UNUSUAL TRICK FOR CHALLENGING CANNULATION OF AN INTRADIVERTICULAR PAPILLA: A BIOPSY FORCEP-ASSISTED CANNULATION

Peri-ampullary diverticulum (PAD) is a herniation of the mucosa and submucosa layers throught a muscolaris propria defect, which prevalence generally increases with the age. Two types of PAD are described: type I (peri-diverticular papilla, PDP) and type II (intra-diverticular papilla, IDP). In type I, the papilla is at the rim or within 2 cm of the edge of the diverticulum, while in type II it lies inside the diverticulum, making difficult successful biliary cannulation.

Several methods have been described to overcome this anatomic drawback, i.e. double-wire endoclip-assisted technique, endoscopic ultrasound-guided or percutaneous-guided rendez-vous techniques. Here we report a video-case of a 61-year-old man, referred to our unit to perform endoscopic retrograde cholangiography to treat iatrogenic, post-cholecystectomy, biliary fistula. Once reached the descending duodenum, a 3 cm diverticulum appeared, with the major papilla hidden inside (IDP).

Despite submucosal lifting, papillary orifice remained inside the inner left edge of the diverticulum, tangential to the sphincterotome (TRUEtome 44, Boston Scientific, USA), and cannulation failed. So, a paediatric biopsy forcep (EndoJaw, Olympus Co., Tokyo, Japan) was introduced into the working channel of the duodenoscope (TJF-160 VR; Olympus Co., Tokyo, Japan), in order to completely expose the papilla, grasping down the redundant duodenal folds. Thanks to this trick, successful biliary cannulation was achieved.

Cholangiography documented a complete lesion of the right hepatic duct and patient was referred to surgery, after placement of covered self-expandable metal stent (diameter 10 mm, length 60 mm, WallFlex Rx Biliary, Boston Scientific, USA) and nasal biliary tube (Flexima, Boston Scientific, USA).

In conclusion, in the presence of an IDP, biliary cannulation can be challenging. In this case, we advise to consider the use of paediatric forcep to expose the papilla in order to obtain easier orifice access.