Migration of a Duodenoscope to the Esophagus Which Was Successfully Retrieved Using a Recovery Method: A Rare Complication of Endoscopic Retrograde Cholangiopancreatography

CASE REPORT A 69-year-old man underwent endoscopic retrograde cholangiopancreatography to remove a common bile duct stone. The trainee initially inserted the TJF-Q290V duodenoscope from Olympus, Japan, with the patient in the inverse-alpha position (Figure 1). The duodenoscope was pulled, and then the inverse-alpha loop shrank (Figure 1). When continuing to pull the duodenoscope to modify the loop, the tip of the duodenoscope migrated to the esophagus and became stuck (Figures 1 and 2). We decided not to perform forcible control since it is associated with either perforation or esophageal dissection.1,2 We inserted a nasal endoscope (GIF-1200 N, Olympus) and pushed the tip of the duodenoscope directly (Figure 2: Endoscopy; X-ray). The duodenoscope was returned to the stomach without any complications, and the procedure was thereafter repeated (Figure 2). The inverse-alpha position at the fornix during duodenoscope insertion can frequently occur in trainees, but this can sometimes occur in expert endoscopists as well. The duodenoscope should ideally be inserted while viewing the lesser curvature of the stomach. It is important to not insert the duodenoscope with inverse-alpha position, but we should also be careful when modifying the scope position. If such a complication occurs, then appropriate recovery methods are necessary.Figure 1.: Course of the duodenoscope migration.Figure 2.: The X-ray of the duodenoscope migration to the esophagus (A). A nasal endoscope was inserted (B: Endoscopy) and pushed the tip of the duodenoscope directly (C: X-ray). The duodenoscope was returned to the stomach (D: Endoscopy).DISCLOSURES Author contributions: Y. Koya, K. Yamaguchi, S. Mukawa, and K. Miyagawa drafted and edited the manuscript. Y. Koya and K. Yamaguchi provided the images. All authors approved the final version. Y. Koya is the article guarantor. Financial support: None to report. Informed consent was obtained for this case report.