Reverse guidewire anchoring of the papilla for difficult cannulation due to a periampullary diverticulum

Papillary Cannulation Facilitated by Submucosal Saline Injection Into the Intradiverticular Papilla

“…Several techniques have been introduced to facilitate cannulation in the setting of intradiverticular papilla (Table 1). 1,6,[9][10][11][12][13][14][15][16][17][18] To enable informed decisions and ensure the best outcomes, endoscopists should be aware of differences in technical feasibility and safety of each technique. The best method depends on the endoscopist' s preference and patient conditions.…”

“…The main goal of various techniques involves bringing the papilla into a better orientation by grasping, pushing, or lifting, or by performing pancreatic duct stenting. 7 Several different methods, such as submucosal injection, 6 endoscopic clipping, 9 two-devices-in-one-channel, 10 reverse guidewire anchoring, 11 double endoscopy, 12 cap-assisted with forward viewing endoscopy, 13 entering the duodenal diverticulum with the distal tip of the duodenoscope, 14 and pre-cut biliary sphincterotomy after pancreatic duct stent placement 1 have been introduced. Endoscopic clips are used to evert and stabilize the papillary opening.…”

“…5 Several techniques have been introduced to evert the papillary opening to facilitate cannulation. 1,[6][7][8][9][10][11][12][13][14][15] Submucosal injection, 6 endoscopic clipping, 9 and two-devices-in-one-channel, 10 have been introduced. The submucosal injection method involves lifting of the mucosa to enable eversion and fixing of a papilla in the diverticulum and allows selective cannulation of the biliary tree.…”

ERCP Success Rate and Periampullary Diverticula: The Pocket Makes No Difference

“…The variation in location of the papilla in the setting of PAD can lead to an atypical orientation or obscured location, complicating endoscopic cannulation and stone extraction using traditional techniques. Indeed, there are many case reports highlighting innovative techniques to facilitate biliary cannulation in the setting of PAD including clip placement [8], the use of small diameter forceps [9][10][11], cap-fitted forward viewing endoscopy [12], and a reverse guidewire technique [13]. Further, there is concern for both orientation and length of sphincterotomy when the typical landmarks are not present, due to the diverticulum.…”

Cannulation in patients with large periampullary diverticulum using SpyBite miniforceps

“…Another instrument, either a cannula or sphincterotome, can then be introduced and biliary cannulation can be attempted with the coordination of the two instruments [ 4 ]. Use of reversed guidewire method [ 5 ], double endoscope method [ 6 ], balloon dilatation of the diverticular neck [ 7 ], endoclip or cap assisted cannulation [ 8 , 9 ], prior pancreatic duct stenting [ 10 ], and use of rendezvous technique [ 11 ] have been described in the literature.…”