# Forceps-Assisted Endoscope Rigidity Reinforcement for Difficult Duodenal Intubation due to Cascade Stomach

## TL;DR

A new technique using forceps to help with difficult endoscope insertion in the duodenum is shown to be effective in elderly patients.

## Contribution

A novel, equipment-free method using forceps to reinforce endoscope rigidity during ERCP is introduced and validated.

## Key findings

- Forceps inserted through the accessory channel increased endoscope rigidity and enabled successful duodenal intubation.
- The technique minimized scope looping and allowed rapid access to the duodenum within 2 minutes.
- The method was successfully applied in two ERCP procedures, enabling biliary cannulation and drainage.

## Abstract

A 92-year-old woman underwent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholecystitis and bile duct stones. A cascade stomach caused significant difficulty in duodenal intubation, despite multiple standard maneuvers. As a large-diameter overtube was unavailable, forceps were inserted through the accessory channel to increase endoscope rigidity. This technique minimized scope looping and enabled duodenal access within 2 minutes. Biliary cannulation, sphincterotomy, and drainage were completed successfully. The same method was used in a subsequent ERCP with similar success. This case demonstrates that forceps-assisted rigidity reinforcement is a simple, effective, and equipment-free option for managing duodenal intubation difficulties during ERCP.