Endoscopy 2019; 51(12): E386-E387
DOI: 10.1055/a-0958-9265
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Countertraction applied using clips and a rubber band: a new simple method for cannulation of intradiverticular or hidden papillae

Marion Schaefer
1   Service d’Hépato-gastro-entérologie, CHU de Nancy, Vandoeuvre-lès-Nancy, France
,
Bastien Dirrenberger
1   Service d’Hépato-gastro-entérologie, CHU de Nancy, Vandoeuvre-lès-Nancy, France
,
Mathilde Morin
1   Service d’Hépato-gastro-entérologie, CHU de Nancy, Vandoeuvre-lès-Nancy, France
,
Arthur Belle
1   Service d’Hépato-gastro-entérologie, CHU de Nancy, Vandoeuvre-lès-Nancy, France
,
Sophie Gueyl
2   Service d’Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
,
Jérémie Jacques
2   Service d’Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
3   BioEM, UMR 7252, CNRS, Limoges
,
Jean-Baptiste Chevaux
1   Service d’Hépato-gastro-entérologie, CHU de Nancy, Vandoeuvre-lès-Nancy, France
› Author Affiliations
Further Information

Corresponding author

Marion Schaefer, MD
Service d’Hépato-gastro-entérologie
CHU de Nancy
Rue du Morvan
54500 Vandoeuvre-lès-Nancy
France   
Fax: +33-3-83153633   

Publication History

Publication Date:
16 July 2019 (online)

 

A juxtapapillary diverticulum is a frequent age-related condition that may affect 10 % – 20 % of patients undergoing endoscopic retrograde cholangiopancreatography, and increases the prevalence of stones in the principal bile duct [1]. This can render biliary duct cannulation difficult. Papillae can also be hidden by lipomas, gastrointestinal stromal tumors, or mucosal folds. To facilitate cannulation, the two-devices-in-one-channel technique of Fujita et al. can be used. A pediatric biopsy forceps is employed to evert the papilla out of the diverticulum, and other devices are inserted in parallel, in the operative channel [2]. The principal drawback is the poor maneuverability of both the duodenoscope and the elevator. Scotiniotis et al. used a clip to apply traction (the weight of the clip) to the papilla [3]. This allowed for good scope maneuverability but traction was minimal; the papilla remained unstable. We here report two cases of difficult biliary access ([Video 1]).

Video 1 Two cases of countertraction applied with clips and rubber band to improve exposure of the papilla.


Quality:

A 78-year-old woman was referred because of abdominal pain and abnormal liver function test results. An intracholedochal stone was evident on endoscopic ultrasonography ([Fig. 1]). The intradiverticular papilla could not be cannulated ([Fig. 2]). We used the clip plus rubber band strategy previously employed during endoscopic submucosal dissection [4] to apply countertraction; this exposed the papilla well in the axis of the infundibulum. First, a dental rubber band was placed on the tip of a rotating re-openable clip and inserted via the duodenoscope. The clip was placed on the peridiverticular mucosa and the rubber band was grasped with a second clip that was placed on the third part of the duodenum to establish continuous countertraction ([Fig. 3]). Given the good papillary exposure, biliary cannulation, sphincterotomy, and balloon removal of the stone proceeded uneventfully. Although some bleeding was noted, this was treated via mechanical balloon compression and insertion of a fully covered self-expandable metal stent.

Zoom Image
Fig. 1 Main bile duct stone on endoscopic ultrasound examination.
Zoom Image
Fig. 2 Intradiverticular papilla.
Zoom Image
Fig. 3 Traction of the peridiverticular mucosa with two clips and a rubber band.

Our second case was a 65-year-old man with cholangitis and a stone evident on computed tomography. He underwent duodenoscopy but a lipoma concealed the papilla despite changing the patient’s position [(Fig. 4]). We applied the countertraction described above to place the head of the lipoma in the duodenal bulb; this ensured excellent papillary exposure ([Fig. 5]).

Zoom Image
Fig. 4 Lipoma hiding the papilla.
Zoom Image
Fig. 5 Everted lipoma and accessible papilla.

In summary, clip plus rubber band countertraction effectively exposes intradiverticular or hidden papillae. Traction is continuous and steady, the duodenoscope and elevator can move freely, and the suction channel is fully functional, which is essential to counter bleeding.

Endoscopy_UCTN_Code_TTT_1AR_2AC

Endoscopy E-Videos
https://eref.thieme.de/e-videos

Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.

This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos


#

Competing interests

None

  • References

  • 1 Egawa N, Anjiki H, Takuma K. et al. Juxtapapillary duodenal diverticula and pancreatobiliary disease. Dig Surg 2010; 27: 105-109
  • 2 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
  • 3 Scotiniotis I, Ginsberg GG. Endoscopic clip-assisted biliary cannulation: externalization and fixation of the major papilla from within a duodenal diverticulum using the endoscopic clip fixing device. Gastrointest Endosc 1999; 50: 431-433
  • 4 Jacques J, Charissoux A, Legros R. et al. Double-clip counter-traction using a rubber band is a useful and adaptive tool for colonic endoscopic submucosal dissection. Endoscopy 2018; 50: 179-181

Corresponding author

Marion Schaefer, MD
Service d’Hépato-gastro-entérologie
CHU de Nancy
Rue du Morvan
54500 Vandoeuvre-lès-Nancy
France   
Fax: +33-3-83153633   

  • References

  • 1 Egawa N, Anjiki H, Takuma K. et al. Juxtapapillary duodenal diverticula and pancreatobiliary disease. Dig Surg 2010; 27: 105-109
  • 2 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
  • 3 Scotiniotis I, Ginsberg GG. Endoscopic clip-assisted biliary cannulation: externalization and fixation of the major papilla from within a duodenal diverticulum using the endoscopic clip fixing device. Gastrointest Endosc 1999; 50: 431-433
  • 4 Jacques J, Charissoux A, Legros R. et al. Double-clip counter-traction using a rubber band is a useful and adaptive tool for colonic endoscopic submucosal dissection. Endoscopy 2018; 50: 179-181

Zoom Image
Fig. 1 Main bile duct stone on endoscopic ultrasound examination.
Zoom Image
Fig. 2 Intradiverticular papilla.
Zoom Image
Fig. 3 Traction of the peridiverticular mucosa with two clips and a rubber band.
Zoom Image
Fig. 4 Lipoma hiding the papilla.
Zoom Image
Fig. 5 Everted lipoma and accessible papilla.