Consideration of Endoclips to Help Cannulate an Ampulla Hidden in a Duodenal Diverticulum at ERCP

Abstract

We thank Drs. Nadir and Chuang for their thoughtful letter [1] in response to our recent single case report [2] of successful deployment of two endoclips at ERCP to expose an ampulla of Vater, initially inaccessible due to the ampulla lying within a large diverticulum, with consequent successful cannulation, sphincterotomy, and stone retrieval. They report one case in which an endoclip was deployed to evert and expose an ampulla that was initially inaccessible within a large duodenal diverticulum, and deployed a second endoclip for stabilization that inadvertently caused greater instability of the ampulla. Despite this difficulty, they were able to use the sphincterotome to evert the ampullary opening and successfully cannulate for therapeutic ERCP. We have two comments. First, despite their difficulties, the outcome was successful cannulation after multiple unsuccessful attempts before deploying the endoclips. Second, we experienced a similar problem of instability during cannulation after deploying one endoclip which resolved after deploying a second endoclip. This finding argues for carefully placing endoclips to achieve stability. Endoclips should currently be considered only when (1) cannulation is otherwise impossible due to ampulla location within a diverticulum, (2) ERCP is required for potentially life-saving endoscopic therapy, and (3) the endoscopist is highly skilled in both ERCP and endoclip deployment. This technique should currently be considered experimental with use restricted to these circumstances due to insufficient outcomes data.