A duodenoscope anchoring technique in a case of difficult scope intubation due to scope–pyloric ring misalignment

Endoscopists are occasionally confronted with difficult scope intubation in a patient in the prone position due to misalignment between the scope and the pyloric ring. We present a case of difficult scope intubation through the pyloric ring during endoscopic retrograde cholangiopancreatography (ERCP), with tips for duodenoscope intubation.

A 69-year-old man with biliary plastic stents in place for a benign biliary stricture and common bile duct (CBD) stones was referred to our department because of a difficult scope intubation through the pyloric ring to remove the stents. The stents were 7-Fr biliary plastic stents placed in a side-by-side fashion ([Fig. 1]). With the patient in a prone position, we made repeated attempts to pass the scope beyond the pyloric ring, but these were unsuccessful because of scope–pyloric ring misalignment ([Fig. 2]). As a next step, we advanced a four-wire basket (FG-V436P; Olympus, Tokyo, Japan) over the guidewire through the pyloric ring to grasp the ends of the stents, anchor the scope on the stents, and then adjust the scope–pyloric ring misalignment ([Fig. 3]; [Video 1]). We then shortened the duodenoscope through coordinated pulling of the basket catheter into the working channel ([Fig. 4]; [Video 1]). Finally, the scope was able to pass the pyloric ring and reached the ampulla of Vater ([Fig. 5]; [Video 1]). The stent was retrieved and the CBD stones extracted without adverse events.

Fig. 1 Fluoroscopic image showing transpapillary 7-Fr biliary stents in a side-by-side position.

Fig. 2 Fluoroscopic image showing the duodenoscope can not pass the pyloric ring due to scope-pyloric ring misalignment (inset: endoscopic view).

Fig. 3 Fluoroscopic image showing anchoring on the biliary stent using a basket catheter to pass the pyloric ring (inset: endoscopic view).

Video 1 Technique for advancing a duodenoscope through a scope–pyloric ring misalignment.

Fig. 4 Fluoroscopic image showing the duodenoscope is advanced during scope shortening with continuous pulling of the basket catheter into the scope channel.

Fig. 5 Fluoroscopic image showing the duodenoscope enface on the ampulla of Vater (inset: endoscopic view).

Prone ERCP is preferred to supine ERCP due to the high technical success rate and shorter procedure duration [1]. One of the advantages of a supine position is that abdominal compression can be used if necessary [2]. However, the position is technically more difficult and potentially more risky [2]; the operator must turn his or her back on the patient to maintain an appropriate endoscopic view [3].

In cases where scope intubation in the prone position is difficult due to a misalignment between the scope and the pyloric ring, anchoring on a previously placed biliary stent using a basket catheter is useful to achieve scope intubation before changing the sedated patient to a supine position with abdominal compression.

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Publication History

Article published online:
04 February 2021

• References

• 1 Mashiana HS, Jayaraj M, Mohan BP. et al. Comparison of outcomes for supine vs. prone position ERCP: a systematic review and meta-analysis. Endosc Int Open 2018; 6: E1296-E1301
• 2 Wilcox CM. Should patients undergoing ERCP be placed in the prone or supine position?. Nat Clin Pract Gastroenterol Hepatol 2008; 5: 488-489
• 3 Tringali A, Mutignani M, Milano A. et al. No difference between supine and prone position for ERCP in conscious sedated patients: a prospective randomized study. Endoscopy 2008; 40: 93-97