Advances in Diagnosis and Treatment With Cholangiopancreatoscopy

Endoscopic retrograde cholangiopancreatography (ERCP) remains the standard for diagnosing and treating pancreatobiliary diseases. Although non-invasive imaging modalities have significantly improved, ERCP continues to play an indispensable role in clinical practice. However, ERCP has inherent limitations. Diagnostic challenges persist in cases of indeterminate biliary strictures, and stone extraction can be difficult when stones are large, impacted, or located within anatomically complex regions. To address these limitations, direct visualization of the bile and pancreatic ducts using peroral cholangioscopy (POCS) and peroral pancreatoscopy (POPS) has gained increasing attention. These techniques enable targeted biopsies under direct vision, thereby enhancing diagnostic accuracy for indeterminate strictures. In addition, advanced intraductal lithotripsy modalities, such as electrohydraulic lithotripsy and laser lithotripsy, can be delivered through cholangioscopes, allowing effective fragmentation of stones that are refractory to conventional ERCP-based techniques. Recent advances in digital cholangioscopes have further improved image resolution, maneuverability, and irrigation control, broadening their clinical utility. Despite these technological improvements, POCS and POPS remain technically demanding, and their indications must be carefully selected according to ductal anatomy and the clinical scenario. In particular, the narrow diameter of the main pancreatic duct limits the application of POPS, restricting its use to specific situations, such as intraductal papillary mucinous neoplasms or indeterminate ductal strictures. Overall, the integration of cholangioscopy and intraductal lithotripsy into ERCP practice represents a significant advancement, enabling more precise diagnosis and expanding therapeutic options for complex pancreatobiliary disorders. This narrative review summarizes recent progress in diagnostic and therapeutic applications of cholangiopancreatography in pancreatobiliary disease.