Clin Endosc.  2019 Jan;52(1):83-86. 10.5946/ce.2018.060.

Papillary Cannulation Facilitated by Submucosal Saline Injection into an Intradiverticular Papilla

Affiliations
  • 1Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea. smpark@chungbuk.ac.kr
  • 2Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea.

Abstract

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.

Keyword

Cholangiopancreatography, endoscopic retrograde; Gallstones; Ampulla of Vater; Intradiverticular papilla; Submucosal injection

MeSH Terms

Aged
Ampulla of Vater
Bile Ducts
Biliary Tract
Catheterization*
Cholangiopancreatography, Endoscopic Retrograde
Diverticulum
Female
Gallstones
Humans

Figure

  • Fig. 1. Abdominal computed tomography. (A) Pre-contrast axial scan showed a hyperdense lesion inside the dilated common bile duct. (B, C) Post-contrast axial scan and coronal view revealed the presence of a periampullary diverticulum (arrowheads).

  • Fig. 2. Duodenoscopic findings during endoscopic retrograde cholangiopancreatography. (A) The major duodenal papilla (arrow) is positioned inside the diverticulum. (B) Saline injection was performed at 3 and 9 o’clock (stars) for eversion and fixation of the papilla (arrow). (C) Endoscopic papillary balloon dilation preceded stone extraction.


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Kook Hyun Kim, Sung Bum Kim, Tae Nyeun Kim
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Reference

1. Fogel EL, Sherman S, Lehman GA. Increased selective biliary cannulation rates in the setting of periampullary diverticula: main pancreatic duct stent placement followed by pre-cut biliary sphincterotomy. Gastrointest Endosc. 1998; 47:396–400.
Article
2. Parlak E, Suna N, Kuzu UB, et al. Diverticulum with papillae: does position of papilla affect technical success? Surg Laparosc Endosc Percutan Tech. 2015; 25:395–398.
3. Boix J, Lorenzo-Zúñiga V, Añaños F, Domènech E, Morillas RM, Gassull MA. Impact of periampullary duodenal diverticula at endoscopic retrograde cholangiopancreatography: a proposed classification of periampullary duodenal diverticula. Surg Laparosc Endosc Percutan Tech. 2006; 16:208–211.
Article
4. Chen L, Xia L, Lu Y, Bie L, Gong B. Influence of periampullary diverticulum on the occurrence of pancreaticobiliary diseases and outcomes of endoscopic retrograde cholangiopancreatography. Eur J Gastroenterol Hepatol. 2017; 29:105–111.
Article
5. Güitrón-Cantú A, Adalid-Martínez R, Gutiérrez-Bermudez JA, Segura-López FK, García-Vázquez A. [Difficulty to cannulate papilla of Vater in the presence of periampullary duodenal diverticulum]. Rev Gastroenterol Mex. 2010; 75:273–280.
6. Harada H, Suehiro S, Shimizu T, Katsuyama Y, Hayasaka K. Submucosal injection can facilitate biliary access in patients with periampullary diverticula. Gastrointest Endosc. 2016; 84:185–186.
Article
7. Altonbary AY, Bahgat MH. Endoscopic retrograde cholangiopancreatography in periampullary diverticulum: the challenge of cannulation. World J Gastrointest Endosc. 2016; 8:282–287.
Article
8. Parlak E, Köksal AS, Dişibeyaz S, et al. Additional biliary cannulation methods in patients with juxtapapillary duodenal diverticula. Dig Dis Sci. 2012; 57:2982–2987.
Article
9. Cappell MS, Mogrovejo E, Manickam P, Batke M. 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.
Article
10. Fujita N, Noda Y, Kobayashi G, Kimura K, Yago A. ERCP for intradiverticular papilla: two-devices-in-one-channel method. Endoscopic retrograde cholangiopancreatography. Gastrointest Endosc. 1998; 48:517–520.
11. Elmunzer BJ, Boetticher NC. Reverse guidewire anchoring of the papilla for difficult cannulation due to a periampullary diverticulum. Gastrointest Endosc. 2015; 82:957.
Article
12. Külling D, Haskell E. Double endoscope method to access intradiverticular papilla. Gastrointest Endosc. 2005; 62:811–812.
Article
13. Myung DS, Park CH, Koh HR, et al. Cap-assisted ERCP in patients with difficult cannulation due to periampullary diverticulum. Endoscopy. 2014; 46:352–355.
Article
14. Wang BC, Shi WB, Zhang WJ, et al. Entering the duodenal diverticulum: a method for cannulation of the intradiverticular papilla. World J Gastroenterol. 2012; 18:7394–7396.
Article
15. Kim HJ, Kim YS, Myung SJ, et al. A novel approach for cannulation to the ampulla within the diverticulum: double-catheter method. Endoscopy. 1998; 30:S103–S104.
Article
16. Tóth E, Lindström E, Fork FT. An alternative approach to the inaccessible intradiverticular papilla. Endoscopy. 1999; 31:554–556.
Article
17. Calvo MM, Bujanda L, Heras I, et al. The rendezvous technique for the treatment of choledocholithiasis. Gastrointest Endosc. 2001; 54:511–513.
Article
18. Tarantino I, Barresi L, Fabbri C, Traina M. Endoscopic ultrasound guided biliary drainage. World J Gastrointest Endosc. 2012; 4:306–311.
Article
19. Testoni PA, Mariani A, Aabakken L, et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy. 2016; 48:657–683.
Article
20. García-Cano J. Use of an ultrathin gastroscope to locate a papilla hidden within a duodenal diverticulum. Endoscopy. 2010; 42 Suppl 2:E96–E97.
Article
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