LAUSR

A woman in her 50s with situs inversus presented to our hospital with high fever, jaundice, and pain in the left hypochondriac region. The patient had undergone Roux-en-Y hepaticojejunostomy following iatrogenic bile duct injury during cholecystectomy 9 years earlier. Abdominal computed tomography and magnetic resonance cholangiopancreatography revealed bile duct dilatation, with areas suspicious for stenosis at the hepaticojejunostomy anastomosis, with the visceral organs in a mirror image location from their normal positions (▶Fig. 1, ▶Fig. 2). We diagnosed obstructive jaundice with cholangitis, and performed endoscopic retrograde cholangiopancreatography (ERCP) for biliary drainage using double-balloon enteroscopy (EI-580BT; Fujifilm, Tokyo, Japan). The patient was placed in the abdominal position, with the endoscopist standing at the patient’s right side, which is the standard position for ERCP. Endoscope insertion to the hepaticojejunostomy anastomosis was successful without requiring any modification or positional change for the patient or the endoscopist. The anastomotic site showed severe stenosis, with dilation of the intrahepatic bile ducts (▶Fig. 3, ▶Fig. 4). After insertion of a guidewire across the anastomosis, we performed dilation to the stenosis using the Soehendra stent retriever (Cook Medical Inc., Bloomington, Indiana, USA). Then, a 7 Fr plastic stent was placed in the intrahepatic bile duct (▶Fig. 5, ▶Video1). The procedure time was 24 minutes. No adverse event occurred. The patient’s symptoms and laboratory data rapidly improved after the endoscopic treatment. For situs inversus, ERCP is challenging, and it has been suggested that alteration of patient and/or endoscopist positioning is warranted [1, 2]. However, there are no reports of patients with situs inversus undergoing balloon enteroscopyassisted ERCP. In the present case, the procedure could be performed using the same technique as that used in patients with normal anatomy. Even in situs inversus, balloon enteroscopy-assisted ERCP can be performed in the usual manner for patients with surgically altered anatomy.