Advancing in ERCP: the Slim Duodenoscope as a cornerstone for challenging anatomies – Insights from an Italian case series

Aims Endoscopic retrograde cholangiopancreatography (ERCP) is an essential therapeutic procedure for several biliary and pancreatic conditions. However, anatomical and pathological conditions make conventional ERCP unfeasible for a subset of patients. Consequently, many patients are relegated to alternative options (PTC, EUS-biliary drainage when available). An advancement that allows ERCP to be performed in patients with difficult anatomies would offer significant clinical benefits. The Slim Duodenoscope (ED32-i10 Pentax medical, Japan) with disposable elevator cap for infection prevention and its reduced outer diameter (10.8 mm insertion tube, 12.5 mm distal vs. 11.6 mm and 13.6 mm in standard duodenoscopes), is designed to facilitate endoscopic procedures in patients with challenging anatomy; the 3.2 mm working channel allows therapeutic manouvres including insertion of metal biliary stents. The aim of this case series is to assess the efficacy and safety of the Slim Duodenoscope in clinical practice, particularly in patients with complex anatomical conditions.

Methods Consecutive patients where approach to the papilla of Vater failed with a conventional duodenoscope and underwent an attempt to ERCP with the slim duodenoscope, were prospectively enrolled at 2 italian referral Endoscopy Unit.

Results Nineteen procedures were performed in 18 patients. Indications to ERCP were: choledocholithiasis (n=5), cholangitis and pre-existing metal stents placed for pancreatic adenocarcinoma (n=5), biliary strictures (2 malignant and 2 of uncertain etiology), biliary stent removal (1), post-surgical biliary fistula (1) and anastomotic biliary stricture following liver transplantation (n=1). Among these 18 patients, 12 exhibited duodenal strictures caused by malignant infiltration (n=8) or peptic disease (n=4). Additionally, 5 patients had esophageal strictures (1 corrosive ingestion, 2 esophageal diverticulum, 2 cervical osteophytes) and one a previous sleeve gastrectomy with tight and angled residual stomach. In 14 (77.7%) patients, the duodenoscope successfully passed the stricture segment, making therapeutic intervention possible and successful in all the cases. In the remaining 4 (22.3%), overcoming the stricture was not feasible due to malignant duodenal strictures (n=3) and benign esophageal strictures (n=1). No complications were reported.

Conclusions The Slim Duodenoscope represents a valuable tool for complex anatomical scenarios offering benefits for patients with luminal narrowing, where standard duodenoscopes may fail. The versatility of the Slim Duodenoscope highlights its essential role in settings where challenging anatomies require a specialized endoscopic approach.

 

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Conflicts of Interest

Boston Scientific Corporation (Apollo Endosurgery), Nitinotes, and EndoTools

Publication History

Article published online:
27 March 2025