Abstract
We thank Matsushita et al for their valuable trial of direct peroral cholangioscopy (POC) using a “short” double-balloon enteroscope in patients with altered GI anatomy. They reported an interesting case involving the treatment of hepatolithiasis with this technique.1Takaoka M. Shimatani M. Ikeura T. et al.Diagnostic and therapeutic procedure with a short double-balloon enteroscope and cholangioscopy in a patient with acute cholangitis due to hepatolithiasis.Gastrointest Endosc. 2009; 70: 1277-1278Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar In our previous feasibility study, we did not perform overtube balloon-assisted direct POC in a patient with altered GI anatomy.2Choi 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: 935-940Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar However, we performed intraductal balloon-guided direct POC in several patients with Billroth II gastrectomies.3Moon J.H. Ko B.M. Choi H.J. et al.Intraductal balloon-guided direct peroral cholangioscopy with an ultraslim upper endoscope (with videos).Gastrointest Endosc. 2009; 70: 297-302Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar Direct POC using an ultraslim upper endoscope is useful for retained common bile duct stones, because it permits direct visualization for electrohydraulic or laser lithotripsy. In addition, lithotripsy under direct visualization with POC was also effective in patients with Billroth II gastrectomy.4Moon J.H. Ko B.M. Choi H.J. et al.Direct peroral cholangioscopy using an ultra-slim upper endoscope for the treatment of retained bile duct stones.Am J Gastroenterol. 2009 July 21; ([Epub ahead of print])Google Scholar ERCP is technically challenging in patients with altered anatomy, and some authors have reported the usefulness of double-balloon enteroscopes in such patients.5Emmett D.S. Mallat D.B. Double-balloon ERCP in patients who have undergone Roux-en-Y surgery: a case series.Gastrointest Endosc. 2007; 66: 1038-1041Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar However, the long length of a double-balloon enteroscope limits its clinical application because of the lack of appropriate long accessories. Matsushita et al performed direct POC through the overtube remaining after a cholangiogram and dilation by using a balloon catheter with a short double-balloon enteroscope, which allowed the use of conventional accessories.6Matsushita M. Shimatani M. Takaoka M. et al."Short" double-balloon enteroscope for ERCP with conventional accessories in patients with altered GI anatomy.Gastrointest Endosc. 2009; 69: 981Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar We expect that their combination technique will be useful for the diagnosis and treatment of biliary disease in patients with altered GI anatomy.
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