Two-devices-in-one-channel method: a challenging cannulation of intradiverticular major papilla

Video

Video 1

Two-devices-in-one-channel method with a SpyGlass retrieval basket (Boston Scientific, Marlborough, Mass, USA) grabbing and pulling one of the previously placed through-the-scope clips and biliary cannulation with a conventional sphincterotome, using the double-guidewire technique.

Case Presentation

An 84-year-old female patient with a medical history of end-stage kidney disease, heart failure, atrial fibrillation, and hypertension was admitted to the emergency department with hypovolemic shock after a hemodialysis session. An abdominal CT scan revealed small-bowel ischemia, without perforation. She underwent exploratory laparotomy. Irreversible gallbladder ischemia was identified, and cholecystectomy was performed. Signs of reversible small-bowel ischemia were seen. Thus, no further interventions were pursued. The surgery was complicated with a biliary leak without improvement under conservative treatment. Thus, the patient was referred for ERCP.

Procedure

ERCP was performed with a conventional duodenoscope (TJF-Q190V; Olympus, Tokyo, Japan). The major papilla was located inside a large duodenal diverticulum and thus was not readily accessible for cannulation (Fig. 1). Eversion of the papilla was not possible despite several attempts with a sphincterotome and suction. Mucosal traction with biopsy forceps was not successful because of frailty of the duodenal mucosa. Despite the placement of 2 through-the-scope (TTS) clips, the eversion of the papilla was not achieved. We then decided to use the 2-devices-in-1-channel method (Video 1, available online at www.videogie.org). Instead of using a biopsy forceps, a SpyGlass retrieval basket (Boston Scientific, Marlborough, Mass, USA) was used to grab and pull one of the previously placed TTS clips, allowing eversion and exposure of the major papilla (Fig. 2). Biliary cannulation was then performed successfully with a conventional sphincterotome, using the double-guidewire technique (Fig. 3). Traction with the basket was kept until achievement of biliary cannulation because of uncertainty regarding whether the stiffness of the pancreatic guidewire would be enough to maintain the papilla exposed. In addition, the possibility of performing slight forward and backward movements with the basket also facilitated the access to the bile duct even after placement of the pancreatic guidewire. The biliary leak was identified during the cholangiography, originating from a subvesical bile duct (Luschka duct; Fig. 4). Sphincterotomy was performed, followed by placement of a 10F 4-cm double-pigtail plastic stent (Figs. 5 and 6). The total procedure time was 50 minutes (20-minute duration of the 2-devices-in-1-channel technique).

Figure 1.

Endoscopic image of a duodenal diverticula with major papilla hidden inside, that is, not readily accessible for cannulation.

Figure 2.

A SpyGlass retrieval basket (Boston Scientific, Marlborough, Mass, USA) was used for grabbing and pulling one of the previously placed through-the-scope clips, allowing eversion and exposure of major papilla for cannulation.

Figure 3.

Biliary duct cannulation was achieved with a conventional sphincterotome via the 2-devices-in-1-channel method and the double-guidewire technique.

Figure 4.

Cholangiogram showing a biliary leak originating from a subvesical bile duct.

Figure 5.

Fluoroscopic still image after sphincterotomy and placement of a 10F 4-cm double-pigtail plastic stent.

Figure 6.

Endoscopic image after sphincterotomy and placement of a 10F 4-cm double-pigtail plastic stent.

Outcome

Technical and clinical success was achieved without any periprocedural or postprocedural adverse events. The patient had progressive improvement of biliary drainage from surgical drains, with complete resolution within 1 week after ERCP.

Conclusion

In recent years, several adjuvant techniques have been described to overcome the challenges of cannulation of an intradiverticular papilla, that is, the use of mucosal traction with clips attached to dental floss, rubber band, and cap-assisted cannulation, or 2 devices in the same channel.^1,2 The 2-devices-in-1-channel method has been previously described as useful and safe for selective biliary cannulation of intradiverticular papillas.³ Previous cases used either pediatric biopsy forceps or a duodenoscope with a wide instrument channel to allow both devices in the same channel.4, 5, 6, 7, 8 Because we could not exert traction with the biopsy forceps owing to mucosal frailty, grabbing the TTS clip previously placed near the papilla allowed us to evert the papilla and achieve biliary cannulation. Similar technical and clinical outcomes would probably also be achieved with the use of small-caliber snares, like the SpyGlass retrieval snare. Our case may allow endoscopists to widen their endoscopic armamentarium to deal with the challenges of cannulating intradiverticular papillas.

Disclosure

The authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Two-devices-in-one-channel method with a SpyGlass retrieval basket (Boston Scientific, Marlborough, Mass, USA) grabbing and pulling one of the previously placed through-the-scope clips and biliary cannulation with a conventional sphincterotome, using the double-guidewire technique.