Modification of intubation techniques during ERCP in patients with Zenker’s diverticulum

Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with Zenker’s diverticulum can be technically difficult and is associated with the risk of oesophageal perforation with subsequent mediastinitis. Therefore, resistance is felt during oesophageal intubation with a duodenoscope, the operator should use a gastroscope to visualize any obstruction. If the existence of an oesophageal pouch is recognised, intubation can be safely performed using a guide-wire over tube technique. However, in specific situations (e.g., narrow oesophageal orifices in patients with low body mass index (BMI)) despite use of guide-wire technique, intubation can still be difficult. Therefore we present a modified guide-wire technique involving rotation of the duodenoscope under fluoroscopy, which opens the entrance to the oesophagus and enables safe intubation.