LAUSR

The main reconstruction procedure presently used after total gastrectomy is the Roux-en-Y method, but jejunal interposition was previously performed [1]. The most appropriate technique for endoscopic retrograde cholangiopancreatography (ERCP) after jejunal interposition has not been determined because of a lack of reported cases. A 70-year-old woman with a history of jejunal interposition after total gastrectomy was hospitalized for a common bile duct stone. Although ERCP was attempted using a short-type double-balloon endoscope (EI-580T; Fujifilm Holdings Corp, Tokyo, Japan), biliary cannulation failed despite reaching the duodenum. Laparoscopic exploration of the common bile duct and cholecystectomy were subsequently performed. After 2 years, the patient presented with a recurrent common bile duct stone on contrast-enhanced computed tomography (▶Fig. 1). A side-viewing duodenoscope could not be passed into the duodenum owing to sharp bowel angulation resulting from adhesions. Therefore, a passive-bending colonoscope (PCF-H290ZI; Olympus Corp., Tokyo, Japan) was maneuvered into the duodenum. After the duodenum was reached, a double-guidewire was advanced through to the jejunum (▶Fig. 2 a). The colonoscope was exchanged for a side-viewing duodenoscope (TJF-Q290V; Olympus Corp) with the wire left in place (over-the-wire technique). Under fluoroscopic and endoscopic visualization, a duodenoscope was carefully pushed and passed into the duodenum (▶Fig. 2b), and the doubleguidewire was removed. Successful biliary cannulation was performed using the pancreatic guidewire placement method (▶Fig. 2 c). After a prophylactic pancreatic stent placement, a sphincterotomy with stone removal was successfully achieved (▶Fig. 2d). Six days after the ERCP, the pancreatic stent was removed (▶Video 1). This case demonstrates an over-the-wire technique that is effective in ERCP after total gastrectomy with jejunal interposition. By leaving the wire in place, the duodenoscope can be safely advanced under endoscopic and fluoroscopic guidance.