What are the steps to insert a side viewing duodenoscope into the 2nd part of the duodenum?

Steps for Inserting a Side-Viewing Duodenoscope into the 2nd Part of Duodenum

The proper insertion of a side-viewing duodenoscope into the second part of the duodenum requires a systematic approach with specific technical maneuvers to navigate the upper gastrointestinal anatomy safely and effectively.

Pre-Procedure Preparation

• Patient should fast for at least 8 hours prior to the procedure to ensure adequate mucosal visualization 1
• Assess for contraindications and obtain informed consent 1
• Consider appropriate sedation based on patient factors (age, comorbidities) following safe sedation guidelines 1
• Position the patient in the left lateral decubitus position 2

Equipment Preparation

• Ensure high-definition video endoscopy system is available with image capture capability 1
• Prepare mucosal cleansing agents (water flush, simethicone) to improve visualization 1
• Check that the duodenoscope is functioning properly with appropriate elevator and tip deflection controls 1

Insertion Technique

1. Initial Insertion

   • Insert the duodenoscope through the mouth with gentle pressure, keeping the tip in neutral position 1
   • Advance the scope through the oropharynx under direct visualization 1

2. Esophageal Passage

   • Guide the duodenoscope through the upper esophageal sphincter with gentle pressure 1
   • Advance down the esophagus with minimal air insufflation 1

3. Stomach Navigation

   • Upon entering the stomach, insufflate moderately to distend the gastric lumen 1
   • Rotate the duodenoscope slightly to visualize the lesser curvature and antrum 1
   • Advance the scope along the greater curvature toward the antrum 1, 3

4. Pyloric Passage

   • Identify the pylorus and position the duodenoscope in front of it 1
   • Use a combination of tip deflection and torque to navigate through the pylorus 3
   • In difficult cases, consider using a guidewire to facilitate passage 4

5. Duodenal Bulb Navigation

   • Once through the pylorus, advance into the duodenal bulb (first part of duodenum) 1
   • Straighten the scope and reduce air insufflation to prevent loop formation 1, 3

6. Entry into Second Part of Duodenum

   • From the duodenal bulb, use a combination of clockwise rotation and upward tip deflection to navigate the superior duodenal angle 1, 5
   • Apply gentle pressure while rotating the scope to advance beyond the angle 5
   • Once past the angle, the side-viewing optics will allow visualization of the medial wall of the second part of the duodenum 5, 2

7. Final Positioning

   • Position the duodenoscope to visualize the ampulla of Vater (typically located on the medial wall of the second part of duodenum) 5, 6
   • Make fine adjustments using the elevator and tip controls to achieve optimal viewing angle 6

Common Challenges and Solutions

• Difficult Pyloric Passage: In cases of pyloric stenosis or difficult anatomy, use a balloon-assisted technique or guidewire to facilitate passage 4, 6
• Loop Formation: Reduce excessive looping by decreasing air insufflation and applying gentle external abdominal pressure 1
• Anatomical Variations: In patients with altered anatomy (e.g., post-surgical), additional maneuvers may be required, such as 180° rotation of the endoscope 2

Post-Positioning Documentation

• Once properly positioned, obtain photo-documentation of relevant anatomical landmarks 1
• Document the quality of mucosal visualization achieved 1
• Record the total inspection time, particularly for surveillance procedures 1

Safety Considerations

• Monitor patient's vital signs throughout the procedure 1
• Be prepared to manage any sedation-related complications 1
• Exercise caution when using combined sedation and topical anesthesia, particularly in patients at risk for aspiration 1

Following these systematic steps will help ensure successful insertion of a side-viewing duodenoscope into the second part of the duodenum for diagnostic and therapeutic procedures.