Endoscopy 2021; 53(12): E455-E456
DOI: 10.1055/a-1327-1813
E-Videos

A duodenoscope anchoring technique in a case of difficult scope intubation due to scope–pyloric ring misalignment

1  Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
2  Department of Gastroenterology and Hepatology, Division of Endoscopy and Center for Digestive Disease, University of Miyazaki Hospital, Miyazaki, Japan
,
Yoshimasa Kubota
1  Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
2  Department of Gastroenterology and Hepatology, Division of Endoscopy and Center for Digestive Disease, University of Miyazaki Hospital, Miyazaki, Japan
,
Tesshin Ban
1  Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
2  Department of Gastroenterology and Hepatology, Division of Endoscopy and Center for Digestive Disease, University of Miyazaki Hospital, Miyazaki, Japan
,
Hiroshi Hatada
1  Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
2  Department of Gastroenterology and Hepatology, Division of Endoscopy and Center for Digestive Disease, University of Miyazaki Hospital, Miyazaki, Japan
,
Souichiro Ogawa
1  Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
2  Department of Gastroenterology and Hepatology, Division of Endoscopy and Center for Digestive Disease, University of Miyazaki Hospital, Miyazaki, Japan
,
Naomi Uchiyama
1  Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
2  Department of Gastroenterology and Hepatology, Division of Endoscopy and Center for Digestive Disease, University of Miyazaki Hospital, Miyazaki, Japan
,
Daisuke Kuroki
2  Department of Gastroenterology and Hepatology, Division of Endoscopy and Center for Digestive Disease, University of Miyazaki Hospital, Miyazaki, Japan
› Author Affiliations
 

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.

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Fig. 1 Fluoroscopic image showing transpapillary 7-Fr biliary stents in a side-by-side position.
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Fig. 2 Fluoroscopic image showing the duodenoscope can not pass the pyloric ring due to scope-pyloric ring misalignment (inset: endoscopic view).
Zoom Image
Fig. 3 Fluoroscopic image showing anchoring on the biliary stent using a basket catheter to pass the pyloric ring (inset: endoscopic view).

Video 1 Technique for advancing a duodenoscope through a scope–pyloric ring misalignment.


Quality:
Zoom Image
Fig. 4 Fluoroscopic image showing the duodenoscope is advanced during scope shortening with continuous pulling of the basket catheter into the scope channel.
Zoom Image
Fig. 5 Fluoroscopic image showing the duodenoscope enface on the ampulla of Vater (inset: endoscopic view).

Prone ERCP is preferred to supine ERCP due to the high technical success rate and shorter procedure duration [1]. One of the advantages of a supine position is that abdominal compression can be used if necessary [2]. However, the position is technically more difficult and potentially more risky [2]; the operator must turn his or her back on the patient to maintain an appropriate endoscopic view [3].

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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Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Hiroshi Kawakami, MD, PhD
Division of Gastroenterology and Hepatology
Department of Internal Medicine
Faculty of Medicine
University of Miyazaki
5200, Kihara
Kiyotake
889-1692 Miyazaki
Japan   

Publication History

Publication Date:
04 February 2021 (online)

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Fluoroscopic image showing transpapillary 7-Fr biliary stents in a side-by-side position.
Zoom Image
Fig. 2 Fluoroscopic image showing the duodenoscope can not pass the pyloric ring due to scope-pyloric ring misalignment (inset: endoscopic view).
Zoom Image
Fig. 3 Fluoroscopic image showing anchoring on the biliary stent using a basket catheter to pass the pyloric ring (inset: endoscopic view).
Zoom Image
Fig. 4 Fluoroscopic image showing the duodenoscope is advanced during scope shortening with continuous pulling of the basket catheter into the scope channel.
Zoom Image
Fig. 5 Fluoroscopic image showing the duodenoscope enface on the ampulla of Vater (inset: endoscopic view).