Use of a rigidizing overtube for altered-anatomy ERCP.

ERCP is important in managing biliary and pancreatic disorders. However, the success of altered anatomy ERCP depends on overcoming challenges including traversing the variable length of the afferent jejunal limb, intubating the surgical anastomosis, cannulating the papilla, and restrictions of tools depending on the endoscope used.,

Developments to help achieve altered-anatomy ERCP have included the multibending backward–oblique-viewing duodenoscope, variable-stiffness duodenoscope, and multibending forward-viewing endoscope. Although single-balloon and double-balloon enteroscopes can be used to perform altered-anatomy ERCP, the long endoscope length limits the use of conventional ERCP accessories. Short-type single-balloon and double-balloon enteroscopes have been developed but are not widely used. Given the challenges with altered-anatomy ERCP, developing new tools to improve procedural success is important.

The U.S. Food and Drug Administration approved the Pathfinder Endoscope Overtube (Neptune Medical, Burlingame, Calif, USA) in August 2019., The Pathfinder Endoscope Overtube is an 85-cm-long single-use overtube (16.5 mm diameter) that can exist in 2 states, flexible or rigidized (Fig. 1). Once the flexible overtube and the endoscope are advanced and in the most reduced position, vacuum application stiffens the overtube up to 15 times. The rigidizing overtube can be used in upper endoscopy, colonoscopy, and enteroscopy. We present 2 cases of altered-anatomy ERCP (Video 1, available online at www.VideoGIE.org).

Figure 1

The Pathfinder endoscope is an 85-cm-long single-use overtube that can exist in 2 states, flexible or stiffened. Application of a vacuum stiffens the endoscope up to 15 times.

Case 1

A 53-year-old woman with a history of recurrent pyogenic cholangitis secondary to choledochal cysts leading to a Roux-en-Y hepaticojejunostomy (in 1993) presented for management of intrahepatic stones. Since 1993, the patient had undergone 2 surgical revisions and multiple ERCPs. Six months before the current presentation, she underwent an ERCP that identified a severe localized stricture at the hepaticojejunostomy anastomosis that could not be traversed. Interventional radiology subsequently helped place a percutaneous biliary drain and later a fully covered metal stent across the hepaticojejunostomy.

During the current procedure, a thin colonoscope was introduced with the rigidizing overtube, and the scope easily reached the widely patent jejunojejunostomy anastomosis. The afferent jejunal limb was traversed and the scope reached the hepaticojejunostomy and identified the fully covered metal stent (Fig. 2). Contrast injection demonstrated a patent stent and mild dilatation of the intrahepatic bile ducts. The stent was removed, and with the overtube maintained in its rigidized position, the endoscope easily returned to the hepaticojejunostomy. The anastomosis was characterized by 2 orifices. The smaller of the 2 orifices was dilated, and plastic stents were placed in this orifice as well as in different branches of the intrahepatic ducts (Fig. 3).

Figure 2

Case 1. A, Widely patent jejunojejunal anastomosis with healthy-appearing mucosa. B, Fully covered metal stent found across the hepaticojejunostomy.

Figure 3

A, Hepaticojejunostomy site after removal of stent. The anastomosis was characterized by 2 orifices. The smaller orifice is marked with the arrow. B, Dilation of the smaller orifice was performed. C, Plastic stents were placed in the smaller of the 2 orifices at the hepaticojejunostomy anastomosis as well as in different branches of the intrahepatic ducts.

Case 2

A 49-year-old man with a history of World Health Organization grade I insulinoma leading to pylorus-preserving Whipple 6 months earlier presented for altered-anatomy ERCP. Three months after Whipple, the patient had biliary obstruction. ERCP at the time identified a completely occluded choledochojejunostomy. Interventional radiology placed a right-sided transhepatic biliary drain, which was later converted to a right-sided transhepatic internal-external biliary drain with the stricture traversed by a plastic catheter.

During the current procedure, a thin colonoscope and overtube were introduced and demonstrated a widely patent postpyloric anastomosis. The choledochojejunostomy was identified in the afferent jejunal loop. The bile duct was cannulated alongside the catheter, and cholangiogram demonstrated mild dilation of the common hepatic duct and normal caliber of the intrahepatic ducts. Dilation of the choledochojejunostomy anastomosis was performed, and a double-pigtail plastic stent was inserted into the common bile duct (Fig. 4).

Figure 4

Case 2. A, Strictured choledochojejunostomy with drain by interventional radiology. B, Balloon dilation of the choledochojejunostomy stricture was performed.

Our 2 cases demonstrate the utility of the rigidizing overtube in accomplishing altered-anatomy ERCP. Success varies with intubation and cannulation in ERCP for patients with surgically altered anatomy. The rigidizing overtube is a simple tool to overcome the challenges of altered-anatomy ERCP. Although both cases had undergone ERCP before, the performance of ERCP in the current presentation was significantly enhanced with the rigidizing overtube. The overtube reduces looping, allowing for increased distances that shorter scopes (such as a side-viewing duodenoscope) are unable to achieve. This is particularly important in managing gastric loops and the tight angulation at surgical anastomoses, including the jejunojejunostomy anastomosis. The overtube can accommodate an endoscope up to 11.5 mm in diameter and as such can be used with a duodenoscope, thin colonoscope, or therapeutic upper endoscope, allowing traditional ERCP tools to be used, unlike with single-balloon or double-balloon enteroscopy. Furthermore, the overtube can help stabilize the endoscope tip, allowing for fine therapeutic maneuvers. Overall, we believe that these benefits come with very minimal increased risk beyond the average risk of altered-anatomy ERCP. In fact, by reducing looping, decreasing procedural time, and improving ease of procedure, performing altered-anatomy ERCP with a rigidizing overtube may actually decrease risk as well as cost. However, additional safety and cost-effectiveness studies will be needed to better evaluate these possibilities.

Although additional studies are needed, here we have demonstrated its use in assisting with the challenging altered-anatomy ERCP.

Disclosure

Dr Friedland is a consultant for Capsovision. Dr Watson is a consultant/speaker for Apollo Endosurgery, Boston Scientific, and Neptune Medical. Dr Hwang is a consultant for Olympus, Medtronic, Boston Scientific, Micro-Tech, and Lumendi. All other authors disclosed no financial relationships.