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VIDEO Dual-operator technique by use of digital cholangioscope through colonoscope-assisted ERCP in a patient with altered anatomy Figure A, Pancreaticodudeonectomy with partial gastrectomy B, Spyglass via colonoscope: single-operator attachment C, Spyglass via colonoscope: dualoperator technique D, Spyglass via colonoscope: dual-operator attachment E, Cholangioscope exiting colonoscope F, Biliary stones on cholangioscopy Written transcript of the video audio is available online at www.VideoGIE.org 76 VIDEOGIE Volume 1, No : 2016 www.VideoGIE.org Video A 60-year-old woman who had undergone a choledochojejunostomy after subtotal gastrectomy and pancreaticoduodendectomy (Fig 1A) for gastric cancer 15 years earlier presented to an outside hospital with cholangitis resulting from choledocholithiasis The initial therapeutic intervention involved ERCP procedures through a colonoscope to the choledochojejunostomy orifice, with only partial stone removal by balloon extraction She was then referred to our institution for further biliary stone management after her cholangitis had improved She was placed in the prone position for the procedure ERCP through an adult cap-fitted colonoscope with a 1680-mm long and a 3.7-mm diameter working channel (CFQ180AL, Olympus Medical Systems, Center Valley, Pa) was performed There was incomplete stone removal with balloon sweep; therefore, cholangioscopy with a Spyglass DS system (2140-mm long and 3.6-mm diameter catheter; SpyGlass DS system; Boston Scientific, Natick, Mass) was used Simply connecting the SpyGlass DS to the colonoscope for single-operator use did not allow an adequate length of catheter to exit the colonoscope working channel (Fig 1B) Therefore, a dual-operator approach was required to use the SpyGlass DS through a colonoscope to allow about 25 to 27 cm of catheter to exit the colonoscope (Figs 1C and D) At cholangioscopy, multiple biliary stones in the common hepatic duct and the left and right hepatic ducts (Figs 1E and F) were seen Electrohydraulic lithotripsy (EHL) for stone fragmentation followed by balloon extraction was performed, and significant amounts of stones were removed A 7F cm straight plastic biliary stent was then placed because www.VideoGIE.org of the large stone burden and concern about retained stones Repeated ERCP with cholangioscopy and EHL was performed by the same technique, weeks later More stones were removed, and complete clearance of biliary stones was confirmed by cholangioscopy (Video 1, available online at www.VideoGIE.org) Direct cholangioscopy in altered GI anatomy has been previously described; however, the approaches used an ultraslim gastroscope with or without single-balloon or double-balloon enteroscopy through an overtube for peroral direct cholangioscopy The technique described here is advantageous because it uses devices that may be more readily available for biliary access by use in a novel way in patients with altered anatomy DISCLOSURE All authors disclosed no financial relationships relevant to this publication Erik Rahimi, MD, MSc, Nirav Thosani, MD, MHA, Marc Catalano, MD, Division of Gastroenterology, Hepatology, & Nutrition, University of Texas Health Science Center at Houston, Houston, Texas, USA Published by Elsevier, Inc on behalf of the American Society for Gastrointestinal Endoscopy This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) http://dx.doi.org/10.1016/j.vgie.2016.10.003 Volume 1, No : 2016 VIDEOGIE 77 ... by use in a novel way in patients with altered anatomy DISCLOSURE All authors disclosed no financial relationships relevant to this publication Erik Rahimi, MD, MSc, Nirav Thosani, MD, MHA, Marc... double-balloon enteroscopy through an overtube for peroral direct cholangioscopy The technique described here is advantageous because it uses devices that may be more readily available for biliary access... significant amounts of stones were removed A 7F cm straight plastic biliary stent was then placed because www.VideoGIE.org of the large stone burden and concern about retained stones Repeated ERCP with