Post written by Yohei Koyama, MD, from the Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.

Balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) has improved the outcomes of ERCP in patients with surgically altered anatomy. However, BE-ERCP requires high technical expertise, and biliary cannulation is often difficult. An 83-year-old man previously underwent total gastrectomy with Roux-en-Y reconstruction owing to a gastric ulcer. The patient had acute cholangitis and acute pancreatitis owing to impacted common bile duct stones. The patient underwent emergency BE-ERCP. We described the 2-devices-in-1channel method in a Roux-en-Y patient.

Selective biliary cannulation failed because the orifice of the major papilla was not visible owing to the hooding fold. Thus, we performed biliary cannulation using the 2-devices-in-1-channel method. Initially, the cholangioscopy forceps was inserted in the accessory channel, and the papilla was pushed downward by the opened forceps to visualize the orifice endoscopically. Then, a slim catheter with a guidewire was inserted alongside the forceps in the same channel, selected biliary wire-guided cannulation with contrast injection was conducted, and selective biliary cannulation was successfully accomplished.

We think the 2-devices-in-1-channel method using the cholangioscopy forceps is a safe and effective alternative technique for difficult cases involving biliary cannulation in the setting of surgically altered upper gastrointestinal tract anatomy.

Basically, our policy for the treatment of bile duct stones is transpapillary stone removal. Then, if ERCP fails, we will consider EUS-guided antegrade stone extraction as a salvage therapy.

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