Facilitating duodenoscope insertion with a balloon overtube in a patient with gastric deformity

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The side-viewing feature of duodenoscopes, which are dedicated endoscopes for endoscopic retrograde cholangiopancreatography (ERCP), can occasionally complicate endoscopic insertion, particularly in patients with gastric deformity or tumor infiltration. We report a case in which balloon overtube placement facilitated duodenoscope insertion in a patient with gastric deformity. An 86-year-old man with malignant biliary obstruction secondary to pancreatic cancer had previously undergone transpapillary placement of a covered self-expandable metallic stent (cSEMS). The patient presented with cholangitis, and computed tomography (CT) confirmed biliary dilation suggestive of recurrent stent occlusion ([ Fig. 1 ]). ERCP with stent exchange was planned. However, duodenoscope insertion was unsuccessful due to gastric deformity, likely caused by tumor invasion. Therefore, the duodenoscope was exchanged for a balloon endoscope (SIF-Q260, Olympus) with a balloon overtube (ST-CB1, Olympus) with an inner diameter of 13.8 mm and a length of 77 cm. The forward-viewing endoscope enabled a successful insertion into the duodenum. The balloon overtube was then advanced into the gastric antrum ([ Fig. 2 ]), and the balloon was inflated to secure its position. The endoscope was removed while maintaining overtube placement. Subsequently, a duodenoscope with an outer diameter of 12.9 mm (JF-240, Olympus) was successfully inserted through the overtube ([ Fig. 3 ], [ Video 1 ]). Stent exchange with a 6 mm diameter cSEMS was then performed without complications ([ Fig. 4 ]). Fig. 1 Computed tomography image showed dilation of the bile duct due to the stent occlusion. Fig. 2 The balloon overtube was then advanced into the gastric antrum. Fig. 3 The duodenoscope was inserted through the overtube. Fig. 4 Stent exchange with a 6 mm diameter covered self-expandable metallic stent was performed. Quality: mobile 360 480 720 Download A duodenoscope with an outer diameter of 12.9 mm was inserted through the overtube.Video 1 Several techniques have been reported to facilitate duodenoscope insertion, including guiding technique using a guidewire and catheter for esophageal insertion [ 1 ], anchoring technique by a dilation balloon or basket catheter for stricture [ 2 ] [ 3 ], and application of overture to increase pushability of the endoscope for perigastric adhesions [ 4 ]. Regarding through overtube techniques, esophageal insertion using a short overtube has been reported to manage the pharyngeal pouch [ 5 ]. This duodenoscope insertion technique using the balloon overtube offers a valuable option for overcoming upper gastrointestinal obstacles, although the overtube inner diameter may limit duodenoscope selection. Endoscopy_UCTN_Code_TTT_1AR_2AB Endoscopy E-Videos https://eref.thieme.de/e-videos E-Videos is an open access online section of the journal Endoscopy , reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/ ). This section has its own submission website at https://mc.manuscriptcentral.com/e-videos . Publication History Article published online: 06 May 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

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