CLIPS + RUBBER BAND COUNTERTRACTION: A NEW SIMPLE METHOD TO ALLOW INTRADIVERTICULAR PAPILLA CANNULATION

The prevalence of lithiasis biliary pathologies is high in patients with peri-ampullary diverticula.

We report the case of a patient with main bile duct stones, confirmed after EUS examination. The endoscopic view of the duodenal tract showed an intradiverticular papilla. In order to facilitate the exposure of the papilla, we proceed to a counter traction by clip and rubber band. A first Boston Resolution 360 clip, on which was hung a dental rubber band (Ormco Ostrich 19.1 mm) was set up in para-papillary position by the operating channel of the duodenoscope (Olympus). A second clip was introduced into the operator channel to tract the elastic on the outer edge of the duodenum. The papillary exposure was improved and cannulation of the main bile duct was achieved in 3 minutes and 10 seconds with a Boston Jagwire guide wire and a Boston sphincterotome 4.4. After performing a sphincterotomy, the stones were extracted with an balloon and hemostatic compression was performed due to post-sphincterotomy bleeding. The haemostasis was completed by the placement of a covered SEMS Cook Evolution 40 × 10 mm, then by the injection of saline and adrenaline 1/1000.

The use of a pediatric biopsy forceps in the same working channel as the sphincterotome has been described to pull the infindibulm and facilitate its catheterization. This technique is not easy and the movements of the erector and sphincterotome are limited by the presence of the pediatric forceps throughout the cannulation tentatives. The use of a counter-traction facilitates the exposure of an intra-diverticular papilla and the bile duct cannulation and it allows a higher maneuverability of the erector and the sphincterotome during the procedure.

The use of a counter-traction by two clips and an elastic can be useful for ERCP in the case of intra-diverticular papilla.