Diagnosis of biliary strictures remains challenging because of the low sensitivity of conventional transpapillary sampling using endoscopic retrograde cholangiopancreatography. New devices and tips have been developed to increase the diagnostic yield of conventional transpapillary sampling. However, additional endoscopic procedures are often necessary for indeterminate biliary strictures. Two major approaches for indeterminate biliary strictures are endoscopic ultrasonography-guided sampling and peroral cholangioscopy (POCS)-guided biopsy. The selection of modalities should be considered based on the stricture location. Although endoscopic ultrasound is the preferred approach for distal biliary strictures, POCS is preferred for perihilar biliary strictures. Endoscopic ultrasonography-guided sampling is highly sensitive in cases with a mass, but the sensitivity of POCS-guided biopsies is unsatisfactory, and discrepancy with the visual diagnosis of POCS is common. Whether these advanced techniques should be performed as the initial procedure or as a rescue after a failed diagnosis by conventional transpapillary sampling needs to be clarified in terms of diagnostic yield and cost-effectiveness.

The purpose of this research was to develop a reflection program to support the practice of end-of-life care for nurses and to examine its effectiveness and feasibility. We developed and examined the effectiveness of a facilitator-based reflection program (FRP) and card-based reflection program (CRP). Average scores for both the FRP and CRP were measured using a Knowledge, Attitude and Difficulty Scale for palliative care and Self-education Ability Scale implemented before, immediately after, and 3 months after the program. The changes in scores were compared. This research was conducted with approval from the ethics review committee. Nine people participated in the FRP, and 15 in the CRP. FRP significantly reduced difficulty concerning palliative care compared to CRP. FRP significantly increased knowledge compared to CRP. Similar results were obtained within the FRP group. Both FRP and CRP were considered highly feasible because the program evaluation was high. In the future, it is necessary to clarify the effect of the reflection program by reviewing the research design.