The assistance of underwater immersion for identification and cannulation of an intra-diverticular ampulla during ERCP. Ampullary duodenal diverticuli can present as a major challenge during ERCP. The first major step is identification of the ampulla, which can be challenging to find. The ampulla can be inside, on the margin, or adjacent to the diverticulum. Another variant includes an ampulla within two diverticuli. Multiple methods have been described to find the ampulla for this challenging situation. Some of these methods are using a hemoclip, or second guide wire, to help evert and keep the ampulla in view for cannulation. Another method is changing to a straight-tip cannula. Here we describe a technique using underwater immersion, which helps us to locate and confirm the ampulla prior to cannulation. This is a 77-year-old male who was presented for an outpatient ERCP for a history of cholecystectomy from an outside hospital with positive IOC with cholecystectomy, who then had an outside subsequent ERCP that was aborted due to a duodenal diverticulum. The duodenal opening was estimated to be about 2 cm with a large diverticular pouch with food and debris inside the pouch. We initially used a sphincter tome to help prod away redundant folds to locate the ampulla. The ampulla was not found using this method. Here you can see the sphincter tome coming out, and here we're gently everting the folds away to help us locate where the ampulla was. Here in the video we're demonstrating using the tome to look around the entire rim of the diverticulum to help locate the ampulla. This was not successful. Now we're using a rat tooth to help evert the folds away as well to see if this can assist us in finding the ampulla. We also used a rat tooth to remove all the food and debris inside the duodenal diverticulum in case the endoscope is needed to be advanced into the diverticulum itself. If we were to find the ampulla using the rat tooth, we would have then switched to a hemoclip to help clip the redundant folds that are outside the diverticulum to assist in cannulation. Another strategy is to use a guide wire along with a sphincter tome in a sort of fashion of double guide wire technique to keep the everted folds away. Here we advanced the endoscope into the duodenal diverticulum since we were still unable to find the ampulla under CO2 immersion. Given this finding, we decided to use water immersion to help us locate the ampulla. Here the bile is suctioned and normal saline is irrigated into the duodenal diverticulum. The small papilla can be seen here, but we are not entirely confident this is the ampulla still. We then suctioned underwater and noted that there was bile coming from the papilla. This helped us to confirm that this was indeed the papilla prior to cannulation. Once we identified the ampulla, we performed standard sphincter tome and guide wire cannulation. Here we are performing a sphincterotomy in a challenging position due to the endoscope having to evert inside of the duodenal diverticulum. We elected to perform a partial sphincterotomy followed by a 10 millimeter balloon sphincteroplasty. This was to help us aid in stone extraction. We were then able to easily remove the black pigment stone with a standard 12 to 15 millimeter extraction balloon. We were able to achieve ductal clearance during this ERCP. No stent was placed and the patient was able to go home the same day. No complications from the ERCP. Here we describe an adjunctive technique for identification and cannulation of large intradiverticular ampullas. This technique can help with ampullas that are not immediately visible on the duodenal side directly on the rim of the diverticulum. In conclusion, removal of food and debris is important to help find the ampulla within the diverticulum. Underwater immersion can help to identify and confirm the ampulla before attempted cannulation.

underwater immersion

ERCP

duodenal diverticulum

ampulla identification

cannulation techniques