A Double-Guidewire Technique to Facilitate Deep Cannulation and Stenting in a Patient with Altered Gastrointestinal Anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered gastrointestinal (GI) anatomy remains a challenging procedure. We experience particular difficulty passing a catheter and devices in patients who have biliary stricture or severe deformity, despite successful biliary guiding. A 70-year-old man with Roux-en-Y reconstruction for gastric cancer suffered pancreatic head cancer with biliary stricture. Seven months after biliary stenting, he developed acute occlusive suppressive cholangitis due to stent occlusion. We extracted the stent and inserted a guidewire into the intrahepatic bile duct. However, we were unable to pass the catheter due to severe stricture of the lower common bile duct and axis-dismatch between the bile duct and the catheter. After inserting another of the same guidewire into the bile duct, we were able to easily pass the catheter into the bile duct, resulting in the successful insertion of a new plastic stent. A double-guidewire technique is useful and worth attempting for the deep insertion of devices through biliary strictures in patients with an altered GI anatomy. J Med Cases. 2019;10(1):1-3 doi: https://doi.org/10.14740/jmc3220