Cannulation of the intradiverticular papilla using a duodenoscope: Is it a safe method?

Abstract

Endoscopic cannulation of the biliary tract is a challenging technique in cases of periampullary diverticula. Many new devices and new manipulations for successful biliary cannulation have been reported. Endoscopy used to locate and cannulate a papilla hidden within a duodenal diverticulum is an effective method. However, the question of which endoscope should be chosen for this procedure, duodenoscope or gastroscope, waits to be answered.

Key Words: Endoscopic retrograde cholangiopancreatography; Intradiverticular papilla; Cannulation

Core tip: Endoscopic retrograde cholangiopancreatography is a minimally invasive surgery. However, intradiverticular papilla may cause perforation and bleeding, making it more difficult to be identified. There are many methods for successful biliary cannulation. The best method should be chosen to reduce the risk of complications. Entering the duodenal diverticulum is an excellent modality, but is it safe to perform the procedure using duodenscope?

TO THE EDITOR

We have read with interest the excellent article “Entering the duodenal diverticulum: A method for cannulation of the intradiverticular papilla” by Wang et al[1]. Entering the duodenal diverticulum is a creative method. However, intubation of the distal tip of the duodenoscope into the duodenal diverticulum may lead to perforation. We would like to share some comments with the authors.

Duodenoscope is known as a side-viewing endoscope, which can well view the normal papilla located on the duodenal wall. But, to ensure an excellent view and position, the distal tip, when inserted into the diverticulum, may touch the diverticulum wall, resulting in perforation. On the other hand, the successful cannulation of the intradiverticular papilla depends on the location of the papilla. For the papilla located at the upper part of the diverticulum, duodenoscopy could be a good method. However, it would be difficult to cannulate the intradiverticular papilla located at the lower part of the diverticulum, sometimes even more difficult to identify the papilla.

Gastroscope has the advantage of finding the papilla which is hidden within a diverticulum or somewhere a duodenoscope could not identify. García-Cano[2] described their experience of using gastroscope to locate a papilla hidden within a duodenal diverticulum, which could not be located by duodenoscope. üsküdar et al[3] also succeeded in using a gastroscope to identify the papilla which was located in the deformed bulb of the duodenum just before a partial apical stricture.

In conclusion, “Entering the duodenal diverticulum for cannulation of the intradiverticular papilla” is an excellent idea. However, gastroscopy could be better than duodenoscopy used during the procedure.