A Stomach-Positioned Splinting Tube Technique for Maintaining a Straightened Gastric Axis During Endoscopic Retrograde Cholangiopancreatography in Severe Esophageal Hiatal Hernia

ABSTRACT Severe esophageal hiatal hernia can hinder endoscopic retrograde cholangiopancreatography (ERCP) by causing gastric looping and unstable duodenoscope advancement. We report a 76-year-old woman with gallbladder cancer, hilar biliary obstruction, and severe mixed-type hiatal hernia. Initial ERCP failed because recurrent looping prevented passage beyond the pylorus. During repeat ERCP, a hydrophilic splinting tube was not anchored in the duodenum but was positioned in the prepyloric stomach to maintain gastric axis reduction, defined as straightening of the looped intrathoracic stomach. This prevented recurrent looping, enabled stable duodenoscope advancement, and allowed transpapillary metal-stent placement, potentially reducing mucosal injury or perforation risk by avoiding duodenal bulb manipulation.