Digital single-operator cholangioscopy for selective biliary cannulation after failed conventional guidewire passage across benign biliary stricture

Biliary strictures following liver transplantation, iatrogenic biliary injury, or primary sclerosing cholangitis remain challenging clinical conditions. Although endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment, selective guidewire passage may fail in complex strictures, particularly after living-donor liver transplantation (LDLT). Digital single-operator cholangioscopy (DSOC) enables direct visualization of the biliary tree and may facilitate selective guidewire passage after failed conventional guidewire passage across the biliary stricture. We evaluated the technical and clinical outcomes of DSOC-guided biliary cannulation after failed conventional guidewire passage across the biliary stricture, with a particular focus on LDLT recipients. This retrospective study included patients with benign biliary strictures who underwent DSOC-assisted selective guidewire cannulation after failed conventional guidewire passage across the biliary stricture between 2023 and 2025 in our tertiary referral center. We defined technical success as successful guidewire passage across the stricture followed by dilation and stent placement. Early clinical success was defined as symptomatic and biochemical improvement without reintervention within 1 month. Twenty-five patients were enrolled in the study. Technical success was achieved in 22 patients (88%), and early clinical success in 20 patients (80%). Adverse events occurred in 4 patients (16%), including cholangitis ( n = 2), pancreatitis ( n = 1), and bleeding ( n = 1). In the subgroup of LDLT recipients ( n = 15), the technical success rate reached 86.7%, with the right anterior sectoral duct serving as the most frequently cannulated branch (69.2%). Among patients with biliary injury, technical and early clinical success rates were 100% and 83.3%, respectively. DSOC-guided selective biliary cannulation provided successful endoscopic access in the majority of selected patients with complex benign biliary strictures after failed conventional guidewire passage across the biliary stricture, particularly in LDLT recipients and patients with biliary injury. Comparative studies are needed to determine whether this approach reduces the need for percutaneous or surgical interventions.