Post written by Naminatsu Takahara, MD, PhD, and Yousuke Nakai, MD, PhD, from the Department of Endoscopy and Endoscopic Surgery, The University of Tokyo, Tokyo, Japan.

A 51-year-old man was referred for the management of malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO) due to pancreatic head cancer. A biliary covered metallic stent and gallbladder plastic stent had been placed for MBO and concomitant cholecystitis, followed by duodenal stent (DuS) placement for GOO. Three months later, cholecystitis recurred due to gallbladder plastic stent dysfunction. Since the patient refused percutaneous cholecystostomy, we decided to perform ERCP through the DuS and exchange both biliary and gallbladder stents. Because a duodenoscope (ED-580T; Fujifilm, Tokyo, Japan) could not pass the DuS due to tissue hyperplasia, we exchanged the scope for a double-balloon endoscope (DBE, EI-580BT; Fujifilm); this system consists of a thin and flexible scope with a 3.2-mm working channel and equipment of overtube and balloons, ensuring an advanced scope insertability with stabilization and subsequent interventions using standard ERCP devices. A DBE completely passed through the DuS, and the 2 stents were safely removed. Then, with the endoscopic inversion technique in the second portion of the duodenum (just distal to the DuS), we could successfully achieve the biliary access and stent exchange; a pigtail plastic stent (HANACO medical, Saitama, Japan) for gallbladder and a biliary metallic stent (Zilver, COOK, Tokyo, Japan) were positioned in a side-by-side fashion.

Recently, a new short-type DBE (EI-580BT) was developed to facilitate pancreaticobiliary interventions in patients with surgically altered anatomy. This thin and flexible scope features an advanced forced-transmission insertion tube and adaptive bending, which allowed easy scope passage through the narrow and angulated GI tract as well as DuS. Furthermore, the small bending radius of the scope tip enables an approach to the papilla by making a retroflex position in the duodenum. Therefore, despite the disadvantage of its longer length and lack of elevator system, this scope can be applicable to biliary interventions in patients with normal anatomy but indwelling a DuS.

The endoscopic inversion technique in the duodenum using a double-balloon endoscope can be an alternative for the transpapillary biliary reintervention through an indwelling DuS.

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