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

Summary

This study repurposes endoscopic hemostasis clips for papillary mucosa traction, realigning peri-diverticular or malpositioned papillae axially with the cannulation path. By transforming clips into mechanical traction tools, it standardizes difficult ERCP cannulation in elderly patients, enhancing safety and efficacy.

Abstract

During endoscopic retrograde cholangiopancreatography (ERCP), successful tube placement is the first step. Common clinical challenges include difficult cannulation, elderly patients, and peri-diverticular papilla. The objective of this study is to facilitate papillary exposure using clip traction. This research applied the endoscopic hemostasis clip to pull the mucosa technique, providing a safer and more effective solution for difficult intubation in the elderly by adjusting the papillary spatial orientation. This technique breaks through the traditional hemostatic function of hemostasis clips and uses them as mechanical traction tools. By clamping and adjusting the traction direction of the papillary mucosa, it can realign the papilla close to the diverticulum or the papilla with the intubation path along an axis. It provides a standardized method for difficult ERCP in elderly patients, with significant social benefits and promotional significance. A 67-year-old male patient with choledocholithiasis presented with a major duodenal papilla located within a diverticulum. During ERCP, we successfully cannulated and completely removed the common bile duct stones using a hemostatic clamp-assisted traction technique. Hemostatic clamp-assisted traction facilitates cannulation in patients with difficult cannulation during ERCP, particularly those with duodenal papillary diverticula. Its efficacy requires verification in future large-scale studies.

Introduction

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.

Protocol

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.

Results

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 ...

Discussion

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 Gas...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Biliary Balloon Dilator	Anrei Medical (hz) Co.,Ltd	2025040106D
Endoscopic hemostasis clip	Micro-Tech (Nanjing) Co.,Ltd	MMAC250225592	To expose the major duodenal papilla
Guidewire	Leo Medical Co.,Ltd	020401241115
Sphincterotome	Leo Medical Co.,Ltd	052601250222
Stone Extraction Balloon	Leo Medical Co.,Ltd	030101250409