Clip and snare lifting technique to assist cannulation of a papilla hidden behind a mucosal fold

Endoscopic retrograde cholangiopancreatography (ERCP) is a technically complex endoscopic procedure with significant rates of severe complications (0.8 %) and mortality (0.02 %) [1]. Complication rates increase in those patients where cannulation is difficult, defined as a situation in which the operator using a standard technique fails to achieve cannulation within 5 minutes, makes five unsuccessful attempts, or two passages of the guidewire into the pancreas [2] [3]. Features that are known to be associated with difficult, time-consuming, or impossible cannulations are failure to identify the papilla within the diverticulum, a floppy papilla on the edge of diverticula, and a papilla that is hidden by a mucosal fold ([Fig. 1 a]) [4]. The latter situation can be particularly challenging and has few possible solutions [5].

Fig. 1 Endoscopic views showing: a the mucosal fold with the papilla hidden behind it; b, c the snare being tightened around the previously positioned endoscopic clip, and being pulled back; d the papilla, which is successfully visualized after use of a push-and-pull technique, subsequently allowing the common bile duct to be cannulated.

We hereby describe the first two patients in which we used an endoclip and a snare to lift the mucosal fold and allow access to a hidden papilla. The first patient was a 70-year-old woman with a bile leak after hemihepatectomy. She had a flat papilla, underneath a floppy mucosal fold, that could not be cannulated. The second patient was a 55-year-old woman with a post-cholecystectomy bile leak. She had a papilla that was hidden behind a fold and had undergone two ERCPs and a precut sphincterotomy because of unsuccessful bile duct cannulation.

In both patients an endoclip (Resolution Clip; Boston Scientific Corporation, Natick, Massachusetts, USA) was placed on the fold. The duodenoscope was withdrawn and was then re-introduced with a biopsy forceps inside the working channel that was used to grasp a polypectomy snare (Sensation Short Throw, 13 mm; Boston Scientific) so that this was introduced beside the scope. The snare loop was then tightened slightly around the shaft of the endoclip ([Fig. 1 b]) and the wire was pulled up through the mouth ([Fig. 1 c]), which slightly altered the alignment of the papillary region, so allowing the opening of the papilla to be visualized ([Fig. 1 d]) and successfully cannulated.

These are the first successful cases of clip and snare-assisted cannulation, a way of accessing the bile duct in otherwise apparently impossible conditions, by either pulling or pushing ([Fig. 2]) a snared clip that had been previously positioned on the mucosal fold that was hiding the papilla.

Fig. 2 Schematic showing the stages of the clip and snare-assisted cannulation process: a the papilla is not easily visualized as it is hidden behind a mucosal fold; b, c an endoclip is placed on the fold; d the endoscope is withdrawn; e a snare grasped in a biopsy forceps is passed alongside the scope as it is re-inserted; f the snare loop is placed around the shaft of the clip; g the snare is pulled back lifting the fold away from the papilla; h the papilla can then be successfully cannulated.

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• References

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• 2 Udd M, Kylänpää L, Halttunen J. Management of difficult bile duct cannulation in ERCP. World J Gastrointest Endosc 2010; 2: 97-103
• 3 Halttunen J, Meisner S, Aabakken L et al. Difficult cannulation as defined by a prospective study of the Scandinavian Association for Digestive Endoscopy (SADE) in 907 ERCPs. Scand J Gastroenterol 2014; 49: 752-758
• 4 Tham TC, Kelly M. Association of periampullary duodenal diverticula with bile duct stones and with technical success of endoscopic retrograde cholangiopancreatography. Endoscopy 2004; 36: 1050-1053
• 5 Fujita N, Noda Y, Kobayashi G et al. ERCP for intradiverticular papilla: two-devices-in-one-channel method. Endoscopic Retrograde Cholangiopancreatography. Gastrointest Endosc 1998; 48: 517-520