Clip-Assisted Traction Technique for Cannulation of a Peri-Diverticular Papilla During Endoscopic Retrograde Cholangiopancreatography: A Case Report

Endoscopic retrograde cholangiopancreatography (ERCP) plays an important role in the treatment of biliary and pancreatic diseases. It has opened up new opportunities for minimally invasive treatment of biliary and pancreatic diseases¹. Selective cannulation is the key to ERCP, and despite the significant overall success rate of selective cannulation at present, the cannulation failure rate could still reach 5%-10% due to various reasons². Clinically, the common causes of difficult ERCP cannulation mainly include tumors at the ampulla causing the papilla to twist or block the bile duct opening, periampullary diverticulum (PAD) causing deformation of the bile duct intestinal wall segment, and inflammatory stricture of the papilla, etc.³. PAD denotes a cyst-like structure that emerges the duodenal lumen's mucosa, extending outward within a 2-3 cm radius from the stomach's body. This condition frequently contributes to selective placement challenges. With the aggravation of population aging, the number of elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) has significantly increased. Due to the high incidence of duodenal papillary diverticula (as high as 20%-30%), anatomical abnormalities, and reduced tissue elasticity, these factors increase the difficulty of cannulation during ERCP in elderly patients. Successful selective biliary cannulation is key to performing ERCP, and improving the success rate of biliary cannulation and reducing the incidence of postoperative pancreatitis are currently hot topics in medical discussions, such as Lv et al., 2022 (Surg Laparosc Endosc Percutan Tech), dental floss traction⁴; Meduri et al., 2015 (Gastrointest Endosc), clip-assisted exposure for lipoma-covered papilla⁵. In these studies, the dental-floss traction and clip-assisted techniques were employed to increase the success rate of ERCP cannulation. Conventional precut or repeated attempts of intubation can easily lead to complications such as pancreatitis and bleeding, especially in elderly patients. The method described here utilizes clip traction on the peripapillary mucosa to expose the papilla from multiple directions, allowing adaptation to the papilla's position within the diverticulum.This clip-assisted mucosal traction method was used here to expose a hidden papilla and facilitate ERCP cannulation in an elderly patient. This method is a potentially reproducible technique for specific anatomical challenges.

Case Presentation
On February 2, 2025, a 67-year-old male patient was admitted to our hospital, presenting with abdominal pain, jaundice, and fever for 1 day. The patient was diagnosed in the emergency department with choledocholithiasis and choledochitis. He had no prior history of cholelithiasis or underlying medical conditions.

Diagnosis, Evaluation, and Plan
The diagnosis revealed choledocholithiasis with acute cholangitis. Further assessments performed were as follows: Liver Function Tests (LFTs): Alanine Aminotransferase (ALT): 390 U/L, Aspartate Aminotransferase (AST): 223 U/L, Albumin: 36.8 g/L, Total Bilirubin: 109.45 µmol/L. Coagulation function: Prothrombin Time (PT): 15.7 s. Imaging examinations: Upper abdominal computed tomography (CT): Choledocholithiasis with biliary dilation (see Figure 1).

Figure 1: AbdominalCT scan. Choledocholithiasis (indicated by red arrow) with associated dilation of the common bile duct. Please click here to view a larger version of this figure.

The plan was to perform endoscopic retrograde cholangiopancreatography (ERCP) for the removal of common bile duct stones. First, a guidewire was cannulated through a sphincterotome under duodenoscopic guidance, followed by contrast injection (cholangiography) to confirm stone location and dimensions. Further lithotripsy using a basket or balloon catheter was performed, followed by cholangiography to confirm complete removal of common bile duct stones. Finally, a nasobiliary drainage catheter was placed based on the condition of the bile duct.

This study was approved by our Institutional Ethics Committee (No. 2025ZSZY-LL-KY-265). Informed consent was obtained from the patient prior to surgery.

1. Specific operation method

NOTE: After the duodenoscope entered the descending part of the duodenum, the steps described below were followed.

1. Locate the descending duodenum.
   1. Under duodenoscopy, observe the duodenal papilla to be located within an adjacent diverticulum (Figure 2A).
2. Expose the papilla.
   1. Expose the duodenal papilla fully by retracting the mucosa beneath the periampullary diverticulum using a sphincterotome, and assess the cannulation direction (Figure 2B).
   2. Deploy a hemostatic clip to traction the mucosa inferior to the diverticulum (Figure 2C), ensuring complete papillary exposure before closing the clip for fixation (Figure 2D).
3. Insert the guidewire.
   1. Ensure the standard cannulation is close to the wall and enters the sphincterotome head at the 11-1 o'clock direction of the papilla.
   2. Some diverticula can easily cause the bile duct at the major duodenal papilla to deviate slightly, making it difficult to insert the guide wire. Expose the major duodenal papilla by hemostatic clip to make the papillary orifice visible, and observe the direction of the sphincterotome to adjust the direction of insertion, enabling guidewire insertion.

