Gastrointestinal: No touch-guidewire cannulation in periampullary diverticulum

Abstract

A 63-year-old female patient presented with biliary-type pain and laboratory cholestasis (γ-glutamyl transpeptidase 1.360 U/L, bilirubin 1.3 mg/dL). Transabdominal ultrasound indicated common bile duct (CBD) dilation with multiple stones. Due to lack of cholangitis, the patient underwent endoscopic retrograde cholangiopancreatography (ERCP) only the following day. Duodenoscopy indicated a wide-necked, type 1 periampullary diverticulum (PAD) with the ampulla at an unfavorable 8 o'clock position (Fig. 1a). Even after optimal adjustment of the duodenoscope position, the bile duct and papillotome axes could not be brought into proper alignment (Fig. 1b). Therefore, we applied a “no-touch” technique first cautiously engaging the papillary orifice with a straight-tipped hydrophilic guidewire (0.035-inch Jagwire, Boston Scientific, Natick, MA, USA) (Fig. 1c). After successful deep wire-guided cannulation, the papillotome was tracked into the CBD without difficulties (Fig. 1d, Video S1). Exuberant bile duct stone disease was confirmed and treated by endoscopic papillotomy and multiple basket extractions. PAD might add different levels of complexity to biliary cannulation, and myriad rescue techniques have been described to this end, highlighting the need for an individualized approach tailored to the distinct anatomy. The “no-touch” technique yielded no universal benefit in terms of cannulation success over a more conventional “touch” approach in a recent randomized trial (TNT trial). However, primary guidewire cannulation, considered more indulgent to deviations in cannulation axis often encountered in PAD-related anatomy, might be tried in the first-line prior to embarking on more complex bailouts with the often associated need to switch accessory and/or scope technology.