CC BY-NC-ND 4.0 · Endoscopy 2022; 54(S 02): E900-E901
DOI: 10.1055/a-1847-7609
E-Videos

A traction device to aid the intubation of a surgically altered bile duct during ERCP

Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan
,
Masahiro Yanagi
Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan
,
Naoki Oishi
Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan
,
Eiki Matsushita
Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan
› Author Affiliations
 

A 92-year-old woman was admitted for acute cholangitis with multiple common bile duct (CBD) stones. We performed endoscopic retrograde cholangiopancreatography (ERCP) using a front-viewing endoscope (PCF-Q260AZI; Olympus, Tokyo, Japan) because she had undergone distal gastrectomy with Billroth II reconstruction. However, the ampulla of Vater was not fixed in front, making it difficult to intubate the CBD ([Fig. 1]). Computed tomography and magnetic resonance cholangiopancreatography showed kinking of the lower end of the CBD due to surgical manipulation ([Fig. 2]). Thus, traction was applied via a traction device (S-O clip; Zeon Medical Inc., Tokyo, Japan), which was connected to the oral side of the ampulla of Vater; the loop of the clip was grasped ([Fig. 3 a]) and secured proximally for traction ([Fig. 3 b]). As a result, the torsion of the CBD resolved, and the ampulla of Vater could be viewed from the front ([Fig. 4 a]). The CBD was then easily intubated ([Fig. 4 b]) and a plastic stent was placed for drainage.

Zoom Image
Fig. 1 Intubating the common bile duct was not possible with conventional methods.
Zoom Image
Fig. 2 Images showing kinking of the end of the common bile duct due to postoperative effects. a Computed tomography. b Magnetic resonance cholangiopancreatography.
Zoom Image
Fig. 3 Application of the traction device. a An S-O clip (Zeon Medical Inc., Tokyo, Japan) was connected to the oral side of the ampulla of Vater and the loop of the clip was grasped. b The clip was secured proximally for traction.
Zoom Image
Fig. 4 Effect of the traction device on the common bile duct (CBD). a The torsion of the CBD was resolved, and the ampulla of Vater was fixed at the front. b Intubation of the CBD was then easily performed.

Later, we attempted to remove the CBD stones via ERCP using a short-type single-balloon enteroscope (SIF-Q260; Olympus, Tokyo, Japan). Unfortunately, the traction on the S-O clip was lost. Thus, the traction device technique was repeated ([Video 1]), and the CBD was easily intubated on the first attempt. Complete removal of stones was achieved via endoscopic papillary large-balloon dilation.

Video 1 The S-O clip traction technique. First, an S-O clip (Zeon Medical Inc., Tokyo, Japan) was connected to the oral side of the ampulla of Vater and its loop was grasped. Next, the clip was secured proximally for traction. The torsion of the common bile duct (CBD) was resolved, and the ampulla of Vater was fixed at the front. The CBD was then easily intubated.


Quality:

Cases of difficult CBD intubation during ERCP have been reported [1]. The traction device (S-O clip) can also be used in complex cases with diverticular papillae during conventional ERCP [2]. CBD intubation using this device for diverticular papilla in Roux-en-Y reconstruction has also been reported [3]. However, our patient had a postoperative bile duct flexure rather than a diverticular papilla, distinct from the previous case. The traction device technique used in our case is summarized in [Fig. 5].

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Fig. 5 A summary of the traction technique used in our patient.

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Competing interests

The authors declare that they have no conflict of interest.

Acknowledgment

We are grateful to Mr. Noriaki Okada (Zeon Medical Inc.) for creating the schema.

  • References

  • 1 Freeman ML, Guda NM. ERCP cannulation: a review of reported techniques. Gastrointest Endosc 2005; 61: 112-125
  • 2 Inoue R, Kawakami H, Kubota Y. et al. Endoscopic biliary intervention using traction devices for periampullary diverticulum. Intern Med 2019; 58: 2797-2801
  • 3 Takeshita K, Asai S, Fujimoto N. et al. Usefulness of the S-O clip in balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography. Endoscopy 2021; 53: E372-E373

Corresponding author

Tsuyoshi Suda, MD
Department of Gastroenterology
Kanazawa Municipal Hospital
3-7-3, Heiwamachi
Kanazawa, Ishikawa 921-8105
Japan   

Publication History

Article published online:
01 July 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Freeman ML, Guda NM. ERCP cannulation: a review of reported techniques. Gastrointest Endosc 2005; 61: 112-125
  • 2 Inoue R, Kawakami H, Kubota Y. et al. Endoscopic biliary intervention using traction devices for periampullary diverticulum. Intern Med 2019; 58: 2797-2801
  • 3 Takeshita K, Asai S, Fujimoto N. et al. Usefulness of the S-O clip in balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography. Endoscopy 2021; 53: E372-E373

Zoom Image
Fig. 1 Intubating the common bile duct was not possible with conventional methods.
Zoom Image
Fig. 2 Images showing kinking of the end of the common bile duct due to postoperative effects. a Computed tomography. b Magnetic resonance cholangiopancreatography.
Zoom Image
Fig. 3 Application of the traction device. a An S-O clip (Zeon Medical Inc., Tokyo, Japan) was connected to the oral side of the ampulla of Vater and the loop of the clip was grasped. b The clip was secured proximally for traction.
Zoom Image
Fig. 4 Effect of the traction device on the common bile duct (CBD). a The torsion of the CBD was resolved, and the ampulla of Vater was fixed at the front. b Intubation of the CBD was then easily performed.
Zoom Image
Fig. 5 A summary of the traction technique used in our patient.