Around the world, a duodenoscope maneuver to permit an en face papillary view with a short duodenoscope position in the setting of duodenal compression. These are our disclosures. Deformities in the first or second portion of the duodenum, such as due to extrinsic compression from a pancreatic head mass or duodenal edema in the setting of pancreatitis, can limit optimal duodenoscope orientation at the major papilla for cannulation during ERCP. We propose an endoscopic technique termed Around the World for improving orientation of the major papilla during ERCPs performed in the setting of a D1 or D2 deformity. To perform the Around the World technique, start with the duodenoscope in the long position in the third or fourth portion of the duodenum. In the context of a D1 or D2 deformity, fluoroscopy while in this position will often reveal the elevator to be positioned caudat and opposite to the medial duodenal wall. Next, under fluoroscopy guidance and with unlocked control section knobs, perform conventional and cautious reduction to the short position by rotating the right-left knob clockwise while withdrawing the endoscope and applying clockwise torque to the endoscope shaft until a 180 degree rotation of the shaft and a 360 degree rotation of the duodenoscope control section is achieved. This maneuver will generate an external loop in the duodenoscope's umbilical cord. To resolve this external loop, unplug the endoscope from the processor, unravel the external loop of the umbilical cord to a neutral position, and reconnect the endoscope to the processor. Following these steps, the duodenoscope will typically be visualizing the medial wall of D2 and fluoroscopy will reveal a cephalad trajectory of the limbs and elevator. Our first of two cases involves a 67-year-old male with history of pancreatic head neuroendocrine tumor who presented to an outside hospital with biliary obstruction. He underwent an attempted ERCP at the outside hospital without successful biliary cannulation, which was attributed to duodenal compression from the pancreatic head mass. He was then referred to our institution for repeat ERCP attempt. During re-attempted ERCP, an ulcerated mass associated with duodenal narrowing was seen invading through the medial wall of D1 and D2. Initially, the major papilla was not visualized in either the long or short position. A decision was then made to incorporate the around-the-world maneuver. Starting with the duodenoscope in D3 in the long position, reduction was performed by rotating the right-left knob clockwise while slowly withdrawing the endoscope and applying clockwise torque to the endoscope shaft until a 180-degree rotation of the shaft and a 360-degree rotation of the duodenoscope control section was completed. The endoscope connector was then unplugged from the processor, the external loop of the umbilical cord was unraveled to a neutral position, and the endoscope connector was reconnected to the processor. Following reconnection, the endoscope was withdrawn slightly further and the major papilla was successfully visualized while in the short position adjacent to the mass. Here is a view of the endoscopist and the nursing assistant during the around-the-world maneuver performed during this case. Note the clockwise rotation of the right-left knob followed by withdrawal of the endoscope while clockwise torque is applied to the endoscope shaft until a 180-degree rotation of the shaft and a 360-degree rotation of the duodenoscope control section is achieved. The endoscope connector is then unplugged from the processor. The external loop of the umbilical cord is unraveled to a neutral position, and the endoscope connector is reconnected to the processor. Returning to the endoscopic view and proceeding with the remainder of the case, attempt was then made to cannulate the bile duct. Cannulation of the bile duct was challenging, and the ventral pancreatic duct was inadvertently cannulated. Pancreatogram demonstrated severe stenosis of the ventral pancreatic duct with mild upstream dilation. A transpancreatic septotomy was then performed, followed by placement of a pancreatic duct stent to aid in biliary cannulation and for post-ERCP pancreatitis prophylaxis. The bile duct was then successfully cannulated. Cholangiogram demonstrated a severe stenosis of the lower third of the main bile duct with upstream dilation. Next, a biliary sphincterotomy was performed, followed by placement of a 10 millimeter by 6 centimeter uncovered self-expandable metal stent into the common bile duct. Our second case involves an 80-year-old female who presented with urinary urgency and was incidentally found to have elevated LFTs and imaging evidence of a pancreatic head mass associated with biliary obstruction. She underwent EGD and EUS, with EGD demonstrating a moderate extrinsic deformity in D1 and EUS demonstrating a mass in the pancreatic head. Fine needle biopsy was performed with on-site cytology consistent with pancreatic adenocarcinoma. She then immediately underwent ERCP for management of malignant biliary obstruction. For this case, we display the endoscopic view on the left and the live floor images on the right. During ERCP, an area of extrinsic compression was visualized at the apex of the duodenal bulb. The major papilla was initially visualized in a strained and long duodenoscope position, exceedingly difficult to approach for biliary cannulation. Given the suboptimal position of the major papilla, a decision was made to perform the around-the-world maneuver, and the endoscope was advanced to the fourth portion of the duodenum in the long position. Under fluoroscopic guidance and with unlocked control section knobs, the endoscope was then reduced to the short position by rotating the right left knob clockwise while slowly withdrawing the endoscope and applying clockwise torque to the endoscope shaft until a 180 degree rotation of the shaft and a 360 degree rotation of the duodenoscope control section was achieved. Following reduction to the short position, the major papilla is revisualized, now in a more favorable position for cannulation compared to prior. The endoscope connector was then unplugged from the processor, the external loop of the umbilical cord was unraveled to a neutral position, and the endoscope connector was reconnected to the processor. Here are the endoscopic view in the fluoroscopic image following reconnection of the endoscope. The bile duct was then successfully cannulated and subsequent cholangiogram demonstrated a moderate stenosis in the middle third of the main bile duct with upstream dilation. Next, a biliary sphincterotomy was performed. Lastly, a 10mm x 6cm uncovered self-expandable metal stent was placed into the common bile duct. With respect to clinical implications, these two cases demonstrate that the Around the World technique has the potential to increase the rate of successful ERCP completion in the setting of D1 or D2 deformities. In conclusion, the Around the World maneuver is an endoscopic technique that can improve the position of the major papilla during ERCPs performed in the presence of a D1 or D2 deformity to optimize approach for visualization and cannulation. Further studies are needed to compare the Around the World technique and standard approach for ERCPs attempted in the setting of D1 or D2 deformities.

endoscopic technique

major papilla orientation

ERCP

biliary obstructions

pancreatic masses