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graphy and cholangioscopy (ERCC) combining a single-balloon enteroscope and an ultraslim endoscope in altered gastrointestinal anatomy An 84-year-old man with coronary artery disease, hypertension, diabetes mellitus, and previous Billroth II gastrojejunostomy presented with purulent cholangitis. He underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and placement of a 10-cm 10-Fr double-pigtail stent. During the second ERCP itwas not possible to access the afferent limb. Thus we performed single-balloon ERCP using a therapeutic enteroscope (DBE-EN-450T5, 13.5-mm outer diameter, working channel 2.8mm; TS13140 overtube, outer diameter 13.2mm, inner diameter 10.8mm, working length 1350mm, total length 1450mm; Fujifilm, Tokyo, Japan). The stabilizing effect of the overtube facilitated the enteroscope to enter into theafferent limbandreachthepapilla, fromwhich an exiting double-pigtail stent was seen (●" Fig.1). The stent was grabbed with a basket (25-mm nitinol basket, Teflon outer coating, with 5-Fr diameter; Fujifilm, Willich, Germany) and retrieved while the overtube was left in place (●" Fig.2). Then the scope was reinserted through the overtube. The cholangiogram revealed a tortuously dilated common bile duct (CBD) and multiple filling defects, includinga largestoneandaerobilia. Because direct cholangioscopy using the enteroscopewas not possible because of the relativelysmallpapillaryopening, adecision to use the ultrathin (transnasal) gastroscope (EVIS EXERA II video gastroscope GIF-XP180N; 110-cm working length, 5.5-mm outer diameter, 2.0-mmworking channel; Olympus, Hamburg, Germany) was taken. Because theultrathingastroscopehada total length of 110cm, it could not be advanced through the longer enteroscopy overtube. Therefore, an approximately 60cm segment of the overtube was cut, leaving about 20cm out of the patient’s mouth (●" Fig.3). Then theultrathin scopewasadvanced throughtheovertube intotheafferent limb, and the papillary orifice was again recognized and easily intubated. After intubation of the CBD, a large stone was visualized (●" Fig.4). Scope-guided cholangiography showed a dilated CBD with stones (●" Fig.5). An over-the-wire balloon (0.025 guide wire, MTW, Wesel, Germany; 12-mm, 5-Fr catheter balloon, MTW, Wesel, Germany) was used to pull the stone into the distal part of the CBD. Here itwasgrabbedwith thebasketandretrieved. After stone extraction, a full cholangioscopywasperformedusing theultraslim gastroscope (●" Fig.6). ERCP in patients with surgically altered upper gastrointestinal anatomy is chalFig.1 Plastic stent exiting the papilla of Vater located in the afferent limb.

endoscopy

Therapeutic endoscopic retrograde cholangiography and cholangioscopy (ERCC) combining a single-balloon enteroscope and an ultraslim endoscope in altered gastrointestinal anatomy