The application of texture and color enhancement imaging in transpapillary biliary cannulation

The efficacy of image-enhanced endoscopy (IEE) has been widely reported in the management of gastrointestinal tract lesions [1] [2] [3]; however, the efficacy of IEE has not been well discussed in the pancreatobiliary field. Recently, a novel IEE tool called texture and color enhancement imaging (TXI; Olympus, Tokyo, Japan) was launched. TXI has two modes: mode 1, which enhances brightness, texture, and color contrast; and mode 2, which enhances brightness and texture [4]. Herein, we report the usefulness of TXI in biliary cannulation ([Video 1]).

Video 1 Texture and color enhancement imaging (TXI) provides enhanced images, because the function amplifies minute visible changes. TXI may help in recognizing the structure around the papilla during biliary cannulation.

Case 1 was a 79-year-old woman who underwent endoscopic retrograde cholangiopancreatography (ERCP) for cholangitis. The flat-shaped papilla was located in the periampullary diverticula. The orifice of the bile duct was unclear under white-light imaging (WLI); however, TXI mode 2 enhanced the brightness and texture of unevenness on the surface of the papilla, leading to the clear recognition of the orifice ([Fig. 1]). Finally, biliary cannulation was achieved without pancreatic ductal intervention.

Fig. 1 Although the orifice of the bile duct was unclear under white-light imaging (WLI), texture and color enhancement imaging (TXI) mode 2 (texture and brightness enhanced) allowed clear recognition of the orifice.

Case 2 was an 81-year-old man with advanced pancreatic cancer who underwent ERCP for a malignant distal biliary obstruction. The scope position was unstable owing to duodenal invasion of the tumor, and use of the transpapillary biliary approach was challenging. Therefore, we performed precutting using a precut needle knife (NeedleCut 3V KD-V441M; Olympus, Tokyo, Japan). Upon observation of the incised surface of the papilla under TXI mode 1, a hole opening on the sphincter muscle suggesting the orifice of the bile duct was well recognized ([Fig. 2]). Successful biliary cannulation was achieved by the insertion of the ERCP catheter into the hole.

Fig. 2 After precutting, the bile duct orifice was more clearly recognized under TXI mode 1 (texture, brightness, and color enhanced) than with white-light imaging (WLI).

The identification of the papilla orifice is important for transpapillary biliary intervention. Texture and color enhancement imaging amplifies the difference in the structure of the papilla, leading to an easier understanding of the papilla orifice. Therefore, TXI can aid in biliary cannulation, especially in cases with an unclear biliary orifice.

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• References

• 1 Sato T. Image-enhanced endoscopy. Tech Gastrointest Endosc 2011; 13: 2-7
• 2 Lemmers A, Bucalau AM, Verset L. et al. Pristine submucosal visibility using texture and color enhancement imaging during saline-immersion rectal endoscopic submucosal dissection. Endoscopy 2021;
• 3 Abe S, Makiguchi ME, Nonaka S. et al. Emerging texture and color enhancement imaging in early gastric cancer. Dig Endosc 2021;
• 4 Sato T. TXI: Texture and color enhancement imaging for endoscopic image enhancement. J Healthc Eng 2021;