숨겨진 십이지장 유두에서 Endoclip을 이용한 담췌관 삽입술: 증례 3예
Endoclip-Assisted Cannulation for a Hidden Duodenal Papilla: Three Cases
Article information
Abstract
내시경적 역행성 담췌관조영술 중 선택적 삽관은 유두가 보이지 않는 경우, 특히 게실 내 유두(intradiverticular papilla, IDP) 또는 점막 주름에 의해 유두가 덮여 있을 때 어려울 수 있다. Endoclip을 이용한 삽관술은 유두를 외번시키고 고정하는 데 효과적이며, 단독으로 또는 다른 기구와 함께 사용할 수 있는 안전한 기술이다. 본 증례에서는 endoclip을 사용하여 IDP 2예와 점막 주름에 의해 유두가 덮인 1예에서 성공적으로 유두 삽관을 수행한 경험을 보고한다. 두 증례에서는 endoclip만을 사용하여 보이지 않는 유두를 재위치시켜 삽관에 성공하였고, 한 증례에서는 endoclip을 이용해 여분의 주름을 카테터로 밀어내어 삽관에 성공하였다. Endoclip을 이용한 유두 삽관술은 다양한 상황에서 단독으로 또는 다른 기구와 함께 적용할 수 있는 유용한 방법으로 평가된다.
Trans Abstract
Selective cannulation during endoscopic retrograde cholangiopancreatography can be particularly challenging when the papilla is invisible, either due to an intradiverticular papilla (IDP) or because it is covered by a mucosal fold. Endoclipassisted cannulation is an effective and safe technique for everting and fixing the papilla and it can be used alone or in combination with other devices. In this report, we achieved successful papillary cannulation in two cases of IDP and one case where the papilla was covered by a mucosal fold. In two cases, cannulation was accomplished by repositioning the invisible papilla using an endoclip alone, while in one case, we used an endoclip-assisted technique to push a redundant fold with a catheter. Endoclipassisted papillary cannulation can be applied in different situations, either alone or in combination with other devices.
INTRODUCTION
An invisible papilla located within a duodenal diverticulum presents a significant challenge for endoscopic retrograde cholangiopancreatography (ERCP) [1]. Various techniques have been introduced as safe and effective methods for managing intradiverticular papilla (IDP), including two-devices-one-channel techniques, such as the use of a biopsy forcep [2] or a catheter [3], submucosal injection [4], entering the duodenal diverticulum [5] and endoclipping [6]. The endoclipping technique, first reported in 1999, is particularly useful for repositioning and fixing an invisible papillary orifice [1]. It can be applied as alone or in combination with other devices, such as deploying a second endoclip [1], using traction with snaring [7,8] or an endoloop [9] and pushing the surrounding duodenal mucosa with a catheter when papilla eversion is incomplete. Additionally, endoclipping has been used to manage a hidden papilla covered by duodenal mucosa [10] or a juxtapapillary lipoma [11] by repositioning these obstacles. We report three cases of successful papillary cannulation using endoclips in two cases of IDP and one case of a hidden papilla obscured by a floppy mucosal fold.
CASES
1. Case 1
A 79-year-old man with underlying hepatocellular carcinoma was admitted to our hospital with a diagnosis of acute cholangitis caused by a benign biliary stricture. During ERCP with duodenoscopy (JF 260; Olympus Medical Systems Corp., Tokyo, Japan), the orifice of major papilla was found invisible, located at the 3 o’clock position of the inner diverticular border (Fig. 1A). Although the papilla could be everted from the diverticulum using a catheter, it would rotate back inside once the mechanical traction was released, making biliary cannulation difficult (Fig. 1B). To address this, an endoclip (EZ clips, HX-610-090, Olympus Medical Systems Corp.) was applied to evert and fix the papilla on the lateral side of the diverticulum (Fig. 1C). This maneuver successfully facilitated biliary cannulation (Fig. 1D, E).
(A, B) The orifice of major papilla is invisible, located just within the diverticulum (black arrow), near its lateral rim. (C) The endoclip (EZ clips, HX- 610-090; Olympus Medical Systems Corp., Tokyo, Japan) was applied at the 3 o’clock postion of diverticulum. (D, E) The papillary orifice is everted and stabilized, facilitating biliary cannulation.
