Successful endoscopic retrograde cholangiopancreatography and bilateral stenting in a patient with situs inversus totalis

Abstract

A 60-year-old man with situs inversus totalis (SIT) presented with jaundice. Two years earlier, he had been diagnosed with unresectable hepatocellular carcinoma (HCC) and treated with transcatheter arterial chemoembolization thrice. Computed tomography and magnetic resonance cholangiopancreatography revealed intrahepatic duct (IHD) dilatation caused by extrinsic compression from the large HCC (Fig. 1). During endoscopic retrograde cholangiopancreatography (ERCP), the patient was placed in the prone position, with the endoscopist on the patient's right side (Fig. 2). Because of SIT, the duodenoscope was rotated through 180° clockwise in the stomach. At the second portion of the duodenum, the duodenoscope was adjusted slightly to visualize the ampulla. For better and easier access, cannulation, sphincterotomy, and selective wire placement in both IHDs were performed by a physician-controlled wire-guided cannulation (PCWGC) technique using a rotatable sphincterotome (Autotome Sphincterotome, Boston Scientific, Marlborough, MA, USA). After wire-guided cannulation, cholangiography showed IHD obstruction by extrinsic compression from the large mass. Two plastic stents were placed in both IHDs without any complications, and the patient was discharged in a good condition.Fig. 2Endoscopic retrograde cholangiopancreatography in our patient with situs inversus totalisShow full caption(a) Endoscopy showing duodenal luminal narrowing due to ischemic damage after transcatheter arterial chemoembolization.(b) Endoscopic view showing the papilla oriented to the right side after adjustment of the left and up angles of the duodenoscope.(c) Successful cannulation and endoscopic sphincterotomy are easily performed using a rotatable sphincterotome.(d) The duodenoscope is rotated 180° clockwise in the stomach and advanced to the second portion of the duodenum.(e) Initial cholangiography showing a non-visible intrahepatic duct and a large mass with lipiodol uptake.(f) Final cholangiography showing two biliary plastic stents (arrowheads; 7Fr. single pig-tail, 12 and 15 cm) in the right and left intrahepatic ducts.View Large Image Figure ViewerDownload Hi-res image Download (PPT)With limited ERCP cases in patients with SIT, several technical tips for successful cannulation have been reported [[1]Lee J.M. Lee J.M. Hyun J.J. et al.Successful access to the ampulla for endoscopic retrograde cholangiopancreatography in patients with situs inversus totalis: a case report.BMC Surg. 2017; 17: 112Crossref PubMed Scopus (9) Google Scholar]. Our experience is that positional and technical changes are not necessary. Additionally, 180° clockwise rotation in the stomach, a rotatable sphincterotome, and a PCWGC technique help achieve successful procedure. A 60-year-old man with situs inversus totalis (SIT) presented with jaundice. Two years earlier, he had been diagnosed with unresectable hepatocellular carcinoma (HCC) and treated with transcatheter arterial chemoembolization thrice. Computed tomography and magnetic resonance cholangiopancreatography revealed intrahepatic duct (IHD) dilatation caused by extrinsic compression from the large HCC (Fig. 1). During endoscopic retrograde cholangiopancreatography (ERCP), the patient was placed in the prone position, with the endoscopist on the patient's right side (Fig. 2). Because of SIT, the duodenoscope was rotated through 180° clockwise in the stomach. At the second portion of the duodenum, the duodenoscope was adjusted slightly to visualize the ampulla. For better and easier access, cannulation, sphincterotomy, and selective wire placement in both IHDs were performed by a physician-controlled wire-guided cannulation (PCWGC) technique using a rotatable sphincterotome (Autotome Sphincterotome, Boston Scientific, Marlborough, MA, USA). After wire-guided cannulation, cholangiography showed IHD obstruction by extrinsic compression from the large mass. Two plastic stents were placed in both IHDs without any complications, and the patient was discharged in a good condition. (a) Endoscopy showing duodenal luminal narrowing due to ischemic damage after transcatheter arterial chemoembolization. (b) Endoscopic view showing the papilla oriented to the right side after adjustment of the left and up angles of the duodenoscope. (c) Successful cannulation and endoscopic sphincterotomy are easily performed using a rotatable sphincterotome. (d) The duodenoscope is rotated 180° clockwise in the stomach and advanced to the second portion of the duodenum. (e) Initial cholangiography showing a non-visible intrahepatic duct and a large mass with lipiodol uptake. (f) Final cholangiography showing two biliary plastic stents (arrowheads; 7Fr. single pig-tail, 12 and 15 cm) in the right and left intrahepatic ducts. With limited ERCP cases in patients with SIT, several technical tips for successful cannulation have been reported [[1]Lee J.M. Lee J.M. Hyun J.J. et al.Successful access to the ampulla for endoscopic retrograde cholangiopancreatography in patients with situs inversus totalis: a case report.BMC Surg. 2017; 17: 112Crossref PubMed Scopus (9) Google Scholar]. Our experience is that positional and technical changes are not necessary. Additionally, 180° clockwise rotation in the stomach, a rotatable sphincterotome, and a PCWGC technique help achieve successful procedure. No conflicts of interest have been declared.