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A duodenoscope anchoring technique in a case of difficult scope intubation due to scope–pyloric ring misalignment
Endoscopists are occasionally confronted with difficult scope intubation in a patient in the prone position due to misalignment between the scope and the pyloric ring. We present a case of difficult scope intubation through the pyloric ring during endoscopic retrograde cholangiopancreatography (ERCP), with tips for duodenoscope intubation.
A 69-year-old man with biliary plastic stents in place for a benign biliary stricture and common bile duct (CBD) stones was referred to our department because of a difficult scope intubation through the pyloric ring to remove the stents. The stents were 7-Fr biliary plastic stents placed in a side-by-side fashion ([Fig. 1]). With the patient in a prone position, we made repeated attempts to pass the scope beyond the pyloric ring, but these were unsuccessful because of scope–pyloric ring misalignment ([Fig. 2]). As a next step, we advanced a four-wire basket (FG-V436P; Olympus, Tokyo, Japan) over the guidewire through the pyloric ring to grasp the ends of the stents, anchor the scope on the stents, and then adjust the scope–pyloric ring misalignment ([Fig. 3]; [Video 1]). We then shortened the duodenoscope through coordinated pulling of the basket catheter into the working channel ([Fig. 4]; [Video 1]). Finally, the scope was able to pass the pyloric ring and reached the ampulla of Vater ([Fig. 5]; [Video 1]). The stent was retrieved and the CBD stones extracted without adverse events.
Video 1 Technique for advancing a duodenoscope through a scope–pyloric ring misalignment.
Prone ERCP is preferred to supine ERCP due to the high technical success rate and shorter procedure duration . One of the advantages of a supine position is that abdominal compression can be used if necessary . However, the position is technically more difficult and potentially more risky ; the operator must turn his or her back on the patient to maintain an appropriate endoscopic view .
In cases where scope intubation in the prone position is difficult due to a misalignment between the scope and the pyloric ring, anchoring on a previously placed biliary stent using a basket catheter is useful to achieve scope intubation before changing the sedated patient to a supine position with abdominal compression.
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04 February 2021 (online)
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