Post written by Mike Tzuhen Wei, MD, from Stanford University, Stanford, and Veterans Affairs Palo Alto, Palo Alto, California.

We present 2 cases in which the rigidizing overtube was used to facilitate performance of altered-anatomy ERCP. In the first case, a 53-year-old woman with history of Roux-en-Y hepaticojejunostomy presented for management of intrahepatic stones. Interventional Radiology had initially placed a percutaneous biliary drain and later a metal stent across the hepaticojejunostomy. With the use of the rigidizing overtube, the hepaticojejunostomy anastomosis site was easily reached, allowing for stent removal, dilation of the anastomosis, and placement of plastic stents in the intrahepatic ducts.

In the second case, a 49-year-old man with history of WHO grade I insulinoma leading to pylorus-preserving Whipple 6 months prior presented for management of biliary obstruction. Three months prior, interventional radiology had placed a right-sided transhepatic internal-external biliary drain across the strictured choledochojejunostomy. In the current ERCP procedure, the rigidizing overtube facilitated accessing the choledochojejunostomy, allowing for dilation of the choledochojejunostomy anastomosis and placement of a double-pigtail plastic stent in the common bile duct.     

These 2 cases illustrate the utility of the recently FDA approved Pathfinder Endoscope Overtube (Neptune Medical, Burlingame, CA, USA). The rigidizing overtube exists in 2 states–flexible and stiffened. Application of a vacuum allows the overtube to stiffen up to 15 times. This capability allows the rigidizing overtube to be used in a wide variety of applications, including upper endoscopy, colonoscopy, and enteroscopy. In particular, we find the rigidizing overtube to be useful in the completion of altered-anatomy ERCP. The overtube prevents looping and improves endoscope tip control.     

Endoscopists can use the rigidizing overtube to overcome many of the frustrations caused by looping. While further studies are needed to demonstrate the utility of the rigidizing overtube, we feel that one way in which the overtube can enhance an advanced endoscopist’s practice is its use in performing altered-anatomy ERCP.

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