Usefulness of a papilla fixation method with an innovative clipping system for bile duct cannulation

Selective bile duct cannulation (SBDC) is difficult when the papilla of Vater is unstable because of a long narrow distal segment. Pancreatic duct guidewire placement techniques, such as the double-guidewire technique (DGT), are used to fix the papilla and facilitate SBDC [1] [2], but it is difficult to approach the pancreatic duct when the papilla is unstable. A simple and easy method of fixing the papilla and stretching a narrow distal segment using an innovative clipping system (SureClip; Micro-Tech, Nanjing, China) is presented.

A 56-year-old man underwent endoscopic retrograde cholangiopancreatography (ERCP) for obstructive jaundice due to cancer of the pancreas ([Fig. 1]). SBDC was difficult because of instability of the papilla caused by a large oral protrusion (a long narrow distal segment was suspected) and softness of the supporting tissue around the papilla ([Fig. 2]). It was even difficult to insert a cannula into the pancreatic duct. To eliminate the instability of the papilla, the mucosa on the anal side of the papilla was fixed in two places using the novel clips. Counter-tension was applied by making the clipping direction parallel to the narrow distal segment (towards the anal side). The papilla was then fixed and the long narrow distal segment was stretched ([Fig. 3]), so that it became possible to easily place the guidewire in the pancreatic duct ([Fig. 4]; [Video 1]). SBDC was performed effortlessly using the DGT, and the treatment was completed.

Fig. 1 Contrast‐enhanced computed tomography (CT) scan showing cancer of the head of the pancreas and a dilated common bile duct.

Fig. 2 Endoscopic views showing a large oral protrusion (a suspected long narrow distal segment) and softness of the supporting tissue around the papilla, which made selective bile duct cannulation difficult because of instability of the papilla.

Fig. 3 Schema showing the course of the narrow distal segment in cases with a large oral protrusion and instability of the papilla, and how the narrow distal segment is changed using the novel clipping system.

Fig. 4 Endoscopic image showing the mucosa on the anal side of the papilla fixed in two places with SureClips, thereby eliminating the instability of the papilla and stretching the long narrow distal segment.

Video 1 Demonstration of a papilla fixation method with SureClips for selective bile duct cannulation in a patient with a suspected long narrow distal segment that made cannulation difficult because of instability of the papilla.

Unlike conventional endoclips, the SureClip is a device that can be easily used for clipping even when the forceps elevator of the duodenoscope is lifted. Previous reports have shown that the visibility of an intradiverticular papilla was improved when endoclips were used [3] [4] [5], but this is the first report in which the papilla was fixed and a long narrow distal segment was stretched using this newly designed clipping system. This method is simple and useful in cases where the papilla is unstable.

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Publikationsverlauf

Artikel online veröffentlicht:
05. März 2021

• References

• 1 Dumonceau JM, Devière J, Cremer M. A new method of achieving deep cannulation of the common bile duct during endoscopic retrograde cholangiopancreatography. Endoscopy 1998; 30: S80
• 2 Tse F, Yuan Y, Moayyedi P. et al. Double-guidewire technique in difficult biliary cannulation for the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis. Endoscopy 2017; 49: 15-26
• 3 Huang CH, Tsou YK, Lin CH. et al. Endoscopic retrograde cholangiopancreatography (ERCP) for intradiverticular papilla: endoclip-assisted biliary cannulation. Endoscopy 2010; 42: E223-E224
• 4 Cappell MS, Mogrovejo E, Manickam P. et al. Endoclips to facilitate cannulation and sphincterotomy during ERCP in a patient with an ampulla within a large duodenal diverticulum: case report and literature review. Dig Dis Sci 2015; 60: 168-173
• 5 Inoue R, Kawakami H, Kubota Y. et al. Endoscopic biliary intervention using traction devices for periampullary diverticulum. Intern Med 2019; 58: 2797-2801