Long-type double-balloon enteroscopy-assisted ERCP using hand-made accessories in Roux-en-Y hepaticojejunostomy (with video)

Min Jae Yang ,Ah Reum Kim ,Jae Chul Hwang,Byung Moo Yoo,Jin Hong Kim

Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea

To the Editor:

Short-type balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) is becoming the procedure of choice for biliopancreatic disease treatment in patients with postoperative anatomy [1,2].However,it has not yet been available in many countries.Although a long-type balloon enteroscope with a 200-cm working length has been widely used for small bowel endoscopy,its use for ERCP was limited by the lack of commercially available extra-long accessories [3] .We hereby describe the successful use of hand-made ERCP accessories for long-type doubleballoon enteroscopy (DBE)-assisted therapeutic ERCP in a case with Roux-en-Y hepaticojejunostomy reconstruction and recurrent bilioenteric anastomotic stricture.A 73-year-old woman presented to our emergency department with a 5-day history of progressive worsening of right upper quadrant pain and jaundice.She had undergone a bile duct segmental resection,cholecystectomy,and Roux-en-Y hepaticojejunostomy 10 years prior for high-grade dysplasia of the common hepatic duct,and a percutaneous transhepatic cholangioscopy and balloon dilation 3 years prior for a benign bilioenteric anastomotic stricture and hepatolithiasis.Abdominal computed tomography showed focal wall thickening at the hepaticojejunostomy anastomotic site and diffuse dilation of the intrahepatic bile duct,which suggested a recurrent anastomotic stricture.Balloon dilation,bile duct clearance,and multiple plastic stenting through long-type DBE-assisted ERCP were indicated.Hand-made ERCP accessories with working length ≥230 cm were prepared before the ERCP procedures.

The cannula was made by cutting the tip of the colonic injection needle catheter with a 230-cm length (Fig.1 A),retracting the outer sheath to expose the inner sheath (Fig.1 B),and inserting the plastic tube tip included in the 22-gauge peripheral venous catheter set into the inner sheath lumen (Fig.1 C,D).The 230 cm-long 7-Fr stent pusher catheter for 7-Fr plastic stent was made by cutting a polytetrafluoroethylene (PTFE) tubing roll (Hans-Christian Grosse Medizintechnik,Hamberg,Germany) (Fig.1 E,G).Basket wires of the commercially available lithotripsy Dormia basket (MTW Endoskopie,Wesel,Germany) are originally connected to an extra-long metallic traction wire (420 cm),but its vinyl sheath is relatively short (195 cm).We therefore removed the original vinyl sheath and re-equipped the traction wire with the cut-out 230 cm PTFE tube (Fig.1 F,H).The commercially available colonic dilation catheter (CRE,Boston Scientific,Natick,MA,USA)has a 245 cm working length,no modifications were therefore required.With the use of these extra-long accessories,bile duct cannulation (Fig.2 A-C),balloon dilation of the hepaticojejunostomy anastomotic stricture (Fig.2 D),and bilateral plastic stenting(Fig.2 E,F) were successfully performed under DBE guidance (Video S1).These self-manufacturing accessories presented in this report will be useful in ERCP centers where only long-type BE is available.

Acknowledgments

None.

CRediTauthorshipcontributionstatement

MinJaeYang:Funding acquisition,Writing original draft,Writing review &editing.AhReumKim:Data curation,Writing original draft.JaeChulHwang:Writing review &editing.ByungMoo Yoo:Writing review &editing.JinHongKim:Conceptualization,Writing review &editing.

Funding

This study was supported by the grant from National Research Foundation of Korea (NRF) funded by the Korean government(NRF-2020R1F1A1071612).

Ethicalapproval

The consent for publication was obtained from the reported patient.

Competinginterest

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

Fig.1.Hand-made cannulation catheter (A-D).Stent pusher catheter (E, G) and basket (F, H).PTFE:polytetrafluoroethylene.

Fig.2.Endoscopic retrograde cholangiopancreatography.A-C:Cannulation;D:papillary balloon dilation;E, F:plastic stenting.

Supplementarymaterials

Supplementary material associated with this article can be found,in the online version,at doi:10.1016/j.hbpd.2021.04.012 .