Biliary strictures arise from diverse benign and malignant etiologies, and accurate differentiation is pivotal for prognosis and treatment selection. Conventional endoscopic retrograde cholangiopancreatography (ERCP)-based sampling (brush cytology and forceps biopsy) suffers from limited sensitivity despite high specificity, leaving a substantial proportion as indeterminate biliary strictures. Peroral cholangioscopy (POCS) enables direct intraductal visualization and targeted biopsies, thereby enhancing diagnostic yield. This review summarizes technological evolution from fiber-optic mother–baby systems to digital single-operator cholangioscopy and direct POCS, as well as the integration of image-enhanced endoscopy and emerging wide-channel scopes. Visual criteria for malignancy—tumor vessels, irregular granular or papillary/villous patterns, and friability—achieve high sensitivity and interobserver reliability with proposed classifications (Monaco, Mendoza). For cholangiocarcinoma, POCS-guided mapping biopsies precisely assess longitudinal intraepithelial tumor spread, informing R0 surgical planning. Randomized trials indicate higher or at least comparable sensitivity of POCS-guided biopsies relative to ERCP sampling, while novel forceps and larger working channels increase specimen size and reduce the number of biopsies. Artificial intelligence (AI) applied to POCS images shows promise for real-time risk stratification and improved targeting. Therapeutically, POCS guides intraductal lithotripsy with high clearance rates, and facilitates management in surgically altered anatomy in concert with endoscopic ultrasound-guided biliary drainage or transendosonographically/ guided created route procedure. Adverse events, chiefly pancreatitis and cholangitis, warrant attention to intraductal pressure control and CO2 insufflation. POCS has established an essential role in the diagnostic algorithm for biliary strictures; future advances will likely come from enhanced imaging, AI assistance, and next-generation digital cholangioscopes with larger biopsy devices.

Selective bile duct cannulation constitutes a crucial step for successful therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Despite recent advances in devices and techniques, difficult biliary cannulation remains a significant risk factor for post-ERCP pancreatitis (PEP) and procedure failure. This comprehensive review presents evidence-based and practical techniques to optimize the success rate of selective cannulation. Meta-analyses have demonstrated that guidewire-assisted cannulation reduces PEP risk by approximately 49% compared to contrast-guided approaches. Additionally, early precut sphincterotomy performed within 5-12 minutes of failed cannulation attempts significantly reduces PEP incidence while maintaining high success rates. Recent studies have also shown that pancreatic stent‑assisted needle‑knife papillotomy can further improve selective biliary cannulation in difficult cases while maintaining an acceptable safety profile. Advanced techniques including double guidewire technique, precut sphincterotomy, and prophylactic pancreatic stenting are discussed with clinical evidence. A systematic and algorithmic approach tailored to specific clinical scenarios is essential to achieve an initial success rate of ≥90%. Specific technical adaptations and endoscopic ultrasound-guided approaches are discussed for special anatomic situations such as periampullary diverticula, postsurgical altered anatomy, and failed conventional ERCP.