Figure 2: Endoscopic visualization of the duodenal papilla. (A) Papilla hidden within diverticulum (before traction, indicated by black arrow). (B) Expose the major duodenal papilla by sphincterotome (indicated by black arrow). (C) Open the hemostatic forceps to retract the periampullary mucosa, fully exposing the major duodenal papilla. Ensure the direction of traction is aligned with the papilla's axis. (D) Confirm full exposure of the major duodenal papilla, then close the hemostatic forceps to retract the periampullary mucosa. Please click here to view a larger version of this figure.

2. Perioperative supportive care

1. On the operative day, maintain nil per os (NPO) status. Initiate intravenous fluid resuscitation for hydration maintenance, electrolyte repletion, and acid-base equilibrium.
2. Administer acid suppression using proton-pump inhibitors (PPI).
3. Provide prophylactic antibiotics for ≤48 h, in accordance with ASGE guidelines.
4. Initiate protease inhibitor therapy as a 24-h course for pancreatitis prevention.

3. Postoperative management

1. Perform laboratory tests 2-3 h post-ERCP: Complete blood count (CBC), and serum amylase.
2. On Day 2 follow-up, repeat CBC, liver function tests (LFTs), and serum amylase tests.
3. Manage asymptomatic hyperamylasemia with advancement to a full liquid diet on postoperative day 1.

The patient's procedure duration was within 70 min. Prior to hemostatic clip traction, two attempts at cannulation had been performed over approximately 6 min. Due to the location of the duodenal papilla within a diverticulum, the papillary axis was suboptimal, making adjustment of the sphincterotome angle difficult. After applying the hemostatic clip to retract the mucosal fold, the duodenal papilla became clearly visible (Figure 2D). Clip-assisted traction enabled realignment of the papillary axis, allowing successful biliary cannulation without a precut sphincterotomy. Subsequent cannulation was then successfully achieved in approximately 2 min (Figure 3). No mucosal injury or any adverse events were observed during the procedure. The patient did not develop post-ERCP pancreatitis, perforation, or bleeding after the procedure.

Figure 3: Successful cannulation. (A) Successful guidewire cannulation under direct vision. (B) Successful guidewire cannulation under fluoroscopy. Please click here to view a larger version of this figure.

ERCP has been playing an important role in the treatment of biliary and pancreatic diseases because of its advantages of less trauma, good curative effect, and quick recovery. Selective biliary cannulation is the key to this operation. Although ERCP technology is gradually improving, difficult cannulation still occurs from time to time during clinical procedures, and if it is impossible to enter the corresponding bile ducts by super-selection, subsequent treatment cannot be carried out. The latest European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommend that difficult biliary cannulation be defined as any of the following >5 attempts at transpapillary cannulation; >5 min of direct visualization of attempted cannulation; >1 unintended pancreatic cannulation or dilation⁶. When facing difficulties in selective cannulation, techniques that can be used include the double-guidewire technique, needle-knife papillotomy, and a biliary-to-ductal membrane incision, among others. There are only a few case reports on the application of the metal clip-assisted cannulation technique for difficult cannulation during ERCP^7,8. One study reported 12 cases of successful ERCP with metal clip-assisted cannulation, with no complications⁹.

The metal clip-assisted operation offers simple use, moderate cost, and high safety, and has been widely used in endoscopic treatment. Many endoscopists have rich experience in using this technique. Therefore, it is also easy for ERCP physicians to accept the application of these two techniques in ERCP-assisted manipulation, as demonstrated by Zhang et al. (2024) - clip-rubber band for hidden papilla¹⁰. However,our method uses only one clip, making it simpler and ensuring the instruments are readily available. This method is a feasible adaptation of a hemostatic clip for improved exposure. By clamping the mucosa around the papilla and adjusting the traction direction, it can realign the papilla adjacent to the diverticulum or, with axial displacement, into the insertion path. Its core advantages include: (i) Accurate anatomical repositioning: Aiming at the characteristics of diverticulum adjacent to the papilla or mucosa relaxation in the elderly patients, the three-dimensional space adjustment is achieved through multi-point clamping; (ii) Safety optimization: The application of this traction technique may reduce the need for precut sphincterotomy and the likelihood of cannulation failure in cases of periampullary diverticulum.

If the hemostatic clip dislodges or the traction angle is suboptimal during the procedure, additional clips may be applied to ensure adequate exposure. In the event of accidental mucosal tearing caused by the clip, immediate hemostasis is required. This method, which utilizes a hemostatic clip to retract the mucosa around a periampullary diverticulum, ensures clear visualization of the duodenal papilla. However, it demands more precise control over the traction direction. The mucosal traction plays a critical role in facilitating guidewire advancement during cannulation. Its clinical efficiency lies in reducing the risk of invasive procedures in elderly patients; improving the success rate of insertion in patients with diverticulum; and expanding the applicability of ERCP in the frail population. However, it is important to note that the current evidence for this method is derived from a single case report, which lacks a control group or quantifiable time-saving data.

Furthermore, its reproducibility may be influenced by the operator's experience and the patient's specific anatomy. Therefore, further validation in a wider range of scenarios is necessary before widespread adoption can be recommended, which may reduce need for precut sphincterotomy in selected elderly patients. We suggest evaluating this method in a larger series of cases with peri-diverticular or inward papillae. We also propose inclusion of this procedure in training modules for managing anatomically challenging ERCP cases.