Entering the duodenal diverticulum: A method for cannulation of the intradiverticular papilla

Difficult Biliary Cannulation for Intradiverticular Papilla: Forceps Technique Revisited

Periampullary diverticula (PAD) have been encountered in 5.9 to 18.5% of patients during all the endoscopic retrograde cholangiopancreatography (ERCP). Cannulation in the presence of PAD can sometimes be difficult, time consuming, and often requires a higher level of endoscopic skills. Several techniques have been reported to facilitate and increase the chances of successful bile duct cannulation in the presence of PAD. The two-devices in one-channel method has been sparingly used. It involves the simultaneous use of a biopsy forceps and another instrument, either a cannula or sphincterotome through the same working channel. We successfully performed ERCP in three cases, where bile duct cannulation was performed in the setting of intradiverticular papilla using two-devices in one-channel method. We feel that the two-devices in one-channel method can be very useful and positioned higher up in the algorithm for successful cannulation in patients with PAD.

Endoscopic Biliary Intervention Using Traction Devices for Periampullary Diverticulum

We describe the case a 92-year-old woman who was admitted to our hospital with choledocholithiasis and periampullary diverticulum (PAD). Due to PAD, clear visualization of the ampulla of Vater could not be obtained. Although selective bile duct cannulation was difficult, a 7-Fr plastic stent was placed during the first session. Fifteen days later, endoscopic retrograde cholangiopancreatography was retried using traction devices, and the papilla became visible. Endoscopic sphincterotomy and stone extraction were performed without any complications. The application of traction devices in endoscopic submucosal dissection may be a promising technique in cases in which endoscopic biliary intervention is difficult due to PAD.

Papillary Cannulation Facilitated by Submucosal Saline Injection into an Intradiverticular Papilla

Endoscopic retrograde cholangiopancreatography (ERCP) of the intradiverticular papilla with its invisible orifice remains challenging. Several techniques have been introduced to evert the papillary opening to facilitate cannulation. A 79-year-old woman with bile duct stones underwent ERCP, which revealed that the papilla was located inside a large diverticulum and tended to rotate inward with a trial of papillary cannulation. Submucosal papillary injection of 3 cc of normal saline was performed at 3 and 9 o’clock. Eversion and fixation of a papilla in the diverticulum with this technique allowed selective cannulation of the biliary tree. Stones were retrieved after endoscopic papillary balloon dilation without complications. She had an uneventful post-procedural course. Our findings suggest that submucosal saline injection technique is safe and effective for selective cannulation and can be recommended when cannulation is very difficult because of an intradiverticular papilla.

Two Biliary Cannulation Techniques for ERCP in Patients With Intradiverticular Papilla: A Retrospective Review

PURPOSE

To compare the effectiveness and complications of the different cannulation techniques for bile duct stones removal in patients with intradiverticular papilla.

MATERIALS AND METHODS

The records of 472 patients with common bile duct (CBD) stones who underwent endoscopic retrograde cholangiopancreatography (ERCP) procedures for bile duct stones removal from January 2014 to December 2016 were retrospectively reviewed. A total of 42 patients with CBD stones were included in the study and data of included patients were collected retrospectively. The outcomes and complications of ERCP procedures were compared.

RESULTS

Of 42 ERCP procedures included in the study, patients were divided into Two-devices-in-one-channel group (n=20) and Endoclip group (n=22). The success rate of CBD cannulation at first attempt in Two-devices-in-one-channel and Endoclip groups was 85.0% (17/20) and 54.5% (12/22), respectively (P<0.05). The average time it took to cannulation in Endoclip group was much longer than that in Two-devices-in-one-channel Group (17.55±2.06 vs. 10.6±2.75 min, P<0.05). Overall complications occurred in 3 cases of Two-devices-in-one-channel group and in 4 cases of Endoclip group, respectively (15.0% vs. 18.2%, P>0.05). There was no statistically significant difference between groups regarding the complications.

CONCLUSIONS

Two-devices-in-one-channel and Endoclip techniques are both safe and effective for bile duct cannulation in patients with intradiverticular papilla.

Endoscopic Sphincterotomy for Gallbladder Muddy Stones or Sludge in Patients With Papillary Disease: A Retrospective Study

BACKGROUND

The formation of gallbladder stones is associated with dysfunctional contraction and duodenal papilla diseases. However, endoscopic sphincterotomy can improve the contraction of the gallbladder and resolve duodenal papilla disease.

AIM

The aim of the study was to assess the feasibility and effectiveness of endoscopic sphincterotomy in the treatment of muddy stones or sludge in the gallbladder during papillary disease.

METHODS

The clinical data of 53 patients with gallbladder muddy stones or sludge undergoing endoscopic sphincterotomy were retrospectively analyzed.

RESULTS

A total of 53 patients received successful endoscopic sphincterotomy with no serious complications. Sphincterotomy did not significantly lower resting gallbladder volume from 63.2±10.8 to 50.1±5.9 mL (P>0.05), but significantly increased gallbladder ejection fraction from 0.41±0.13 to 0.63±0.16 (P<0.01), as measured by the lipoid food test. The static liver and gallbladder imaging examination also showed an increase in gallbladder ejection fraction from 0.45±0.08 to 0.68±0.11 (P<0.01). In addition, the choledochus pressure reduced from 21.9±4.0 to 15.6±2.5 mm Hg, and the gallbladder muddy stones or sludge disappeared after endoscopic sphincterotomy. At the end of the follow-up period, there was no relapse of sludge or muddy stones in the gallbladder.

CONCLUSIONS

The formation of gallbladder muddy stones or sludge is associated with papilla disease. Endoscopic sphincterotomy can resolve papilla disease, decrease gallbladder bile stasis, improve gallbladder evacuation, and prevent the formation of gallbladder stones.

Cannulation of the intradiverticular papilla using a duodenoscope: Is it a safe method?

Endoscopic cannulation of the biliary tract is a challenging technique in cases of periampullary diverticula. Many new devices and new manipulations for successful biliary cannulation have been reported. Endoscopy used to locate and cannulate a papilla hidden within a duodenal diverticulum is an effective method. However, the question of which endoscope should be chosen for this procedure, duodenoscope or gastroscope, waits to be answered.