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.