2. Case 2
A 69-year-old man was admitted to our hospital due to recurrent abdominal pain. An abdominal computed tomography scan showed a 0.7 cm calcified stone located in the proximal pancreatic duct (PD), accompanied by distal PD dilatation. ERCP was performed for the extraction of the PD stone in the context of chronic pancreatitis. During ERCP with duodenoscopy, the papillary orifice was obscured by redundant infundibular folds (Fig. 2A, B). To expose the papillary orifice, the redundant folds were pushed upward and fixed in place using two endoclips (EZ clips, HX-610-090) (Fig. 2C). This maneuver allowed for successful PD cannulation, followed by the insertion of a single pigtail stent (Zimmon® Pancreatic Stent, 5 Fr×12 cm, Cook Medical Ltd., Limerick, Ireland) using a papillotome and guide wire (Fig. 2D, E).
(A, B) The orifice of the major papilla is obscured by stacked infundibular folds. (C, D) Floppy duodenal folds were pushed upward and fixed in place using two endoclips. The visible papilla (black arrow) enabled successful pancreatic duct cannulation. (E) A single pigtail stent (Zimmon® Pancreatic Stent, 5 Fr×12 cm, Cook Medical Ltd., Limerick, Ireland) was successfully inserted following selective cannulation.
3. Case 3
A 85-year-old woman was admitted to our hospital with a diagnosis of acute calculous cholangitis caused by a 1.2 cm sized common bile duct stone. During ERCP with duodenoscopy, the orifice of major papilla was invisible, located on the right side of inner diverticular border (Fig. 3A). The papilla could be partially everted by applying an endoclip (EZ clips, HX-610-090) to the 7 o’clock position of the diverticulum (Fig. 3B). However, this partial eversion was insufficient for biliary cannulation. By pushing the anchored endoclip laterally with the tip of a catheter, further eversion and stabilization of the papillary orifice were achieved (Fig. 3C). This maneuver successfully facilitated biliary cannulation (Fig. 3D, E).
(A) The orifice of the major papilla is invisible, located just within the diverticulum near its medial rim. (B) The papillary orifice (black arrow) is partially everted by the application of one endoclip at the 7 o’clock position of the diverticulum. (C-E) Further eversion and stabilization of the papillary orifice (black arrow) were achieved by pushing the duodenal mucosa with the tip of a catheter (white arrow) inside the endoclip, which facilitated biliary cannulation.
DISCUSSION
Endoclip-assisted papillary cannulation has been reported as a safe and effective technique for cases where the papilla is not visible. In situations where the papilla is hidden by an IDP, stacked duodenal mucosa [10], or a juxtapapillary mass [11], endoclipping facilitates papillary cannulation by retracting or everting the papilla and fixing the duodenal mucosa in place. To successfully achieve endoclip-assisted cannulation, proper orientation of the clip is essential. The availability of 360-degree rotatable and reopenable clips helps to position the major duodenal papilla en face, which is crucial for successful cannulation [12]. Applied endoscopic mucosal clips are known to slough spontaneously after approximately four weeks, with no reported complications. The depth of the clip’s grasp is limited to the muscularis mucosa, minimizing the risk of injury to the intraduodenal segment of the common bile duct [13].
However, achieving proper placement of the endoclip with sufficient traction on the duodenal mucosa can sometimes be challenging. The endoclip can obstruct the view of the papilla and surrounding area, making it harder to identify the correct insertion path. Nadir et al. reported a case of IDP where the placement of two endoclips made the papillary opening more unstable, resulting in more difficult cannulation [14]. In such cases, additional techniques, such as traction or pushing, as demonstrated in our case 3, can be applied. Pushing the duodenal mucosa with a catheter at the base of the endoclip attachment, utilizing a two-devices-in-one-channel technique, facilitated the eversion of the papilla. In this case, the anchored endoclip provided a stable point for the pushing maneuver.
Additionally, modified clip-attached traction techniques, such as snaring [7,8], endoloop [9], dental floss [15,16] or clip-band [17,18] have also been reported.
One study about the outcomes of two-devices-in-one-channel and endoclip techniques in patients with IDP reported that both methods are safe and effective for biliary cannulation [6]. The rates of overall biliary cannulation and complications were 90% and 15% in two-devices-in-one-channel technique, and 86% and 18% in endoclip technique, respectively. All complications were mild including cholangitis, hyperamylasemia, or mild pancreatitis.
In summary, we report three cases where successful papillary cannulation was performed after exposing and stabilizing the invisible papillary orifice using endoclips. The endoclip-assisted method is a safe and effective technique for pancreatic or biliary cannulation in cases of IDP or when the major papilla is covered by stacked duodenal mucosa. When faced with difficult papillary cannulation, endoscopists should carefully evaluate the features and anatomy of the major papilla considering the technical feasibility and safety of each available technique.
Notes
Conflict of Interest
The authors have no conflicts to disclose.