wire traction device-assisted papillectomy of retracted papilla. Here are our disclosures. Endoscopic papillectomy has become the primary therapeutic modality for the management of majority of embolary adenomas. However, cases with fibrosed or retracted papilla regrowth at prior suction site or overhanging dorsal folds could pose a significant challenge for successful endoscopic papillectomy. Wire traction device with clips is a simple tool used for endoscopic submucosal dissection with excellent results. We used this device in a challenging case of a retracted papilla with embolary adenoma with prior failed attempts at resection and achieved successful end block resection. 46-year-old female with a history of acute recurrent pancreatitis underwent ERCP for therapy of pancreatic stricture and was found to have an embolary polyp. Biopsy showed tubular adenoma with low grade dysplasia. Due to the location of the polyp under a fold, flat and retracted nature of the papilla, prior resection attempts were unsuccessful despite numerous tools and lifting. A wire traction device with clips was then used to lift the folds above the ampulla to enhance the prominence of adenoma for successful snare papillectomy. Here you can see the flat and retracted papilla with overhanging duodenal folds and here is a papilla after failed multiple attempts dysplasia using various tools and even the lifting agent. First clip and traction wire complex is deployed to the working channel of the ERCP scope and the first clip is attached just proximal to the ampulla but enough distance was given to avoid interference with the snare placement to achieve successful end block resection. After the deployment of the first clip, the scope was changed to the front viewing scope and the anchoring clip of the traction complex is then placed proximally into the duodenal bulb with traction on it. Once the clip was placed, the wire returned to its pre-curved state, lifting the mucosa above the ampulla, giving good exposure of the ampullary adenoma. Here you can see the excellent exposure of the ampullary adenoma and you can see the difference before and after the deployment of wire traction complex. With improved exposure, the snare can now be adequately placed in a top-down fashion around the ampullary adenoma to capture the entire lesion allowing for an end block papillectomy. After the resection, the polyp was grabbed with the grasping forceps and was retrieved. Here you can see the excellent forcep section margins. Afterwards, under wire guidance, a small pancreatic stent was placed into the ventral pancreatic duct. In a similar fashion, wire was passed into the common bile duct and a biliary stent was successfully placed. Here you can see the excellent position of both pancreatic and biliary stent. After the resection was complete, the traction wire complex was removed by grabbing the first clip with grasping forceps and then gentle traction was applied in a rotatory fashion to detach it from the mucosa without any second hand trauma. The second clip was also detached from the mucosa in a similar fashion with gentle rotatory traction. Our case showcases the utility of wire traction device for successful papillectomy of a retracted papilla where prior resection attempts were unsuccessful despite using multiple tools. The constant traction provided by wire complex could be useful in other procedures by improving the exposure of lesion. Wire traction device is a simple tool which is user-friendly with easy maneuverability and does not add further complexity to the procedure. Further work is needed to assess if traction devices like wire traction could be useful for successful papillectomy or in cases with difficult cannulations can lead to retracted papilla, overhanging folds or intravertical location of the papilla.

retracted papilla

embolary adenoma

failed resection attempts

wire traction device

end block papillectomy