Gastroenterology & Hepatology
May 2014, Volume 10, Issue 5
Imran Sheikh, MD, Richard Heard, MD, Claudio Tombazzi, MD
Department of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee Technical Factors Related to Endoscopic Retrograde Cholangiopancreatography in Patients with Situs Inversus
Address correspondence to:
Dr Imran Sheikh, 956 Court Ave, Rm H-314, Memphis, TN 38103; Tel: 901-448-2510; Fax: 901-448-7836; E-mail: isheik@uthsc.edu
We read with great interest the recent column on difficult endoscopic retrograde cholangiopancreatography (ERCP).1 Another area of difficult ERCP involves patients with situs inversus. We recently performed an ERCP on a 72-year-old man with a remote history of laparoscopic cholecystectomy who presented with progressively worsening abdominal pain, nausea, chills, and obstructive liver function tests. A magnetic resonance cholangiopancreatography showed abdominal situs inversus, remote cholecystectomy, and dilation of the intrahepatic biliary tree and common bile duct up to 1 cm with multiple filling defects up to 7.6 mm in size (Figure 1).
These findings were confirmed on an ERCP (Figure 2) in which the patient was treated with sphincterotomy, stone = removal, and stent placement (with subsequent successful removal of a proximally migrated stent). Situs inversus is a rare, autosomal recessive condition that is often incidentally discovered. It may occur with dextrocardia, levocardia, or situs ambiguous, the latter with either right or left isomerism, along with asplenia or polysplenia, respectively. ERCP in patients with situs inversus has rarely been reported, and there are different techniques that have been described. These include turning the duodenoscope 180° clockwise while in the stomach and again while in the second part of the duodenum.2 A similar technique involves turning the duodenoscope 180° clockwise in the stomach and using a rotating sphincterotome for cannulation.3
The above techniques do not alter the normal room setup, in which the patient is prone and the endoscopist is on his or her right. An alternative mirror-image method places the patient in the right lateral decubitus position, with the equipment behind him or her and with all endoscopic maneuvers performed inversely.4 Another approach entails placing the patient supine with the endoscopist to his or her left.5 In our experience, ERCP was successfully performed with the patient in the usual prone position, with the endoscopist on the patient’s right, using a 180° clockwise rotation as described above. When faced with a patient with situs inversus and a strong indication for ERCP, knowledge of the above techniques coupled with the endoscopist’s experience, comfort level, room setup vis à vis the use of monitored anesthesia care, and fluoroscopy equipment should all be considered in choosing an appropriate approach.
References
1. Baillie J. Difficult endoscopic retrograde cholangiopancreatography. Gastroenterol Hepatol (N Y). 2014;10(1):49-51.
2. Fiocca F, Donatelli G, Ceci V, et al. ERCP in total situs viscerum inversus. Case Rep Gastroenterol. 2008;2(1):116-120.
3. de la Serna-Higuera C, Perez-Miranda M, Flores-Cruz G, Gil-Simón P, Caro-Patón A. Endoscopic retrograde cholangiopancreatography in situs inversus partialis.Endoscopy. 2010;42(suppl 2):E98.
4. García-Fernández FJ, Infantes JM, Torres Y, Mendoza FJ, Alcazar FJ. ERCP in complete situs inversus viscerum using a “mirror image” technique. Endoscopy.2010;42(suppl 2):E316-E317.
5. Byun JR, Jahng JH, Song JC, Yu JS, Lee DK. Supine position endoscopic retrograde cholangiopancreatography in a patient with situs ambuiguous with polysplenia. Dig Endosc. 2010;22(4):322-324.