The authors report the case of an 89-year-old male with several comorbidities, including an invasive periampullary adenocarcinoma and a large hiatal hernia. Due to obstructive jaundice the patient underwent ERCP with self-expandable metal stent (SEMS) placement for palliative biliary drainage. Eight months later, ERCP was repeated due to stent dysfunction and biliary drainage successfully re-established using a stent-in-stent approach to restore patency.

Ten months later the patient presented with acute cholangitis. CT imaging showed biliary stents in situ with dense endoluminal content and upstream biliary dilation without pneumobilia. Worsening of the hiatal hernia with complete intrathoracic gastric displacement with organo-axial volvulus was also noted. Antibiotics were started and a third ERCP was scheduled.

During the procedure, advancement of the duodenoscope was significantly hindered due to entrapment and looping within the herniated stomach. After multiple attempts, the scope could carefully progress into the duodenal bulb, but the second portion of the duodenum could not be reached. A 0.035´´guidewire was passed into the proximal jejunum and a 20mm through-the-scope balloon was introduced over-the-wire. The balloon was inflated in the lumen of the fourth duodenal portion, anchoring the scope. Pulling the balloon catheter with moderate traction, the duodenoscope was straightened and could advance reaching the major papilla in a stable short position. Biliary cannulation was performed and cholangiography confirmed two metal stents with tumoral ingrowth and upstream biliary dilation. Abundant biliary sludge was removed using an extraction balloon and an uncovered SEMS (100x10mm) was placed in a stent-in-stent position achieving effective drainage. The patient was later discharged asymptomatic.

Altered gastrointestinal anatomy causes significant technical challenges in ERCP, requiring tailored endoscopic strategies to achieve biliary access. This case highlights the efficacy and safety of a balloon anchor and traction technique in overcoming duodenoscope advancement difficulty posed by a large hiatal hernia.