Endoscopic retrograde cholangiopancreatography (ERCP) has played a central role in the development of pancreaticobiliary endoscopy in Korea. This review traces the historical evolution of ERCP in Korea, from its first clinical application in the early 1970s to the establishment and growth of an academic society dedicated to pancreaticobiliary diseases. The first ERCP in Korea was performed in 1973, followed by early therapeutic advances such as endoscopic sphincterotomy in the late 1970s. Despite initial technical and infrastructural limitations, a group of dedicated pioneers fostered the dissemination and education of ERCP through regular case-based meetings. In 1991, these efforts culminated in the launch of the ERCP Study Group, which provided a nationwide platform for case discussion, skill acquisition, and professional solidarity among gastroenterologists. The group expanded its academic scope beyond ERCP procedures to encompass a broader spectrum of pancreatic and biliary diseases, leading to the formal establishment of the Korean Pancreatobiliary Association in 1995. Subsequent milestones included the publication of educational atlases, initiation of live demonstration courses, adoption of video endoscopy, and the integration of emerging techniques such as endoscopic ultrasonography (EUS). The society’s progressive expansion, interdisciplinary collaboration, and international engagement ultimately resulted in its reorganization as a full-fledged academic society in 2007 and its official recognition by the Korean Academy of Medical Sciences in 2011. This historical overview highlights how collective enthusiasm, technological innovation, and sustained educational efforts transformed ERCP from a novel procedure into a cornerstone of pancreaticobiliary medicine in Korea, laying the foundation for future academic and clinical advancements.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy (SAA) is technically challenging, not only because of the difficulty in reaching the target site but also in performing subsequent therapeutic procedures. To overcome these challenges, balloon enteroscopy-assisted ERCP has been introduced into clinical practice and has been reported to be both effective and safe. Recently, short-type balloon enteroscopes, with a working length of approximately 150 cm and a 3.2-mm working channel, have been widely adopted, making procedures more efficient. These short-type scopes facilitate the use of larger accessories in various procedures, such as stone extraction or self-expandable metallic stent placement. In addition, several new technologies and devices have recently been introduced to help manage difficult cases. Despite these advancements, multiple technical hurdles remain before procedures can be successfully completed. It is important to identify the key factors that contribute to procedural difficulty in order to improve success rates. At the same time, endoscopists must remain aware of the potential for adverse events, such as perforation, which can occur due to adhesions specific to SAA. In this review, we provide technical tips for short-type single-balloon enteroscopy-assisted ERCP in patients with SAA, aimed at improving procedural success rates and reducing adverse events, while also highlighting recent advancements in technology and devices.

Pancreatic cancer is a highly aggressive malignancy with a poor prognosis, with approximately 80% of patients presenting with unresectable disease at the time of diagnosis. However, with the recent introduction of effective chemotherapy regimens such as FOLFIRINOX and gemcitabine+nab-paclitaxel (GnP), conversion surgery has become feasible in selected patients with initially unresectable locally advanced pancreatic cancer. Recent large-scale studies from Japan have demonstrated that patients undergoing conversion surgery achieve a 5-year overall survival rate of 37.2%, offering new hope for patients with advanced pancreatic cancer. Although various studies have proposed multiple criteria for referral to conversion surgery, standardization has not yet been established, and individualized patient assessment remains important. The most appropriate approach is to proceed with conversion surgery after at least 6 months of adequate neoadjuvant chemotherapy when imaging demonstrates surgical resectability, tumor markers have sufficiently decreased, and multidisciplinary evaluation confirms the patient's fitness for surgery. Preoperative chemotherapy with FOLFIRINOX has been shown to provide superior survival outcomes compared to GnP, and maintaining the same chemotherapy regimen as adjuvant therapy following surgical resection is recommended. The anticipated results from the ongoing PREOPANC-4 study in the Netherlands are expected to provide important standardized guidelines for surgical management of locally advanced pancreatic cancer.

Anomalous union of the pancreaticobiliary duct (AUPBD) is a congenital malformation in which the pancreatic and biliary ducts join outside the duodenal wall, forming an elongated common channel. Because sphincter action does not directly affect this junction, reciprocal reflux of pancreatic juice and bile occurs, increasing the risk of biliary tract cancer. AUPBD is frequently associated with choledochal cysts and is a known risk factor for biliary malignancies. We report a case of a 70-year-old woman diagnosed with gallbladder cancer with liver metastases, accompanied by AUPBD without choledochal cysts. She presented with upper abdominal pain, obstructive jaundice, and a large hepatic mass on imaging. Endoscopic retrograde cholangiopancreatography confirmed pancreatobiliary-type AUPBD. Despite biliary drainage, her condition rapidly deteriorated and she died soon after. This case underscores the role of AUPBD in carcinogenesis and the need for early recognition and management.

Mirizzi syndrome is infrequently associated with fistula formation, particularly a unique biliopleural fistula. The ideal therapeutic strategy remains diverse across guidelines, which usually includes surgical excision to eliminate the source of infection. We reported a case of a 60-year-old jaundiced female with pleural effusion resulting from a biliopleural fistula. Imaging revealed a cystic lesion close to the periphery of the upper right diaphragm, connected to the gallbladder. Following initial pleural drainage, an abdominal exploration was conducted to excise the fistula and remove the gallbladder. A multidisciplinary approach is essential for obtaining optimal outcomes for patients with biliopleural fistula.