Endoscopic retrograde cholangiopancreatography (ERCP) is a well‐established modality for the diagnosis and management of a spectrum of benign and malignant pancreaticobiliary disorders. Common indications include common bile duct (CBD) stones and biliary obstruction from either benign or malignant d

538 1Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore Correspondence: Prof Ang Tiing Leong, Chief and Senior Consultant, Department of Gastroenterology and Hepatology, Changi General Hospital, 2 Simei Street 3, Singapore 529889. Ang.tiing.leong@singhealth.com.sg INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is a well‐established modality for the diagnosis and management of a spectrum of benign and malignant pancreaticobiliary disorders. Common indications include common bile duct (CBD) stones and biliary obstruction from either benign or malignant disorders.(1) In specific situations, ancillary cholangiopancreatoscopy during ERCP is required in order to directly visualise the target lesion for biopsy or definitive therapy.(2) Cholangiopancreatoscopy during ERCP can be performed using a mother‐baby scope system, an ultrathin gastroscope and the SpyGlassTM cholangioscopy system (Boston Scientific Corp, Marlboro, MA, USA). Single‐operator cholangioscopy via the SpyGlass system is the simplest technique, because it uses a disposable 10‐French cholangioscope inserted through the working channel of a standard duodenoscope that can be easily handled by a single endoscopist. In contrast, the mother‐baby scope system requires two endoscopists to operate, while using an ultrathin gastroscope to perform ERCP is technically more difficult: as the diameter of the ultrathin gastroscope is larger, ranging from 4.9 mm to 5.8 mm, it cannot be used in non‐dilated ducts.(2) Since the first report of the clinical feasibility of SpyGlass cholangioscopy in 2007, data concerning its clinical utility has been published from multiple referral centres.(3) In the landmark initial multicentre registry study from the United States (US) and Europe with 297 patients, the overall procedure success rate was 89%. Adequate tissue was obtained for histological examination in 88% of 140 patients who underwent biopsy for stricture evaluation. Overall sensitivity was 78% for diagnosis of malignancy by visualisation but only 49% for biopsy. Procedure success, defined by protocol as visualisation and initiation of stone fragmentation and removal, was 92%, although the rate of complete stone clearance during the study’s SpyGlass session was lower, at 71%.(4) In the context of biliary stricture evaluation, Ramchandani et al (5) showed that the accuracy of SpyGlass visualisation was 89%, and in contrast to the study by Chen et al,(4) targeted biopsies achieved a higher accuracy rate of 82%. Comparing SpyGlass targeted biopsies with brush and blind biopsies, Draganov et al showed a significantly higher accuracy rate (84.6% vs. 38.5% vs. 53.8%).(6) Further publications confirmed the clinical utility of SpyGlass cholangioscopy in the management of a spectrum of pancreaticobiliary disorders.(7‐20) Most studies have evaluated the first generation SpyGlass system, whose optical view has a somewhat limited resolution due to the analogue design of the optical probe. The new digital SpyGlass system became commercially available in 2015 and has significantly clearer optical images than the legacy (fibreoptic) SpyGlass system. Although the digital system is even easier to use due to the improved optical view and may actually achieve higher diagnostic rates in stricture evaluation, published outcome data from this system is more limited.(21) The ease of use of SpyGlass cholangioscopy has resulted in its widespread utilisation in routine clinical practice. INTRODUCTION This study examined the efficacy and safety of cholangiopancreatoscopy via the SpyGlassTM system in routine clinical practice. METHODS The clinical data of endoscopic retrograde cholangiopancreatography (ERCP) performed in a regional hospital from January 2013 to November 2016 was retrieved from an electronic database and reviewed. All patients who had undergone SpyGlass cholangiopancreatoscopy were enrolled. Patient demographics, procedure indication, technical success rates, clinical success rates and complication rates were analysed. A subanalysis of clinical outcomes was performed comparing the SpyGlass legacy (fibreoptic) and digital systems. RESULTS Out of 2,050 ERCP procedures performed, 47 patients underwent 50 cholangiopancreatoscopy procedures. Clinical indications were difficult common bile duct (CBD) stones (59.6%, n = 28), indeterminate CBD stricture (36.2%, n = 17), indeterminate pancreatic duct stricture (2.1%, n = 1) and proximally migrated CBD stent (2.1%, n = 1). Complete stone extraction was achieved in 26 (92.9%) out of 28 patients. Among patients with strictures, a correct diagnosis of malignancy based on image visualisation was achieved in all 11 cases. The sensitivity and specificity for SpyBiteTM biopsies were 81.8% (95% confidence interval [CI] 48.2%–97.7%) and 100.0% (95% CI 15.8%–100.0%), respectively. The proximally migrated CBD stent was successfully extracted. Complications included pancreatitis (2.1%, n = 1), suspected sealed perforation after laser lithotripsy treated conservatively (2.1%, n = 1) and cholangitis (10.6%, n = 5). There was no difference in clinical outcomes between the SpyGlass legacy (n = 20) and digital (n = 30) systems. CONCLUSION SpyGlass cholangiopancreatoscopy is a safe and effective tool in routine clinical practice.