Endoscopy 2021; 53(10): E372-E373
DOI: 10.1055/a-1294-9218
E-Videos

Usefulness of the S-O clip in balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography

Kotaro Takeshita
Department of Gastroenterology, Tane General Hospital, Osaka, Japan
,
Satoshi Asai
Department of Gastroenterology, Tane General Hospital, Osaka, Japan
,
Naoki Fujimoto
Department of Gastroenterology, Tane General Hospital, Osaka, Japan
,
Hitomi Jimbo
Department of Gastroenterology, Tane General Hospital, Osaka, Japan
,
Takumi Ichinona
Department of Gastroenterology, Tane General Hospital, Osaka, Japan
,
Eisuke Akamine
Department of Gastroenterology, Tane General Hospital, Osaka, Japan
› Author Affiliations
 

A 77-year-old woman with a history of total gastrectomy with Roux-en-Y anastomosis was admitted with acute gallstone cholangitis ([Fig. 1]). We attempted endoscopic stone removal with a double-balloon enteroscope (DBE) (EI-580BT; Fujifilm, Osaka, Japan).

Zoom Image
Fig. 1 Computed tomography scan showed a 12-mm biliary stone in the common bile duct.

A DBE with a transparent hood was inserted, and we successfully approached the ampulla. However, the ampulla faced away from the instrument, owing to a fold and periampullary diverticulum. It was difficult to cannulate the bile duct, despite attempting to reposition the ampulla to face the instrument by holding the fold using the hood. We finally used an S-O clip (Zeon Medical, Tokyo, Japan) [1] to pull the periampullary mucosa and reposition the ampulla to face the instrument.

The S-O clip is a through-the-scope endoscopic clip with a 5-mm-long spring attached to a single 4-mm-diameter nylon loop. Once the S-O clip was deployed to the target, the nylon loop was pulled and attached to the distant mucosa, 5 cm away from the first S-O clip, using a second conventional endoscopic clip, producing “countertraction.” We visualized the orifice of the ampulla and cannulated it to access the bile duct ([Fig. 2]). The papilla was dilated to 13 mm using a large-balloon dilator (GIGA2; Century Medical, Tokyo, Japan), and the stone was removed safely using lithotripsy (LithoCrushV; Olympus, Tokyo, Japan) ([Fig. 3], [Video 1]), without adverse events.

Zoom Image
Fig. 2 The orifice of the ampulla was visualized with assistance from S-O clip countertraction.
Zoom Image
Fig. 3 The papilla was dilated to 13 mm using a large-balloon dilator, and the stone was removed safely using lithotripsy.

Video 1 The S-O clip was used to position the ampulla to face the instrument. Then, we visualized the orifice of the ampulla and cannulated it to access the bile duct.


Quality:

Although the usefulness of the S-O clip for endoscopic retrograde cholangiopancreatography (ERCP) has been reported for normal anatomy [2], it has never been reported in DBE-ERCP. Cannulation during enteroscopy-assisted ERCP is sometimes difficult in patients with surgically altered anatomy. Various methods, including the double-guidewire technique, precutting technique, and the Rendezvous approach [3] [4], have been reported. Although additional cases are needed, this safe and straightforward S-O clip-assisted cannulation could be a novel and effective method of cannulation during enteroscopy-assisted ERCP.

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Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Kotaro Takeshita, MD
Department of Gastroenterology
Tane General Hospital
1-12-21, Kujominami
Nishi-ku, Osaka
Japan 550-0025   
Fax: +81-6-65812520   

Publication History

Publication Date:
26 November 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Computed tomography scan showed a 12-mm biliary stone in the common bile duct.
Zoom Image
Fig. 2 The orifice of the ampulla was visualized with assistance from S-O clip countertraction.
Zoom Image
Fig. 3 The papilla was dilated to 13 mm using a large-balloon dilator, and the stone was removed safely using lithotripsy.