Successful cannulation using a novel rotatable sphincterotome in a hepaticojejunal anastomotic stricture with a steep angle

Balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) is useful in patients with a hepaticojejunal anastomotic stricture [1] [2] [3]. However, biliary cannulation for such a stricture is challenging especially in cases with a steep angle, because the balloon enteroscope has no elevator function to angulate the cannulation catheter. We report a case of successful cannulation using a novel rotatable sphincterotome in a patient with a hepaticojejunal anastomotic stricture at a steep angle.

A 68-year-old man who underwent hepaticojejunostomy with Roux-en-Y owing to hilar bile duct cancer was referred to our facility because of recurrent cholangitis. Magnetic resonance imaging revealed a slight biliary dilation in the intrahepatic bile duct ([Fig. 1]). Therefore, ERCP was performed using a short-type single-balloon enteroscope (SIF-H290; Olympus, Tokyo, Japan) with a working length of 152 cm and a working channel diameter of 3.2 mm [2] ([Video 1]). After reaching the hepaticojejunal anastomosis, we observed the occurrence of a hepaticojejunal anastomotic stricture ([Fig. 2]). Biliary cannulation using a conventional catheter was unsuccessful. The steep angle to the bile duct made biliary cannulation difficult. Therefore, we used a rotatable sphincterotome (Seeking Tome ZERO; MTW Endoskopie, Wesel, Germany) with a 1.8-mm tip diameter to achieve biliary cannulation ([Fig. 3]). Guidewire seeking was attempted while angulating the sphincterotome. This allowed successful biliary cannulation ([Fig. 4]). Cholangiography revealed the absence of stones. Subsequently, dilation of the stricture using a 4-mm dilation balloon catheter (REN; Kaneka, Tokyo, Japan) was performed, followed by plastic stent placement ([Fig. 5]).

Fig. 1 Magnetic resonance imaging revealing slight biliary dilation (red arrow) in the intrahepatic bile duct.

Fig. 2 Endoscopic findings revealing the occurrence of a hepaticojejunal anastomotic stricture in the hepaticojejunal anastomosis (red arrow).

Fig. 3 A novel rotatable sphincterotome with a tip diameter of 1.8 mm.

Fig. 4 Endoscopic and fluoroscopic findings. Biliary cannulation is achieved by seeking the guidewire while angulating the sphincterotome.

Fig. 5 Endoscopic and fluoroscopic findings. a Cholangiography revealing the absence of stones. b Cholangiography revealing the dilation of the stricture using a 4-mm dilation balloon catheter. c,d Endoscopic findings and cholangiography showing the plastic stent placement.

Successful cannulation using a novel rotatable sphincterotome in a patient with a hepaticojejunal anastomotic stricture at a steep angle.Video 1

Compared to a previously reported rotatable sphincterotome [4] [5], this novel sphincterotome can be rotated even if there is hardly distance to the target site because it lacks a nose between the blade and the tip, which was helpful for our case. This novel rotatable sphincterotome can improve the success rate of biliary cannulation in difficult cases of hepaticojejunal anastomotic stricture.

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Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

We would like to thank Editage (www.editage.com) for English language editing.

• References

• 1 Yane K, Katanuma A, Maguchi H. et al. Short-type single-balloon enteroscope- assisted ERCP in postsurgical altered anatomy: Potential factors affecting procedural failure. Endoscopy 2017; 49: 69-74
• 2 Tanisaka Y, Ryozawa S, Mizuide M. et al. Usefulness of the “newly designed” short-type single-balloon enteroscope for ERCP in patients with Roux-en-Y gastrectomy: a pilot study. Endosc Int Open 2018; 6: E1417-E1422
• 3 Tanisaka Y, Ryozawa S, Itoi T. et al. Efficacy and factors affecting procedure results of short-type single-balloon enteroscopy-assisted ERCP for altered anatomy: a multicenter cohort in Japan. Gastrointest Endosc 2022; 95: 310-318.e1
• 4 Kurita A, Kudo Y, Yoshimura K. et al. Comparison between a rotatable sphincterotome and a conventional sphincterotome for selective bile duct cannulation. Endoscopy 2019; 51: 852-857
• 5 Takenaka M, Yoshikawa T, Okamoto A. et al. Novel sphincterotomy device that orientates blade along the axis of the bile duct in patients with Roux-en-Y anastomosis. Endoscopy 2019; 51: E132-E134

Publication History

Article published online:
09 April 2024