Keywords
biliary - cannulation - endoscopic retrograde cholangiopancreatography - sphincterotome
An 83-year-old man with a history of distal gastrectomy and Billroth I reconstruction for a gastric ulcer presented to our hospital with jaundice. Contrast-enhanced computed tomography revealed wall thickening and obstruction at the distal bile duct ([Fig. 1a]), revealing he developed cholangitis, even though vital signs remained stable. Suspecting distal bile duct cancer, we planned to perform endoscopic retrograde cholangiopancreatography with the JF-260V (Olympus, Tokyo, Japan). We initially attempted bile duct cannulation using a conventional catheter; however, due to the altered position of the papilla toward the anterior wall following Billroth I reconstruction, proper alignment of the catheter with either the bile duct or pancreatic duct was not possible ([Fig. 1b]). Consequently, we decided to use the ENGETSU (KANEKA Medix, Osaka, Japan), a novel rotatable sphincterotome, to adjust the catheter's axis. The ENGETSU features a thin 3.7 Fr tip that allows for smooth and precise rotation. By smoothly directing the tip of the ENGETSU toward the 2-o'clock position, we initially succeeded in cannulating the pancreatic duct ([Fig. 1c]). Ultimately, by utilizing the pancreatic guidewire technique to adjust the papilla's position and align the biliary axis, we successfully achieved bile duct cannulation. Diagnostic tissue sampling and bile duct stenting were performed, and the procedure was completed ([Fig. 1d]). There were no obvious complications, and jaundice improved rapidly. After the procedure, the cause of the stricture was confirmed to be distal bile duct cancer.
Fig. 1 Application of a novel rotatable sphincterotome for cannulation in a patient with Billroth I reconstruction. (a) CT findings of an 83-year-old man with a history of distal gastrectomy and Billroth I reconstruction for a gastric ulcer, who presented to our hospital with jaundice. Contrast-enhanced CT revealed wall thickening and obstruction at the distal bile duct (red arrowhead), suspecting distal bile duct cancer. He developed cholangitis even though vital signs remained stable. The total bilirubin level was 7.70 mg/dL, and CA19-9 was 54,283 U/mL. (b) The endoscope used was the JF-260V (Olympus, Tokyo, Japan). The papilla's position is altered toward the anterior wall due to the Billroth I reconstruction, preventing proper alignment of the catheter's axis with the bile duct's axis. (c) By bending and rotating the tip of the ENGETSU, we first successfully cannulated the pancreatic duct. Using the pancreatic guidewire method, we further rotated the ENGETSU to the 11 o'clock position to align with the bile duct axis, achieving successful biliary cannulation. (d) Ultimately, biliary stent placement was successfully achieved, resulting in a favorable outcome. CT, computed tomography.
Rotatable sphincterotomes are known to be useful in cases where aligning the catheter's axis with the bile duct is challenging during cannulation,[1] such as postoperative reconstructed intestinal tracts or situs inversus totalis has been reported.[2]
[3] Unlike other rotational sphincterotomes that rotate the tip section, the ENGETSU allows for flexible and precise rotation of the tip using the cutting wire, enabling the creation of the appropriate angle without delay ([Fig. 2a, b]). This makes it an extremely valuable tool for achieving proper alignment during cannulation ([Video 1]).
Fig. 2 The ENGETSU (KANEKA Medix, Osaka, Japan). (a) The ENGETSU is a novel rotatable sphincterotome with a thin tip of 3.7 Fr. (b) By applying torque to the 0.5 mm core wire connected to the tip through the handle, the tip can be freely rotated in real-time, allowing for flexible and precise adjustments to create the appropriate angle without delay.
Video 1 Successful biliary cannulation using a novel rotatable sphincterotome in a patient with Billroth I reconstruction.
