S2330 Altered Anatomy ERCP Using a Novel Dynamic Rigidizing Overtube

Abstract

INTRODUCTION: Biliary stone removal is challenging in patients with surgically altered anatomy. Double Balloon Enteroscopy (DBE) has been used to assist ERCP with cannulation, but it is often difficult and channel size is suboptimal for ERCP equipment. Antegrade EUS-guided techniques can sometimes be used but it can be challenging with higher risk. A novel dynamic rigidizing overtube is now available to help complete colonoscopy in a difficult looping colon. Normally the overtube is completely pliable, but when a vacuum is applied it becomes 15 times more rigid, providing stability and preventing looping. In this case, we use this novel overtube to complete a complex ERCP in a patient with altered anatomy. CASE DESCRIPTION/METHODS: This is a 42-year-old female with a history of iatrogenic bile duct transection during cholecystectomy who underwent Roux-en-Y Hepaticojejunostomy (HJ). Her course was complicated by HJ stricture requiring balloon-assisted enteroscopy with ERCP to place a fully-covered metal stent. After 3 months the stent was removed, but restricturing occurred 6 months later and she developed left-sided intrahepatic stone disease. Double balloon enteroscopy to reach the anastomosis became more difficult. As a result, multiple antegrade procedures via EUS placed Hepaticogastrostomy with lithotripsy were used to treat accessible intrahepatic stones, but several more remained. To facilitate further endoscopic procedures, a shortcut was made using laparoscopic revision to create a new entero-enterostomy from the proximal jejunum to the pancreaticobiliary (PB) limb. Repeat enteroscopy with a slim colonoscope failed to enter the PB limb despite multiple attempts due to difficult angulation and looping in the stomach. A dynamic rigidizing overtube was then used to assist with enteroscopy to reach the HJ. The rigidizing overtube, placed over the colonoscope, allowed the scope to advance to the HJ without looping in the stomach and provided improved control up the ascending PB limb. The colonoscope then deployed a stone extraction balloon to remove biliary duct stones. Cholangiogram confirmed stone removal and bile duct clearance. DISCUSSION: This case demonstrates the use of a rigidizing overtube to prevent looping and assist with complex stone removal via ERCP in altered anatomy. Such a device may be useful in other altered anatomy ERCP cases when anterograde approaches fail and a luminal approach is required.Figure 1.: Demonstration of rigidizing overtube. Overtube is advanced over colonoscope to its hub. Normally it is flexible, providing for normal movement during endoscopy. When a vacuum is applied it allows 1 to 1 movement, providing stability and reducing looping.Figure 2.: Stone removal with visible filling defect distal to injected contrast. Stone was removed using an extraction balloon via colonoscope and clearance was confirmed with a repeat cholangiogram.