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• W2099694520 abstract "Cannulation of the duodenal ampulla is the first step in endoscopic retrograde catheterization of the biliary or pancreatic ductal system. Proper visualization and orientation of the duodenal papilla in relation to the cannulating catheter are two crucial prerequisites to successful ampullary cannulation. Inability to achieve and maintain the aforementioned conditions frequently leads to a failed attempt at endoscopic retrograde cholangiopancreatography (ERCP). Herein, we describe a technique by which proper visualization and orientation of an eccentrically placed ampulla was achieved and maintained by simultaneous application of a guide wire adjacent to the ERCP cannula leading to successful ampullary as well as pancreatobiliary cannulation. Despite being widely used, this useful technique has not been described in the literature. The patient was a 66-year-old man who underwent prelaparoscopic ERCP evaluation for suspected choledocholithiasis. ERCP was performed with a diagnostic side-viewing video-duodenoscope (Olympus JFV10, Olympus America Inc., Melville, N.Y.) equipped with 2.8 mm (8.5F) circular channel. Duodenal intubation revealed a large diverticulum located in the medial wall of the second portion just beyond the duodenal bulb. The diverticulum was washed and suctioned to evacuate the small amount of food debris present in the lumen. Close endoscopic inspection failed to visualize an obvious ampullary opening. A careful search to locate the ampulla was therefore initiated around the mouth of the diverticulum with a 5F standard-tip ERCP catheter (Wilson Cook Medical, Inc., Winston Salem, N.C.), which was advanced through the scope channel. Catheter-assisted search disclosed a flat ampulla located on the inner surface of the rim of the diverticulum. The ampullary orifice, however, could be brought and held in view only by everting the rim of the diverticulum with the help of the cannulating catheter. Consequently, any further attempt at cannulation sharply displaced the ampulla from the visible endoscopic view to its original concealed location in a coil-spring–like movement. Several similar attempts, including endoscope manipulation, patient positioning, and abdominal pressure failed to bring the ampulla in view without the need to evert the rim of the diverticulum by the ERCP catheter. We therefore decided to examine the possibility of deploying an additional accessory to hold the ampulla in endoscopic view so as to free the ERCP catheter for ampullary cannulation. A 0.035 inch (2.7F) guide wire (Wilson Cook Medical, Inc.) was passed through the catheter and kept gently anchored to evert the rim of the diverticulum. The ERCP cannula was then first removed over the guide wire and advanced again through the scope channel by the side of the guide wire already held in place by an assistant. ( Fig. 1, Fig. 2 ) The above sequence of catheter-guide wire exchange and repeat passing of the ERCP catheter was followed to avoid possible damage to the endoscope channel by the guide wire. Fig. 2Schematic representation of video-endoscopic picture shown in Figure 1 .View Large Image Figure ViewerDownload (PPT)Additionally, maximum attention was given to the endoscopic view during the exchange to prevent inadvertent penetration of the wall of the diverticulum or the duodenum by the guide wire. Once both the accessories had been positioned in view in the duodenum, additional adjustments were made by manipulating the guide wire and the ERCP catheter to achieve appropriate orientation of the ampullary orifice. The catheter could then be employed to cannulate the exposed ampullary opening to successfully inject contrast in the pancreatobiliary ductal systems. Anatomic location of the papilla as encountered in our patient and the likelihood of impossible cannulation has been previously noted in the literature.11st ed. Atlas of gastrointestinal endoscopy (ERCP and ERS in perivaterian diverticula). 9. W.B. Saunders, Philadelphia1987: 11-19Google Scholar Standard maneuvers, viz. endoscope shaft and tip manipulation including effective suctioning, patient positioning, and abdominal pressure, were unsuccessful to visualize the ampulla in our patient. The ampullary opening could be observed and maintained in endoscopic view only after everting the rim of the diverticulum substantially with the help of the ERCP cannula. All subsequent attempts to employ the ERCP catheter to cannulate resulted in prompt regression of the ampulla to its original invisible position. Repeated failures led us to test deploy an additional accessory (like a robotic arm) in proximity of the ERCP catheter so as to allow it to be used for cannulation. Our technique describes the subsequent successful application of a guide wire along the side of the ERCP catheter to achieve the desired aim of retaining the eccentrically located ampulla in view, thereby permitting the ERCP catheter to access the ampullary opening. Guide wires have been employed through the ERCP catheter to gain access into the bile duct once the catheter has been somewhat anchored into the ampullary opening.2Siegel JH Pullano W Two new methods for selective bile duct cannulation and sphincterotomy.Gastrointest Endosc. 1987; 33: 38-40Abstract Full Text PDF PubMed Scopus (34) Google Scholar Furthermore, more than one guide wire has been simultaneously employed, for example, to advance two biliary stents one each in right and left hepatic ducts.3Deviere J Baize M de Toeuf J Cremer M Long-term followup of patients with hilar malignant stricture treated by endoscopic internal biliary drainage.Gastrointest Endosc. 1988; 34: 95-101Abstract Full Text PDF PubMed Scopus (296) Google Scholar However, application of the guide wire employed in these techniques is fundamentally different from our approach. We suspect the principal of simultaneous application of two functioning adjacent accessories through the working channel of an endoscope may find additional applications." @default.
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• W2099694520 title "Novel approach to ampullary cannulation" @default.
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• W2099694520 doi "https://doi.org/10.1016/s0016-5107(96)70186-4" @default.
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