Hideaki Harada, MD, from the Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan presents this VideoGIE case “Inverted frontal view method facilitates bile duct cannulation via the intact papilla in patients with Roux-en-Y anastomosis.”

An 85-year-old-man who had undergone total gastrectomy plus Roux-en-Y reconstruction was referred to our department with calculus-related cholangitis. We describe the inverted frontal view method (IFVM) and present a case to demonstrate the effectiveness of the procedure. Using a short-type double-balloon enteroscope, we succeeded in reaching the blind end. We detected the intact papilla, but failed to cannulate the bile duct using wire-guided cannulation because of the tangential approach to the papilla. Therefore, we obtained a frontal view of the papilla using IFVM.

After the endoscope located near the papilla, this makes it necessary to push the endoscope slowly while angling up. Pushing the endoscope fully coincident with sharply angling up and left while confirming states of nothing a feeling of resistance and a catching the wall of duodenum for the tip of the endoscope under fluoroscopic guidance, it is possible to obtain a frontal view of the intact papilla. Because of IFVM, the axis of the bile duct was located at a 5- to 6-o’clock position, opposite to that of conventional ERCP. The catheter emerges in the 6- to 7-o’clock position on opening the forceps port of double-balloon enteroscope. Because the catheter was directed towards the center of the visual field, it was easy to insert the catheter into the bile duct.

IFVM facilitated easy cannulation of the bile duct. IFVM also stabilized the endoscope for inversion of the endoscope tip in the intestinal tract. We believe that IFVM is effective for cannulation of the intact papilla with Roux-en-Y anastomosis.

This case presents that IFVM facilitated both access to the papilla and cannulation by enabling a frontal view and by stabilizing the endoscope, and use of IFVM reduced the time taken to achieve cannulation.

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