Multiloop traction method during endoscopic hemostasis for post-sphincterotomy bleeding of the peridiverticular papilla

Periampullary diverticulum (PAD) is considered a risk factor for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP) because it makes the papilla unidentifiable ¹ . Applying a traction force near the papilla has been reported to be effective in PAD biliary interventions ² . We report a successful case of endoscopic hemostasis in post-sphincterotomy bleeding, using the multiloop traction method (M-loop method), in a patient with PAD ³ ( Video 1 ).

Video 1  Endoscopic hemostasis, achieved using the multiloop traction method for post-sphincterotomy bleeding of the peridiverticular papilla.

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A 79-year-old man, taking direct oral anticoagulants (DOACs) for atrial fibrillation, presented with symptomatic common bile duct stones. His DOAC medication was temporarily discontinued on the day of the procedure. A successful endoscopic sphincterotomy (ES), with complete stone removal, was achieved.

Post-ES bleeding was noted 4 days after the procedure ( Fig. 1 ). Achieving endoscopic hemostasis was challenging because the bleeding source was covered with duodenal mucosal folds. The M-loop method was used to locate and expose the bleeding source ( Fig. 2 ). A SureClip (Micro-Tech, Nanjing, China), attached to a multiple-loop-thread, was deployed to cover the mucosal fold. Additional clips were hooked onto the free loop and attached to the oral side of the duodenal wall. A traction force was generated to pull the duodenal mucosa covering the papilla upward. The bleeding point was sufficiently exposed ( Fig. 3 , Fig. 4 ). A pancreatic stent was placed to avoid post-ERCP pancreatitis. Successful hemostasis was achieved with endoscopic coagulation, using a Coagrasper (Olympus, Tokyo, Japan) ( Fig. 5 ). The threads used in the M-loop method were cut after hemostasis. Rebleeding was not observed after restarting DOAC therapy.

Fig. 1.

 Endoscopy revealed that the unidentifiable bleeding source was in the peridiverticular papilla.

Fig. 2.

 How to make the multiloop traction loop (M-loop). A 3–0 silk suture thread was reeled around a 2.5-mL syringe, and multiple knots were made. The M-loop thread was created by repeating this process. The redundant thread of the M-loop was tied to the claw of a SureClip (Micro-Tech, Nanjing, China).

Fig. 3.

 Schema before and after using the multiloop (M-loop) method.

Fig. 4.

 Endoscopic view after using the M-loop method; the bleeding source was sufficiently exposed.

Fig. 5.

 Endoscopic view after achieving successful hemostasis.

PAD has been reported to be a risk factor for post-ES bleeding ⁴ . Hemostasis for post-ES bleeding may be challenging in patients with PAD due to the deviation of the papilla’s position. Traction, using the M-loop method, provides adequate exposure of the papilla, facilitating hemostasis in patients with post-ES bleeding.

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