Matheus Cavalcante Franco, MD, MSc, from the Cancer Institute of São Paulo, University of São Paulo, in São Paulo, Brazil shares this VideoGIE case, “ERCP with balloon-overtube–assisted enteroscopy in postsurgical anatomy.”

We reported a video case of a 59-year-old man, with past surgical history of partial gastrectomy with Roux-en-Y anastomosis due to peptic ulcer complication. He presented with a 2-week history of jaundice and abdominal pain. Further investigation with MRI revealed choledocholithiasis, and therefore he was referred for endoscopic retrograde cholangiopancreatography (ERCP).

We performed ERCP with balloon-overtube-assisted enteroscopy. After reaching the papilla of Vater with single balloon enteroscopy, we removed the enteroscope and then we straightened the overtube with inflated balloon to minimize the risk of losing its position. At this point we cut almost the entire circumference of the overtube near the patient’s mouth, taking care to spare the balloon channel. The 8.8 mm diameter gastroscope, with a 2.8 mm working channel, was then introduced and the papilla was easily reached. Standard ERCP accessories were used to perform needle-knife sphincterotomy, ampulla balloon dilation and stone removal (Video). The patient’s recovery was uneventful.

We know that the endoscopic access to papilla of Vater or hepaticojejunostomy to perform ERCP is technically challenging after Roux-en-Y anastomosis. Even though it may be possible to reach the excluded biliary limb, successful cannulation is limited if longer accessories are not available. Cutting the overtube near the patient’s mouth is a trick that allowed us to use standard ERCP accessories through a gastroscope.

In some countries, long ERCP accessories are not commercially available. At this point we could not tell whether our approach if preferable to using longer accessories designed for the enteroscope. But, we concluded that the proposed technique may be a possible alternative when longer ERCP accessories are not available.

We hope that videos such as this may have potential applications for other endoscopists who deal with such challenging cases.

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