One-step balloon-assisted direct peroral cholangioscopy prior to placing the anti-reflux self-expandable metal stent

Endoscopic biliary drainage with a self-expandable metal stent (SEMS) is the standard treatment for malignant biliary obstructions. Duodenobiliary reflux, which is an unavoidable concern after SEMS placement, results in stent dysfunction [1]. The usefulness of a duckbill-type anti-reflux self-expandable metal stent (D-ARMS) for recurrent biliary obstruction (RBO) has been reported [2].

A 78-year-old woman who had undergone SEMS placement for ampullary carcinoma was admitted to our hospital with acute cholangitis caused by RBO ([Fig. 1]). The placement of the D-ARMS within the lumen of the SEMS was attempted to prevent duodenobiliary reflux. To avoid early stent dysfunction due to food impaction inside the anti-reflux valve, food and sludge should not be in the bile duct before placement of the D-ARMS. Therefore, direct peroral cholangioscopy (DPOCS) using an ultraslim gastroscope (GIF-1200N; Olympus, Tokyo, Japan) was used to confirm bile duct clearance ([Video 1]). This scope has a large (2.2 mm) working channel; therefore, a balloon catheter (B5-2Q, Olympus) with a 0.018-inch guidewire (Fielder 18, Olympus) can be used as the anchoring device. Initially, the endoscope was advanced toward the inferior duodenal angulus. The scope was then turned, and the ampulla was observed in the retroflex position. The balloon catheter was placed deep into the left intrahepatic bile duct, following the guidewire, and the balloon was inflated to anchor the endoscope. By pushing the scope and pulling the balloon, the scope was easily advanced toward the proximal bile duct ([Fig. 2]). Next to the DPOCS procedure, the scope was exchanged with a duodenoscope, and the D-ARMS was placed ([Fig. 3]). No adverse events were observed, and no stent dysfunction occurred after treatment.

Fig. 1 A large amount of sludge and food residue was extracted with a balloon sweep of the bile duct.

Video 1 One-step balloon-assisted direct peroral cholangioscopy procedure and placement of a duckbill-type anti-reflux self-expandable metal stent.

Fig. 2 One-step balloon-assisted direct peroral cholangioscopy. a Endoscopic image showing clearance of the bile duct. b Fluoroscopic image showing the scope position and the inflated balloon (arrow).

Fig. 3 Endoscopic image showing the duckbill-type anti-reflux self-expandable metal stent placed across the papilla.

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• References

• 1 Misra SP, Dwivedi M. Reflux of duodenal contents and cholangitis in patients undergoing self-expanding metal stent placement. Gastrointest Endosc 2009; 70: 317-321
• 2 Yamada Y, Sasaki T, Takeda T. et al. A novel laser‐cut fully covered metal stent with anti‐reflux valve in patients with malignant distal biliary obstruction refractory to conventional covered metal stent. J Hepatobiliary Pancreat Sci 2021; 28: 563-571