We are presenting a case of endoscopic colidocotomy. Multiple periambular diverticuli is common in elderly patients. This makes biliary canalization for ERCP technically challenging. The standard options are applying traction with sphincterotome toward edge of diverticulum, using pediatric biopsy forceps to avert intra-diverticular papilla. We propose a different approach for difficult canalization. Our patient is an 85-year-old female with gallstones and CBD stones. Multiple dorsal diverticulae were encountered during ERCP and the canalization was difficult since the floppy papilla was wedged between twin diverticulae. We did a direct needle knife dissection over the bilate running upwards between the diverticulae much away from the papilla and we term it colidocotomy. How is this different from fistulotomy? Fistulotomy is a pre-cut technique done over the amylophator a few millimeters away from the orifice, whereas endoscopic colidocotomy is direct incision over the bilate much away from the papilla. This is a good tool in experienced hands when multiple diverticulae make canalization difficult. However, there is only a narrow margin of error as the incision away from the bilate axis leads to certain retrodonal perforation. As the incision is typically small, only small stones can be extracted by this technique. So during ERCP we see there are multiple diverticulae. This first diverticulae is noted over the superior wall of D2. The papilla was wedged between twin diverticulae. We can see the bilate running upward and the ampulla has a floppy morphology. We started with the standard canalization technique using a sphingrotum loaded with wire. We could engage the sphingrotum in the ampullary orifice and make a small cut. However, because of the floppy nature of the ampulla, the wire could not be negotiated deep into the bilate. So we changed to a needle knife papillotum. A standard needle knife papillotum was used. We can see the bilate running upward between diverticulum 1 and 2 and the ampullary orifice is located much away from the proposed area of dissection. 2-3 mm of the cutting wire was exposed and a linear dissection was done using endo cut mode. Further canalization attempt was made using a sphingrotome loaded with a hydrophilic guide wire. A nearly 90 degree angle was required as the bileduct was running acutely upward. After a few attempts, we managed to pass the guide wire deep inside the bileduct. The cholangiogram showed a dilated bile duct with multiple small filling defects in the distal bile duct. The area of dissection has further widened using a sphingrotome. This is not a sphingrotomy because we are doing the dissection much farther away from the ampulla. Bioled clearance was done using multiple balloon sweeps using standard stone extraction balloon. The final occlusion cholangiogram shows complete clearance of the bioled. The final fluoroscopy picture shows the pigtail stent in situ. Patients subsequently underwent cholecystectomy followed by removal of the biliary stent on a future date. The key learning points are Endoscopic cholecystectomy is a novel technique, useful in floppy papilla with multiple periampillary diverticulae, direct needle knife dissection is done over the intramural bile duct impression, small CBD stones extraction and stenting is possible, but caution is needed in inexperienced hands to avoid retrodural perforation.

endoscopic colidocotomy

gallstones

CBD stones

periampullary diverticulae

ERCP