Overtube-assisted placement of a metal stent into the bile duct of a patient with surgically altered upper-gastrointestinal anatomy during double-balloon enteroscopy-assisted ERCP.

Wehere report on a novel approach to deliver a fully covered self-expanding metal stent (SEMS) into the bile duct during double-balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) using the overtube as an “accessory” or working channel. An 87-year-old woman with a history of a Billroth II reconstruction many years previously and complex choledocholithiasis had previously undergone several ERCP attempts via both a colonoscope and a double-balloon enteroscope to clear the bile duct, which had been found to be dilated, tortuous, and distally stenotic (●" Fig.1a). A further DBE-ERCP (DBE-EN-450T5; Fujifilm, Saitama, Japan) was performed. During this procedure, a sphincteroplasty was performed using a 15-mm controlled radial expansion (CRE) balloon (Boston Scientific; Natick, Massachusetts, USA; ●" Fig.1b). An electrohydraulic lithotriptor was then successfully delivered through an ultraslim gastroscope (GIF180; Olympus, USA), which had been advanced into the bile duct through an overtube (●" Fig.1c). After electrohydraulic lithotripsy (EHL) had been successfully performed, large amounts of sludge and stones were removed. Nevertheless, complete clearance of the stones was still not possible. Fig.1 Fluoroscopic images during double-balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) in an 87-year-old woman with a history of a Billroth II reconstruction and complex choledocholithiasis showing: a multiple bile duct stones in the distally stenosed bile duct; b balloon sphincteroplasty being performed; c peroral direct cholangioscopic electrohydraulic lithotripsy being performed via an ultraslim gastroscope.