LETTERS, TECHNIQUES AND IMAGES Unusual location of polypectomy with an ultra-slim gastroscope: Biliary polyp (with video) A 71-year-old female patient presented with severe right upper quadrant pain, jaundice and fever. She had a history of previous hepaticoduodenostomy procedure 15 years ago due to a large biliary stone. Clinical and laboratory evaluation revealed obstructive jaun- dice and acute cholangitis. Magnetic resonance cholangiopancre- atography (MRCP) showed multiple stones in the common hepatic duct and dilated intrahepatic bile ducts. Right and left hepatic ducts did not join in the hilar region which necessitates emergency percu- taneous drainage. Cholangiography revealed a large filling defect in the common hepatic duct (Fig. 1). After the patient was stabilized, ERCP was carried out via hepaticoduodenostomy orifice and stones were extracted after dilatation of the orifice (Video S1). Peroral direct cholangioscopy (PDC) was then carried out with an ultra-slim gastroscope (EG-530N; Fujinon, Saitama, Japan) under fluoroscopy, and the common hepatic duct, left and right hepatic ducts were visualized. A residual stone and diminutive polyp were seen in seg- mental intrahepatic bile ducts (Fig. 2A,B). Saline lavage through the ultra-slim gastroscope flushed residual stone from the bile duct into the duodenum. Biliary polyp was taken by biopsy forceps (Fig. 2C). Pathological examination showed an inflammatory polyp. Initiative attempts for cholangiosopy were made during the late 1970s, but technical difficulties put the procedure outside routine endoscopic practice. 1,2 Recent advances made this challenging pro- cedure more convenient. PDC with an ultra-slim gastroscope offers a single-operator platform, digital image quality, and simultaneous irrigation and therapeutic capabilities. 3,4 However, technical success cannot be guaranteed, especially in patients with altered gastrointes- tinal anatomy. A recent study included 24 cases with altered gas- trointestinal anatomy which suggested that PDC is an effective tool for diagnostic and therapeutic interventions in these patients. 5 In the present case, we used the therapeutic capabilities of an ultra-slim gastroscope in a patient with hepaticoduodenostomy.To the best of our knowledge this is the first report of a polypectomy with an ultra-slim gastroscope in the biliary tree. Cetin Karaca, Bulent Baran and Ozlem M. Soyer Department of Gastroenterohepatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey REFERENCES 1. Urakami Y, Seifert E, Butke H. Peroral direct cholangioscopy (PDCS) using routine straight-view endoscope: First report. Endos- copy 1977; 9: 27–30. 2. Rösch W, Koch H. Peroral cholangioscopy in choledocho- duodenostomy patients using the pediatric fiberscope. Endoscopy 1978; 10: 195–8. 3. Larghi A, Waxman I. Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: A feasibility study. Gastrointest. Endosc. 2006; 63: 853–7. 4. Itoi T, Moon JH, Waxman I. Current status of direct peroral cholan- gioscopy. Dig. Endosc. 2011; 23 (Suppl 1): 154–7. 5. Itoi T, Sofuni A, Itokawa F et al. Diagnostic and therapeutic peroral direct cholangioscopy in patients with altered GI anatomy (with videos). Gastrointest. Endosc. 2012; 75: 441–9. SUPPORTING INFORMATION Additional Supporting Information may be found in the online version of this article: Video S1. After wire-guided balloon dilatation of the hepati- coduodenostomy orifice, stones were extracted. Peroral direct cho- langioscopy revealed a residual stone and a biliary polyp. Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article. Fig. 1. Dilated intrahepatic bile ducts and a large filling defect in the common hepatic duct are seen on cholangiography. A B C Fig. 2. During cholangioscopy (A) a small residual stone (arrow) and (B) a diminutive polyp (arrow) were seen in the segmental intrahepatic bile ducts. (C) Polyp was removed by biopsy forceps. Site of the polyp after removal (arrow). Digestive Endoscopy (2012) 24, 477 doi:10.1111/j.1443-1661.2012.01323.x © 2012 The Authors Digestive Endoscopy © 2012 Japan Gastroenterological Endoscopy Society