'CLIP WITH LINE' TECHNIQUE FOR SUCCESSFUL LUXATION OF THE PAPILLARY ORIFICE FROM A DUODENAL DIVERTICULUM AND SUCCESSFUL CANNULATION

Duodenal diverticula (DD) are a frequent condition (approximately 10 – 20% of all patients). An endoscopic retrograde cholangioscopy (ERC) of those patients can be challenging. We report a patient with a large DD. The papilla vateri (PV) is located completely in the diverticulum. The initial cannulation of the bile duct orifice (BDO) was difficult. This video shows a possibility to make the cannulation and the sphincterotomy feasible in cases with a DD. Transferred from Endoscopic Submucosa Dissection, we used the 'Clip with Line' technique for the first time in an ERC to cannulate the intra-diverticular site of the papillary orifice.

Description:

A 88-year-old women was admitted for jaundice. Ultrasonography showed a dilatated bile duct. An ERC revealed a large DD with the inability to detect the PV. BDO could be hardly visualized by lifting the top of the diverticulum with a catheter. We attached dental floss to a haemoclip to exert traction to the diverticulum and to facilitate the cannulation of the BDO. Outside the patient, a haemoclip was advanced through the working channel and was pushed out of the scope. We opened the clip and we linked the dental floss (about 2.25 m) to one arm of the clip. The endoscope was then re-inserted to the patient. Subsequently, the clip was attached to the mucosa of the papillary roof. Hence, traction was externally exerted by pulling the dental floss. With this movement the cannulation of the PV was facilitated. X-ray showed bile duct stones. A sphincterotomy was performed. Because complete extraction of bile duct stones was not confirmed, a bile duct stent was placed.

Conclusion:

In some cases DD impete the cannulation of the common BDO. Therefore, the clip with line technique is an easy and affordable option to enable the exploration and if necessary a treatment in the common bile duct.