Use of a rigidizing overtube for altered-anatomy ERCP

Abstract

ERCP is important in managing biliary and pancreatic disorders. 1 However, the success of altered anatomy ERCP depends on overcoming challenges including traversing the variable length of the afferent jejunal limb, intubating the surgical anastomosis, cannulating the papilla, and restrictions of tools depending on the endoscope used. 1,2 Developments to help achieve altered-anatomy ERCP have included the multibending backward-oblique-viewing duodenoscope, 3 variable-stiffness duodenoscope, 4 and multibending forward-viewing endoscope. 5 Although single-balloon and double-balloon enteroscopes can be used to perform altered-anatomy ERCP, the long endoscope length limits the use of conventional ERCP accessories. 1 Short-type single-balloon and double-balloon enteroscopes have been developed but are not widely used. 6 Given the challenges with altered-anatomy ERCP, developing new tools to improve procedural success is important. The U.S. Food and Drug Administration approved the Pathfinder Endoscope Overtube (Neptune Medical, Burlingame, Calif, USA) in August 2019. 7,8 The Pathfinder Endoscope Overtube is an 85-cm-long single-use overtube (16.5 mm diameter) that can exist in 2 states, flexible or rigidized (Fig. 1). Once the flexible overtube and the endoscope are advanced and in the most reduced position, vacuum application stiffens the overtube up to 15 times. The rigidizing overtube can be used in upper endoscopy, colonoscopy, and enteroscopy. We present 2 cases of altered-anatomy ERCP (Video 1, available online at www.VideoGIE.org).

Combination of a dynamic rigidizing overtube and a novel injectable needle-type knife to facilitate colorectal endoscopic submucosal dissection

“…13,14 Recently, a novel rigidizing overtube was introduced for colonoscope stabilization for various applications in colonoscopy and for ERCP in surgically altered anatomy. [3][4][5] As we demonstrated, we were able to use the rigidizing overtube for stabilization during a challenging ESD at the hepatic flexure. It is important to note that the rigidizing overtube was primarily used in this case to gain access to challenging locations in the right colon segment without loop formation.…”

“…Recently, a novel dynamic rigidizing overtube (Pathfinder; Neptune Medical, Burlingame, Calif, USA) was approved by the U.S. Food and Drug Administration. [3][4][5] The device consists of a flexible overtube that is connected to a vacuum for rigidization via an attached stopcock (Fig. 1).…”

Biliopancreatic Endoscopy in Altered Anatomy

“…Even if the underwater technique is primarily used to perform colonoscopy, the underwater-ERCP using a cap-assisted pediatric colonoscope was recently proposed in six patients with altered anatomy as an alternative, achieving a success rate of 100% without any AEs [ 19 ]. Furthermore, many case reports have been published during the last decade, showing alternative techniques for ERCP in different scenarios, varying from management of Mirizzi syndrome in Billroth II reconstruction to cholangiocarcinoma in RYGB [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. In 2006, the short length double-balloon enteroscopy (s-DBE) was firstly used to perform ERCP in RYGB patients [ 28 ].…”

Flexible Over-the-Tube Device for Soft-Tethered Colonoscopy

“…FOD is substantially different from prior over-the-tube assistive devices, such as Endo-Ease Discovery [37] and Pathfinder [38]. FOD is a relatively short compliant device that is conceived to move along soft tethers, whereas previous devices (having a characteristic length around 100 cm) are steadily mounted at the distal section (close to tip) of conventional (less flexible) colonoscope shafts.…”