Endoscopic Removal of a Bile-Duct Stone Using Sphincterotomy and a Large-Balloon Dilator in a Patient with Situs Inversus Totalis

Abstract

A 45-year-old female with known situs inversus totalis presented with colicky pain in the left upper abdominal quadrant. The laboratory parameters showed elevated neutrophils and a bilirubin level of 2 mg/dL. CT confirmed situs inversus totalis and dilatation of the intra- and extrahepatic ducts with a 10-mm common bile duct (CBD) stone and a 10-mm gallstone. She underwent papillary dilatation using a radial expansion balloon after sphincterotomy, after which the CBD stone was removed with a basket and balloon. There were no complications, such as bleeding, pancreatitis, or perforation. It might be reasonable to attempt a "partial" biliary endoscopic sphincterotomy followed by a large-balloon dilator in patients with concomitant distal bile duct, papillary stenosis, or altered anatomy (e.g., periampullary diverticulum, Billroth II anatomy). However, when performing an "adequate" biliary endoscopic sphincterotomy this is technically difficult, or in some cases even impossible, and is associated with a higher risk of complications. This paper further expands on the application of these techniques and shows that a papillary balloon dilatation after endoscopic sphincterotomy is a safe, easy, and effective technique for removing bile-duct stones in a patient with situs inversus totalis.

ERCP and EUS technique in situs inversus totalis: preparing for a left-sided plot twist

“…However, the ease of insertion may come with difficulty cannulating the papilla, which usually sits in the 1 to 3 o'clock position. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] Another technique involved changing the patient position during the procedure, which brought challenges to the endoscopy and was limited by patient intolerance. 20,21 There are few reports in the literature of successful EUS in patients with SIT.…”

“…Changed position of room equipment. 180-degree clockwise turn 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 Prone, left lateral Right 180-degree clockwise rotation in stomach or duodenum. Alternatively, “pursuing endoscopy in direction inverse to usual.” Difficulty cannulating and performing papillotomy of 1-3 o’clock papilla needing advanced papillotomy techniques.…”

Laparoendoscopic rendezvous procedure in a patient with situs inversus totalis: A case report and review of the literature

“…4 In patients with SIT and cholelithiasis complicated with choledocholithiasis, reported cases have been treated mainly by a twostage procedure with LC and preoperative or postoperative ERCP. [5][6][7][8][9][10] LC + LCBDE as a one-stage procedure has also been reported. [11][12][13][14] Even though ERCP has shown to be an adequate treatment with acceptable rates of choledocholithiasis resolution in SIT patients, it is not spared of morbidity and patients may need more than one procedure to achieve a complete common bile duct clearance.…”

“…LC is the standard of care for the treatment of cholelithiasis, and it has also proven to be a safe method in patients with SIT 4 . In patients with SIT and cholelithiasis complicated with choledocholithiasis, reported cases have been treated mainly by a two‐stage procedure with LC and preoperative or postoperative ERCP 5‐10 . LC + LCBDE as a one‐stage procedure has also been reported 11‐14 …”