Bile duct cannulation via balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography
(ERCP) can be challenging, particularly in complex anatomical scenarios [1]
[2]. This case report emphasizes the clinical application of a novel rotatable sphincterotome
in a 75-year-old man who presented to a local clinic with a 1-week history of bilirubinuria.
The patient had a history of gastric cancer and had undergone a distal gastrectomy
with Roux-en-Y reconstruction 6 years previously. Laboratory tests revealed elevated
liver enzymes, prompting a referral to our hospital. Contrast-enhanced computed tomography
and magnetic resonance cholangiopancreatography revealed mild common bile duct wall
thickening and stricture with upstream biliary dilation ([Fig. 1], [Fig. 2]), which was eventually diagnosed as recurrent gastric cancer 6 months after ERCP.
Fig. 1 Contrast-enhanced computed tomography in a patient with a history of gastric cancer
treated with distal gastrectomy and Roux-en-Y reconstruction revealed mild thickening
and stricture (arrow) of the common bile duct wall and upstream biliary dilation.
Fig. 2 Magnetic resonance cholangiopancreatography revealed a stricture of the common bile
duct with upstream biliary dilation.
A double-balloon endoscope was used to access the papilla. However, significant challenges
prevented successful bile duct cannulation. Retroflex position, a technique often
used to facilitate cannulation [3], was unsuccessful due to the narrow duodenal lumen. Furthermore, conventional sphincterotomy
failed as the instrument could not rotate adequately under balloon-assisted endoscopy,
and the curvature of the knife did not align with the bile duct axis. Subsequently,
a novel, upgraded sphincterotome (Aimingtome; Asahi Intecc Co., Ltd., Seto, Japan)
was used ([Fig. 3]) [4]. This device features a more rotatable and flexible tip, which enabled guidewire
insertion into the duodenal papilla ([Video 1]). The guidewire was then successfully advanced into the main pancreatic duct, facilitating
bile duct cannulation via the pancreatic duct guidewire technique. Endoscopic sphincterotomy
was performed using the same sphincterotome ([Fig. 4]), followed by the placement of a biliary plastic stent ([Fig. 5]). The patient was discharged 3 days after the procedure. In cases where frontal
visualization of the papilla using balloon endoscopy-assisted ERCP is challenging,
the use of a novel rotatable sphincterotome can effectively facilitate bile duct cannulation
and subsequent endoscopic sphincterotomy.
Fig. 3 Macroscopic overview of the novel sphincterotome. Source: Asahi Intecc, Seto, Japan.
An upgraded rotatable sphincterotome successfully facilitated bile duct cannulation
using balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography. Source
for sphincterotome: Asahi Intecc, Seto, Japan.Video 1
Fig. 4 Endoscopic sphincterotomy using the novel sphincterotome. Compared to a conventional
sphincterotome, it allows 360° rotation and greater backward flexibility.
Fig. 5 Biliary and pancreatic stents placed in the common bile duct and main pancreatic duct:
a endoscopic view; b radiographic image
Endoscopy_UCTN_Code_TTT_1AR_2AC
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
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