Successful endoscopic biliary intervention for duodenal peridiverticular papilla using a novel traction device

Abstract

Figures

Endoscopic visualization of the peridiverticular papilla in the duodenum.

When the traction device is manipulated, the duodenal papilla is moved out of the diverticulum.

Successful selective biliary cannulation after repositioning of the papilla.

Endoscopic sphincterotomy is performed.

After stone extraction and placement of a biliary drainage tube, the line used for traction is cut using an endocutter.

Full text

Periampullary diverticulum is defined as herniation of the mucosa or submucosa through a defect in the muscular layer around the papilla 1 . Achieving selective biliary cannulation for peridiverticular papilla is challenging 1 , and several endoscopic devices and techniques have recently been developed 1 2 3 4 . Herein, we present a case of successful endoscopic biliary intervention using a novel traction device for the peridiverticular papilla in a patient with choledocholithiasis.

A 92-year-old woman was diagnosed with choledocholithiasis on computed tomography after treatment for aspiration pneumonia. Endoscopic sphincterotomy and stone extraction were performed ( Video 1 ). On endoscopy, a duodenal papilla was identified as being situated within the diverticulum at its periphery ( Fig. 1 ); however, biliary cannulation failed because of poor visualization of the papillary orifice. Therefore, we used a novel traction device (EndoTrac; TOP Corporation, Tokyo, Japan) comprising a line with a clinch-knotted loop encased in a plastic sheath 5 . An endoclip was inserted through the endoscopic channel to the tip and the EndoTrac line was tied to it. The endoscope and traction device were simultaneously inserted into the duodenum. The endoclip with EndoTrac was positioned at the distal mucosa of the diverticular edge. The tip of the plastic sheath was advanced toward the endoclip, and the EndoTrac was pushed for repositioning of the papilla. The duodenal papilla was moved from the diverticulum by manipulating the device ( Fig. 2 ). The traction force exerted by the device was adjusted to ensure optimal positioning of the duodenal papilla. The selective biliary cannulation was successful ( Fig. 3 ). Sphincterotomy and balloon dilatation were performed ( Fig. 4 ), and stone extraction was completed ( Fig. 5 ). Endoscopic biliary procedures using the EndoTrac device can provide good visualization of the papilla and facilitate biliary cannulation for the peridiverticular papilla.

Successful biliary cannulation for a duodenal peridiverticular papilla using a novel traction device (EndoTrac).Video 1

Endoscopic visualization of the peridiverticular papilla in the duodenum.

When the traction device is manipulated, the duodenal papilla is moved out of the diverticulum.

Successful selective biliary cannulation after repositioning of the papilla.

Endoscopic sphincterotomy is performed.

After stone extraction and placement of a biliary drainage tube, the line used for traction is cut using an endocutter.

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