Commentary

Takenaka et al. describe an innovative technique for cannulation of a mobile papilla at the rim of a periampullary diverticulum. Although this is an interesting rescue technique, caution should be exercised. First, contrast injection-based cannulation is needed to show the anatomy of the pancreatic duct. However, wire-assisted cannulation is preferable if possible, because contrast-guided cannulation is associated with a higher risk of post endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis [1]. Second, when cannulation with a guidewire (of one of the ducts) fails in patients with a mobile periampullary diverticula, this is often due to a “hidden” biliary orifice in the diverticulum itself. The technique described will not facilitate cannulation in such a case. Instead, a traction device (such as a clip) can be used to reorientate the papilla towards the duodenal lumen. Lastly, as with many ERCP tricks and devices for cannulation, it is advised to use accessories that the performing endoscopist feels comfortable with. In the case of failure with these accessories, consider referral to an expert colleague or, if you are an expert, try novel techniques such as the one described.

Publication History

Article published online:
16 December 2021

• References

• 1 Testoni PA, Mariani A, Aabaken L. et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2016; 48: 657-683