 ]). Fig. 1 EUS-BD was performed via a transgastric approach to B3. Fig. 2 The “single-session” technical innovation achieves integrated diagnosis and therapy. ( a ) Direct visualization confirmed the malignant stricture at the distal bile duct. ( b ) Under cholangioscopic guidance, the guidewire was successfully advanced across the stricture segment. ( c ) Direct visualization confirmed no distal obstruction in the duodenal cavity. Fig. 3 Combined biliary drainage: ( a ) EUS-AS and ( b ) EUS-HGS. Video 1 Concurrent endoscopic ultrasound-guided biliary drainage and ultra-slim (6.5-French) cholangioscopy for malignant biliary obstruction: A one-procedure technical innovation. Download Video Single-session EUS-BD with 6.5Fr cholangioscopy is technically feasible and safe for malignant biliary obstruction. The ultra-slim profile enables immediate fistula traversal, accelerating diagnosis and therapy. Endoscopy_UCTN_Code_TTT_1AS_2AH Publication History Received: 08 April 2026 Accepted after revision: 18 May 2026 Article published online: 23 June 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany