Successful ERCP for management of traumatic pancreatic disruption in a patient with situs inversus

Abstract

Endoscopic retrograde cholangio-pancreatography (ERCP) is an important tool for treatment of pancreaticobiliary diseases. However, ERCP may be difficult in patients who have altered gastrointestinal anatomy due to congenital or surgical reasons. A 40-year-old male with HIV infection presented with abdominal pain following abdominal trauma. The patient was diagnosed to have traumatic pancreatic injury and underlying situs inversus. The pancreatic fluid collection was drained using radiology guided pigtail placement done for the symptoms of abdominal pain and vomiting. The resulting external pancreatic fistula was successfully managed with ERCP and stenting. The patient improved with disappearance of ascites and resolution of pigtail output which was then removed. We report the technique used for ERCP in this patient. We also review the literature on pancreatic endotherapy in patients with situs inversus. The published literature suggests that with modifications in the standard ERCP technique like mirror image technique, 180 degree turn technique, left lateral technique these patients can be managed successfully.

WITHDRAWN: Double Rarity: Malignant Masquerade Biliary Stricture in a Situs Inversus Totalis Patient. A Case Report

“…The inverse location of the organs might lead to misdiagnosis as a result of the false projection of the pain to the opposite side of the body, and sometimes it requires technical changes in the diagnostic procedures. In endoscopic and minimally invasive surgical procedures, 'mirror image technique' can be used; they place the patient and the equipment on the opposite side and the procedure itself is performed inversely, the operating surgeon stands on the left side of the patient [6]. In laparoscopic procedures, the careful consideration of the trocar positioning is necessary [7].…”

Successful endoscopic retrograde cholangiopancreatography using pancreatic guidewire placement for biliary cannulation in a patient with situs inversus and Billroth‐I gastrectomy (with video)

“…Currently, this approach is widely applied for various treatments such as common bile duct stone removal. However, there are a limited number of reports on ERCP in patients with situs inversus . Here, we report a patient with situs inversus who underwent Billroth‐I gastrectomy.…”

“…In subjects with SIV, a mirror image of the normal anatomy makes it more difficult for the endoscopist to gain access to duodenal papilla. In previous reports, we found that most of the patients were placed in a left lateral position or prone position, which is the usual position in ERCP, and the endoscopist preferred to be on the right side of the operating table. Adjustments such as a 180° turn in the stomach or special techniques such as a “mirror image” were shown to contribute to maintenance of the duodenal papilla.…”

“…However, the “mirror image” technique is complicated for the endoscopist because the patient must be in the right lateral position. Recently, a case of traumatic pancreatitis related to external pancreatic fistula was successfully managed using pancreatic ductal stenting while maintaining the usual endoscope and patient position . The authors of that report mentioned that, with this technique, the endoscopist could comfortably maintain the usual position of the endoscope and the patient.…”

A Challenging Abdominal Pain

“…In fact, the procedure in these patients is considered difficult and has been reported to fail in some cases. 3 Concerning patient positioning, which is the main issue in this situation, in most reported cases the patient was in the prone position and there is no case published with the patient in supine position. If we put a patient without situs inversus in the prone position ( Figure E), the organs disposition is almost the same as that of a patient with situs inversus in supine position ( Figure F).…”