Clinical Practice Guidelines for Peroral Cholangioscopy

BACKGROUND/PURPOSE: Peroral cholangioscopy (POCS) has emerged as a valuable endoscopic modality for the diagnosis and treatment of biliary tract diseases. Despite its growing clinical application, no standardized clinical practice guidelines have previously been established in Japan. In response, here we describe how the Japan Biliary Association (JBA) developed evidence-based guidelines to support the safe and effective implementation of POCS. METHODS: Following the Minds 2020 methodology, a multidisciplinary committee formulated 31 key clinical, background, and future research questions across six domains: definitions, indications and roles, procedures, special cases, adverse events, and diagnostic/therapeutic outcomes. Recommendations were based on a systematic review of literature, supplemented by expert consensus where evidence was limited. RESULTS: Key topics include appropriate indications, management of antithrombotic therapy, necessity of papillary intervention, antibiotic prophylaxis, procedural risks, and the role of POCS-guided biopsy and lithotripsy. Notably, the guidelines highlight the utility of POCS in evaluating indeterminate biliary strictures, papillary cholangiocarcinoma, and difficult bile duct stones, while addressing adverse events such as cholangitis and perforation. CONCLUSIONS: These guidelines are intended to serve as a practical reference for clinicians and endoscopists involved in biliary endoscopy, with the flexibility of their adaptation based on institutional practices and patient characteristics.