Utilizing a novel highly rotatable and dual-action sphincterotome for precise cannulation and endoscopic sphincterotomy in surgically altered anatomy

Abstract

Balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) has become increasingly common in the management of pancreatobiliary diseases in patients with surgically altered anatomy.^{1, 2} In cases of Billroth II or Roux-en-Y reconstruction where the duodenal papilla is preserved, papillary interventions are essential for both diagnostic evaluations or treatments. However, performing precise cannulation and endoscopic sphincterotomy (EST) during BE-ERCP can be challenging.³ One reason for this difficulty is that the endoscope's angulation required for directly facing the papilla often causes the sphincterotome's tip and blade to orient away from the desired direction, typically opposite of the oral protrusion (Fig. 1a,b). While various sphincterotomes have been reported to be useful,^{4, 5} the optimal device and technique remain unclear. Recently, a novel highly rotatable and dual-action sphincterotome (ENGETSU; KANEKA Medix Co., Osaka, Japan) has become available, offering the potential to change the incision direction freely to switch between push and pull modes with rotation, thereby enabling precise cannulation and EST (Fig. 1c,d; Video S1).

A 68-year-old man with a history of total gastrectomy followed by Roux-en-Y reconstruction presented with choledocholithiasis. BE-ERCP with short-type double balloon enteroscope (EI-580BT; Fujifilm Co., Tokyo, Japan) was performed to access the papilla. Upon inserting the sphincterotome, the curvature of the endoscope tip caused the blade to be directed opposite the side of the oral protrusion. By utilizing the rotational capability and alternating between push and pull modes, the catheter tip was successfully cannulated and the blade was directed towards the oral protrusion, allowing for precise incision (Fig. 2). Endoscopic papillary large-balloon dilatation was added after EST and the stones were successfully removed without adverse events. The novel sphincterotome enabled efficient cannulation and EST, demonstrating the device's utility not only in cases with normal anatomy using side-viewing duodenoscopes, but also in surgically altered anatomy with balloon-assisted endoscopy.

Authors declare no conflict of interest for this article.