Cholangioscopy performed during endoscopic retrograde cholangiopancreatography (ERCP) can facilitate the management of complex biliary stones and improve the evaluation of biliary strictures. Treating biliary disease in patients with surgically-altered anatomy or an inaccessible ampulla, however, remains a particular challenge. Historically, antegrade cholangioscopy (AC) has been performed through the tract of a prior percutaneous transhepatic biliary drain (PTBD). More recently, options for AC have included cholangioscope insertion following EUS-guided hepatico-gastrostomy (HGS). The aim of this study was to review the approach and outcomes of AC in patients treated at a large specialist hepatopancreatobiliary (HPB) centre.

We performed a retrospective review of all patients who underwent AC at a large HPB centre between January 2020 and October 2025. Procedures were performed either via IR-PTBD or EUS-HGS using a Spyglass^TM cholangioscope (Boston Scientific Inc) (with Spyglass Discover^TM used for percutaneous cases since 2021). Patient demographics, surgical anatomy, procedural indications, techniques, and clinical outcomes were analysed.

A total of 25 patients underwent AC (median age was 64 years, 52% male), within an overall total of 3019 biliary endoscopic procedures/ERCPs (< 1%). All patients were discussed in a multi-disciplinary team meeting (MDM) prior to their procedure. Indications for cholangioscopy included management of stone disease (19 patients (76%)) and biliary stricture assessment (6 (24%)). An antegrade approach was required in 23 patients (92%) due to surgically-altered anatomy which precluded transpapillary access. Of these 13 (52%) had a Roux-en-Y hepaticojejunostomy, 5 (20%) had a Roux-en-Y gastric bypass, 2 (8%) had a Roux-en-Y Whipple’s procedure, 2 (8%) had a total gastrectomy with Roux-en-Y reconstruction and 1 (4%) had a Billroth II gastrectomy. In the 2 patients (8%) without surgically-altered anatomy, one patient had had extensive head and neck surgery which precluded oesophageal intubation, and in the other patient an uncovered metal stent through the right hepatic system prevented retrograde left-sided access via ERCP.  AC was performed via PTBD in 22 (88%) patients and EUS-HGS in 3 (12%) patients. All procedures were performed with anaesthetic support (Propofol or general anaesthesia). In those undergoing percutaneous AC, prior PTBD was inserted between 4-365 days (median 59 days) prior to AC. Extended duration of PTBD related to intervention prior to referral for consideration of AC. Patients with HGS had their fully covered metal stents changed to plastic double pigtail stents to retain access. 23 patients (92%) had antibiotics at the time of AC, and these were continued for at least 3 days afterwards. Clinical success, defined as stone clearance or diagnosis clarification, was achieved in all patients. In 2 patients with intrahepatic stones above a previous biliary anastomosis, a biodegradable balloon-expandable stent (Unity B^TM, Q3-Medical) was placed to facilitate biliary patency and stone fragment passage. One patient (4%) developed post-procedure bleeding following PTBD catheter removal requiring IR-guided embolisation and a 6-day ICU admission. There was no mortality at 30 days from the procedure. In 3 of 6 patients undergoing AC for stricture assessment, a diagnosis of malignancy was made on Spybite^TM biopsy-directed histology.

In this single-centre experience, AC was required in <1% of cases but provided a valuable tool where conventional papillary access was precluded. Biliary access, intraductal visualisation, and therapy were successful via both PTBD and EUS-HGS, and insertion of the 3.5mm (10F) cholangioscope to the required site within the biliary tree was achieved in all cases. Stone therapy with EHL for stone disease was effective, but it was observed that clearing stone fragments from the biliary tree was more challenging with an antegrade approach than with a conventional ERCP. AC appears to be safe, with the only observed complication related to prior PTBD insertion. Further advances in cholangioscope development (e.g. smaller-calibre cholangioscopes) and the expanding use of EUS-guided antegrade biliary access may broaden the role and clinical applications of AC.