Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography
(DBE-ERCP) facilitates management of pancreatobiliary disorders in cases with surgically
altered anatomy [1]
[2]
[3]. However, owing to difficulties in positioning the biliary orifice and obtaining
a suitable angulation of the bile duct and endoscope, it can be challenging to access
a peripheral bile duct during DBE-ERCP. Here we present a case where a migrated stent
in the bile duct at segment III (B3) was successfully removed using the previously
reported technique ([Video 1]) [4].
Video 1 The “zipline” technique utilized to access a peripheral bile duct and remove a migrated
plastic stent during double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography.
A 61-year-old man with a history of Roux-en-Y reconstruction was referred to our institution
for management of a migrated plastic stent ([Fig. 1]). We inserted a double balloon endoscope (EI-580BT; Fujifilm, Tokyo, Japan) and
removed a plastic stent placed across the anastomosis site using a snare. Following
biliary cannulation, a 0.025-inch guidewire was passed into B3. While we were attempting
to grasp the migrated stent using a wire-guided basket catheter after balloon dilation
of the anastomosis site, the stent migrated further into the peripheral portion of
B3. Therefore, we added a looped nylon thread to one cup of the forceps (Radial Jaw
4 pediatric; Boston Scientific, Natick, Massachusetts, USA) and inserted the forceps
with the loop over the prepositioned guidewire ([Fig. 2]). The stent was readily grasped and withdrawn to the jejunum. We then withdrew the
stent through the endoscope using the snare.
Fig. 1 Computed tomography delineating a migrated stent in B3 (arrows) of a patient with
a history of Roux-en-Y reconstruction. The patient underwent extended right hepatectomy
with hepaticojejunostomy for intraductal papillary neoplasm of the bile duct. Proximal
migration of a stent for the hepaticojejunostomy anastomosis site caused cholangitis,
and a plastic stent was placed across the anastomosis site in a previous hospital.
Fig. 2 The “zipline” technique utilized to remove a migrated stent in B3. a Biopsy forceps with a looped nylon thread passed through the holes of one cup, which
allows the forceps to be advanced over a guidewire. b Double- balloon enteroscopy-assisted cholangiogram delineating a migrated stent in
B3. c The stent grasped via the zipline technique. We successfully passed the threaded
forceps into B3. We readily grasped and removed the migrated stent.
Radial Jaw has been one of the most popular series of biopsy forceps and has hole(s)
at each cup that enable the attachment of a looped thread. Wire-guided biopsy forceps
are not available for DBE-ERCP owing to the limited length of the shaft [5]. The “zipline” technique during DBE-ERCP may facilitate target biopsy of the peripheral
bile duct as well as stent removal.
Endoscopy_UCTN_Code_TTT_1AR_2AZ
Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online. Processing charges apply (currently EUR
375), discounts and wavers acc. to HINARI are available.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
