Standard ERCP with biliary stenting requires fluoroscopy, exposing patients and staff to radiation. We describe a novel technique using SpyGlass-cholangioscopy and transabdominal ultrasound (TUS) guidance to eliminate radiation exposure entirely. Aim is to evaluate feasibility, safety and efficacy of fluoroscopy-free endoscopic biliary stenting using SpyGlass and TUS guidance.

Twelve patients (8F/4M; mean age 72) with malignant distal biliary obstruction from pancreatic head cancer underwent standard duodenoscopy with selective bile duct cannulation. The length and localization of tumor stenosis were accessed by SpyGlass cholangioscopy. It’s allow to choose right stent design, take biopsy. Guidewire advanced to upper part of biliary tree by direct visualization Stent deployment (8 plastic, 4 SEMS) were monitored in real-time using TUS instead of fluoroscopy. Adequate placement was confirmed by bile flow and resolution of biliary dilation on ultrasound. In case with SEMS placement, position control may be access with SpyGlass.

Technical success was achieved in all 12 cases (100%). Clinical success with jaundice resolution was 100%. Mean procedure time was shorter than conventional fluoroscopic ERCP. No complications occurred. The key advantage was zero radiation exposure for patients and staff.

SpyGlass-cholangioscopy/TUS-guided endoscopic biliary stenting is feasible and safe, completely eliminating radiation exposure while maintaining high success rates. The technique is applicable for both: plastic and metal stents, offering a promising radiation-free alternative for palliative biliary drainage.