LAUSR

Endoscopic retrograde cholangiopancreatography (ERCP) using a short-type single-balloon enteroscope (short SBE) (SIF-H290; Olympus Medical Systems, Tokyo, Japan), with a working length of 152 cm and a working channel diameter of 3.2mm, has been reported to be effective in patients with surgically altered anatomy (SAA) [1–3]. However, endoscopic sphincterotomy (ES) in such patients is challenging, as the appearance of the papilla is inverted and the position is frequently tangential, which makes visualizing the correct incision direction difficult. Despite the effectiveness of reported devices, they do not always achieve the correct incision direction [4, 5]. To overcome this limitation, a new sphincterotome (New CleverCut3V; KDV410V-0720; OlympusMedical Systems), with a working length of 240 cm, was developed for balloon enteroscopy-assisted ERCP in patients with SAA (▶Fig. 1). The blade of the sphincterotome can be easily adjusted around the 5 o’clock position, which indicates the bile duct direction in patients with SAA. Moreover, the blade can be stretched and loosened to modify the incision direction (▶Fig. 2). We report a case of successful ES using this novel sphincterotome in a patient with SAA. A 47-year-old woman presented with cholangitis due to suspected debris in the common bile duct (CBD). She had undergone total gastrectomy with Rouxen-Y for gastric cancer. ERCP was performed using a short SBE (▶Video 1). As there was a native papilla (▶Fig. 3 a), ES was needed to clear the debris from the CBD. The new sphincterotome was inserted into the papilla after selective biliary cannulation. The blade was easily adjusted to the 5 o’clock position (▶Fig. E-Videos