# Poster Session I - A77 THE DUAL-CHANNEL CLIP-AND-SNARE TRACTION TECHNIQUE: A NOVEL APPROACH TO BILIARY CANNULATION DURING ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN A PATIENT WITH ROUX-EN-Y ANATOMY

## TL;DR

A new technique using a dual-channel endoscope helps with biliary cannulation in patients with complex gastrointestinal anatomy during ERCP.

## Contribution

The dual-channel clip-and-snare traction technique is introduced as a novel method for biliary cannulation in patients with Roux-en-Y anatomy.

## Key findings

- The dual-channel clip-and-snare traction technique successfully enabled biliary cannulation in a patient with Roux-en-Y anatomy.
- This is the first reported use of the CST technique with a dual-channel gastroscope for biliary cannulation.
- The method allows dynamic mobilization of the papilla, improving cannulation efficiency in complex anatomies.

## Abstract

Suboptimal exposure of the ampullary orifice during ERCP renders biliary cannulation technically difficult. Moreover, ERCP in patients with surgically altered gastrointestinal anatomy is challenging. In such cases, traditional guidewire-assisted techniques can be unsuccessful, and innovative approaches may be necessary to facilitate biliary cannulation. Various strategies have been reported in the literature, including endoscopic clipping, submucosal injection, and two-device-in-one-channel methods. The clip-and-snare traction technique has proven to be effective in accomplishing successful biliary cannulation during ERCP in patients with an intradiverticular papilla.

In this case report, we describe a novel approach to biliary cannulation during ERCP in a patient with Roux-en-Y anatomy: the dual-channel clip-and-snare traction (CST) technique. This novel approach uses a dual channel endoscope allowing simultaneous mobilization of the papilla with a clip and snare to assist in biliary cannulation in patients with altered anatomy.

Here, we report a successful case of dual-channel biliary cannulation using the CST technique during ERCP in a patient with malignant biliary obstruction and Roux-en-Y anatomy, performed in our centre at Hôpital du Sacré-Coeur in Montreal, Quebec.

An 88-year-old man with Roux-en-Y anatomy presented with jaundice due to malignant compression of the distal common bile duct. ERCP was performed for biliary drainage. A dual channel gastroscope with a distal attachment cap was used to advance to the duodenum via cannulation of the biliopancreatic limb. Upon arrival at the duodenum, a large protruding papilla was observed. Traditional guidewire-assisted cannulation was difficult due to the tangential position of the papillary orifice. Therefore, a MANTIS clip was inserted inferior to the papilla and grasped using a snare inserted through the second channel of the gastroscope. Clip-and-snare traction was performed through the second channel, which enabled successful cannulation of the common bile duct followed by placement of an uncovered metal stent to allow for biliary drainage.

Biliary cannulation can be technically challenging during ERCP in patients with surgically altered gastrointestinal anatomy. The novel clip-and-snare traction technique has proven to be effective in such cases. While the parallel use of CST has been reported to assist in biliary cannulation using a duodenoscope, this case is, to our knowledge, the first report of CST-assisted biliary cannulation using a dual channel gastroscope. The CST method using a dual channel system allows for dynamic mobilization of the papilla due to separate access for devices, thus favoring more efficient biliary cannulation in patients with complex anatomy.

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