Endoscopic retrograde cholangiopancreatography in a patient with complete situs inversus viscerum: A case report and literature review

Abstract

Complete situs inversus viscerum (SIV) is a rare congenital condition, defined by a left‐right transposition of all viscera with dextroposition of the heart. In patients with SIV that requires endoscopic intervention, namely endoscopic retrograde cholangiopancreatography (ERCP), the left‐right coordination can be technically demanding even with skilled endoscopist. We report a case of a patient with underlying SIV who presented with septic shock secondary to ascending cholangitis compounded with a malaria infection. Despite the ascertainment of a relatively large Common Bile Duct (CBD) stone, ERCP and stenting were pursued as an initial treatment modality in view of the clinical presentation of cholangitis and COVID‐19‐related delays in surgical intervention at our center. This case is unique as the patient was maintained in a supine position throughout the procedure. The patient underwent a successful ERCP procedure followed by a CBD Exploration and cholecystectomy 2 weeks later. A key factor that contributed to the success of this procedure was the combined utilization of a rotatable sphincterotome and extractor balloon which assisted with cannulation and shortening manoeuvre of the duodenoscope to facilitate biliary stenting.

Outcomes of endoscopic retrograde cholangiopancreatography in patients with situs inversus viscerum

“…[10][11][12] Other case reports suggested changing the patient's position from right lateral decubitus to prone upon reaching the second duodenal portion to facilitate papillary identification and cannulation. 7 Other experts suggested rotating the duodenoscope counterclockwise while in the duodenum with the left arm hanging straight down while advancing from the duodenal bulb to the second duodenal portion.…”

“…This technique has been utilized in different clinical scenarios as well as in patients with SIV, but existing data are limited to case reports. 7,[13][14][15][16] Guidewire placement allows for better ampulla visualization and/or allows endoscopic biliary cannulation using a catheter over a guidewire or another guidewire adjacent to the percutaneously placed guidewire. In one case, the patient had multiple duodenal diverticula and the ampulla was not visible in the index ERCP despite extensive interrogation and multiple positional changes.…”

“…5,6 The success rate of ERCP in patients with SIV is unknown and data are limited to case reports. 7 This study aimed to report the outcomes of therapeutic ERCP in patients with SIV using data collected from a large national database.…”

Laparoscopic common bile duct exploration to treat choledocholithiasis in situs inversus patients: A technical review

“…A total of 12 records were identified by the literature search. In accordance with the study exclusion criteria, two articles were excluded for reporting the same patient[ 11 , 12 ], and the other two articles were excluded for open surgery[ 13 , 14 ]. Finally, eight case reports were included in this review[ 8 , 15 - 21 ].…”