Facilitating duodenoscope insertion with a balloon overtube in a patient with gastric deformity

The side-viewing feature of duodenoscopes, which are dedicated endoscopes for endoscopic retrograde cholangiopancreatography (ERCP), can occasionally complicate endoscopic insertion, particularly in patients with gastric deformity or tumor infiltration. We report a case in which balloon overtube placement facilitated duodenoscope insertion in a patient with gastric deformity.

An 86-year-old man with malignant biliary obstruction secondary to pancreatic cancer had previously undergone transpapillary placement of a covered self-expandable metallic stent (cSEMS). The patient presented with cholangitis, and computed tomography (CT) confirmed biliary dilation suggestive of recurrent stent occlusion ([Fig. 1]). ERCP with stent exchange was planned. However, duodenoscope insertion was unsuccessful due to gastric deformity, likely caused by tumor invasion. Therefore, the duodenoscope was exchanged for a balloon endoscope (SIF-Q260, Olympus) with a balloon overtube (ST-CB1, Olympus) with an inner diameter of 13.8 mm and a length of 77 cm. The forward-viewing endoscope enabled a successful insertion into the duodenum. The balloon overtube was then advanced into the gastric antrum ([Fig. 2]), and the balloon was inflated to secure its position. The endoscope was removed while maintaining overtube placement. Subsequently, a duodenoscope with an outer diameter of 12.9 mm (JF-240, Olympus) was successfully inserted through the overtube ([Fig. 3], [Video 1]). Stent exchange with a 6 mm diameter cSEMS was then performed without complications ([Fig. 4]).

Fig. 1 Computed tomography image showed dilation of the bile duct due to the stent occlusion.

Fig. 2 The balloon overtube was then advanced into the gastric antrum.

Fig. 3 The duodenoscope was inserted through the overtube.

Fig. 4 Stent exchange with a 6 mm diameter covered self-expandable metallic stent was performed.

A duodenoscope with an outer diameter of 12.9 mm was inserted through the overtube.Video 1

Several techniques have been reported to facilitate duodenoscope insertion, including guiding technique using a guidewire and catheter for esophageal insertion [1], anchoring technique by a dilation balloon or basket catheter for stricture [2] [3], and application of overture to increase pushability of the endoscope for perigastric adhesions [4]. Regarding through overtube techniques, esophageal insertion using a short overtube has been reported to manage the pharyngeal pouch [5]. This duodenoscope insertion technique using the balloon overtube offers a valuable option for overcoming upper gastrointestinal obstacles, although the overtube inner diameter may limit duodenoscope selection.

Endoscopy_UCTN_Code_TTT_1AR_2AB

Publication History

Article published online:
06 May 2025

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