Transpancreatic biliary sphincterotomy using a novel rotatable sphincterotome in a patient with Roux-en-Y gastrectomy

Biliary cannulation in patients with Roux-en-Y gastrectomy under balloon enteroscopy is challenging [1] [2]. When pancreatic duct cannulation is performed, transpancreatic biliary sphincterotomy is a useful rescue technique for achieving biliary cannulation in difficult cases. However, transpancreatic biliary sphincterotomy in patients with Roux-en-Y gastrectomy is considered difficult as the blade of conventional sphincterotomes does not always face the correct direction for the incision. Recently, a novel rotatable sphincterotome (ENGETSU; Kaneka Corp., Osaka, Japan) was launched, which allows the blade to be rotated in the correct direction for endoscopic sphincterotomy by turning the handle ([Fig. 1]) [3] [4]. We report a case of Roux-en-Y gastrectomy in which transpancreatic biliary sphincterotomy was successfully performed using a novel rotatable sphincterotome to achieve selective biliary cannulation.

Fig. 1 The novel rotatable sphincterotome (ENGETSU; Kaneka, Japan). a The product overview. b The blade can be loosened. c The blade can be also stretched.

A 79-year-old man who underwent Roux-en-Y gastrectomy and presented with a biliary stricture caused by the recurrence of gastric cancer was referred to us ([Fig. 2]). Endoscopic retrograde cholangiopancreatography was performed using a short-type single-balloon enteroscope (SIF-H290; Olympus, Tokyo, Japan) with a working length of 152 cm and a working channel 3.2 mm in diameter [5] ([Video 1]). Since only pancreatic duct cannulation was successful, the double-guidewire technique was used; however, selective biliary cannulation remained difficult to achieve. ([Fig. 3] a–c). Subsequently, transpancreatic biliary sphincterotomy was attempted using a novel rotatable sphincterotome. Although the blade of the sphincterotome was initially not facing the 5 oʼclock direction ([Fig. 4] a), which corresponds to the bile duct, it was adjusted to face 5 oʼclock by turning the handle, and a successful incision was made ([Fig. 4] b, c). The orifice of the bile duct was identified at the incision site ([Fig. 4] d), allowing selective biliary cannulation to be achieved ([Fig. 4] e, f). Finally, biliary drainage was completed ([Fig. 5]).

Fig. 2 Computed tomography revealing biliary stricture (red arrow) in the hilar bile duct.

Successful transpancreatic biliary sphincterotomy using a novel rotatable sphincterotome in a patient with Roux-en-Y gastrectomy.Video 1

Fig. 3 Endoscopic retrograde cholangiopancreatography findings. a The finding of the papilla. b, c Selective biliary cannulation is attempted; however, only pancreatic duct cannulation is successful, despite the use of the double-guidewire technique.

Fig. 4 Endoscopic retrograde cholangiopancreatography findings. a The blade of the sphincterotome was initially not facing the 5 oʼclock direction (red arrow). b It is adjusted to face the 5 oʼclock direction (red arrow) by turning the handle. c A successful incision is made. d The bile duct orifice is identified at the incision site (red arrow). e, f Selective biliary cannulation is achieved.

Fig. 5 Endoscopic retrograde cholangiopancreatography findings. a,b Finally, biliary drainage is completed.

This novel rotatable sphincterotome could improve advanced selective biliary cannulation techniques such as transpancreatic biliary sphincterotomy under balloon enteroscopy.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Tanisaka Y, Ryozawa S, Itoi T. et al. Efficacy and factors affecting procedure results of short-type single-balloon enteroscopy-assisted ERCP for altered anatomy: a multicenter cohort in Japan. Gastrointest Endosc 2022; 95: 310-318.e1
• 2 Tanisaka Y, Takenaka M, Mizuide M. et al. Efficacy of texture and color enhancement imaging for short-type single-balloon enteroscopy-assisted biliary cannulation in patients with Roux-en-Y gastrectomy: Multicenter study (with video). Dig Endosc 2024; 36: 1030-1040
• 3 Tanisaka Y, Ryozawa S, Mizuide M. et al. Successful endoscopic sphincterotomy using a novel rotatable sphincterotome in a patient with Roux-en-Y gastrectomy. Endoscopy 2024; 56: E1038-E1039
• 4 Kuraishi Y, Shimizu Y, Nakamura A. et al. Enhanced biliary cannulation and sphincterotomy using a novel rotatable sphincterotome for surgically altered anatomy. Endoscopy 2025; 57: E22-E24
• 5 Tanisaka Y, Ryozawa S, Mizuide M. et al. Usefulness of the “newly designed” short-type single-balloon enteroscope for ERCP in patients with Roux-en-Y gastrectomy: a pilot study. Endosc Int Open 2018; 6: E1417-E1422

Publication History

Article published online:
03 June 2025