Follow the carrot: a route through the difficult esophagus or duodenum

The side-viewing optics of the duodenoscope present a challenge during esophageal and duodenal intubation. Strictures and diverticula can make this challenge even greater. Techniques including intubation over a wire or through an overtube have been reported to allow passage of the duodenoscope in such cases. We have encountered 5 cases in which intubation was not possible despite using these techniques. The cases displayed a variety of endoscopic challenges and we devised a novel solution that allowed endoscopic retrograde cholangiopancreatography to be successfully completed in all. With this method all procedures could be effectively performed with no complications and no greater risk to the patient than conventional endoscopic retrograde cholangiopancreatography. This simple, low-cost technique could be adopted by any biliary endoscopist when standard techniques fail.