Reply to Matsushita et al.

Reply to Matsushita et al.

P. Murali Krishna

We sincerely appreciate the interest of Dr. Matsuhita and colleagues in our case report and thank him for highlighting that the working channel of the EN-450P5/20 double-balloon enteroscope (outer diameter 8.5 mm) measures 2.2 mm and that of the EN-450T5 (outer diameter 9.4 mm) measures 2.8 mm [1]. We regret not attaching the details. In the conclusion we actually mentioned an option with a 2.8 mm channel, which we gathered from our case series ([Fig. 1]).

We are aware of the recent excellent published work of their team on the use of a shorter double-balloon enteroscope for endoscopic retrograde cholangiopancreatography (ERCP). The central idea of our report is to emphasize that it is time to progress beyond diagnostic visualization of the biliary system (cumbersome conventional mother–baby cholangioscopy; Spyglass system) and explore ways of adapting different therapeutic endoscopic techniques that are otherwise available in conventional endoscopy. This will only be possible when an instrument with a larger working channel can be manoeuvred into the common bile duct. The technique we described works for dilated ducts. Since the reported case, we have used this technique successfully in nine other patients

In situations with nondilated ducts, diagnostic visualization and sampling will be the major issues and use of the Spyglass system will be a much easier option [2], while alternatives such as the use of slim gastroscopes [3] and short double-balloon endoscopy (DBE) scopes are evolving. The ideal scope for choledochal intubation would have a longer flexible section with extra bending capability ([Fig. 2]) that could be used with an outer tube to reduce looping in the stomach. Double-balloon enteroscopes meet these characteristics, pending the development of more specifically dedicated instruments.

Fig. 1 Cholangioscopy showing dysplastic lesion and common bile duct (CBD) stone. Fig. 2 Flexibility of double-balloon endoscopy (DBE) scope compared with a slim gastroscope.

Competing interests: None.

References

• 1 Double balloon endoscopy. http://www.fujinonendoscopy.com/default.aspx?pageid=125
• 2 Chen Y K, Pleskow D K. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study.  Gastrointest Endosc. 2007;  65 832-841
• 3 Choi H J, Moon J H, Ko B M. et al . Overtube-balloon–assisted direct peroral cholangioscopy by using an ultra-slim upper endoscope [with videos].  Gastrointest Endosc. 2009;  69 935-940