Endoscopic biliary drainage using a narrow-diameter endoscope in a patient with obstructive jaundice and pancreatic cancer

Endoscopic biliary drainage using a narrow-diameter endoscope in a patient with obstructive jaundice and pancreatic cancer Standard endoscopic retrograde cholangiopancreatography (ERCP) involves the insertion of a duodenoscope and sideviewing endoscope.However, advancement of the scope into the correct gas-trointestinal lumen can be challenging in patients with a deformed superior duodenal angle caused by peritoneal dissemination or direct tumor invasion [1].A 68-year-old Japanese woman presented with cholangitis and obstructive jaundice secondary to pancreatic cancer.Two months before presentation, a biliary plastic stent was placed to alleviate ob-E-Videos Fig. 1 Endoscopic retrograde cholangiopancreatography (ERCP) with existing endoscopic equipment.a We attempted to insert a side-view- ing endoscope in the duodenum; however, the endoscope could not be passed through the stenosis at the first part of the duodenum.b, c We attempted to insert a side-viewing endoscope deep in the duodenum using an ERCP cannula and guidewire.d, e We attempted to insert a sideviewing endoscope deep into the duodenum after using a balloon to perform gastrointestinal dilation; however, deep insertion could not be achieved. Fig. 2 Endoscopic ultrasound-guided hepaticogastrostomy procedures with existing endoscopic equipment.a, b We attempted endoscopic ultrasound-guided hepaticogastrostomy of the stomach.Biliary puncture with a 19-gauge needle was successful.c The guidewire could not reach the central bile duct; therefore, this drainage approach was abandoned.