A 92-year-old woman was admitted for acute cholangitis with multiple common bile duct (CBD) stones. We performed endoscopic retrograde cholangiopancreatography (ERCP) using a front-viewing endoscope (PCF-Q260AZI; Olympus, Tokyo, Japan) because she had undergone distal gastrectomy with Billroth II reconstruction. However, the ampulla of Vater was not fixed in front, making it difficult to intubate the CBD ([Fig. 1]). Computed tomography and magnetic resonance cholangiopancreatography showed kinking of the lower end of the CBD due to surgical manipulation ([Fig. 2]). Thus, traction was applied via a traction device (S-O clip; Zeon Medical Inc., Tokyo, Japan), which was connected to the oral side of the ampulla of Vater; the loop of the clip was grasped ([Fig. 3 a]) and secured proximally for traction ([Fig. 3 b]). As a result, the torsion of the CBD resolved, and the ampulla of Vater could be viewed from the front ([Fig. 4 a]). The CBD was then easily intubated ([Fig. 4 b]) and a plastic stent was placed for drainage.
Fig. 1 Intubating the common bile duct was not possible with conventional methods.
Fig. 2 Images showing kinking of the end of the common bile duct due to postoperative effects. a Computed tomography. b Magnetic resonance cholangiopancreatography.
Fig. 3 Application of the traction device. a An S-O clip (Zeon Medical Inc., Tokyo, Japan) was connected to the oral side of the ampulla of Vater and the loop of the clip was grasped. b The clip was secured proximally for traction.
Fig. 4 Effect of the traction device on the common bile duct (CBD). a The torsion of the CBD was resolved, and the ampulla of Vater was fixed at the front. b Intubation of the CBD was then easily performed.
Later, we attempted to remove the CBD stones via ERCP using a short-type single-balloon enteroscope (SIF-Q260; Olympus, Tokyo, Japan). Unfortunately, the traction on the S-O clip was lost. Thus, the traction device technique was repeated ([Video 1]), and the CBD was easily intubated on the first attempt. Complete removal of stones was achieved via endoscopic papillary large-balloon dilation.
Video 1 The S-O clip traction technique. First, an S-O clip (Zeon Medical Inc., Tokyo, Japan) was connected to the oral side of the ampulla of Vater and its loop was grasped. Next, the clip was secured proximally for traction. The torsion of the common bile duct (CBD) was resolved, and the ampulla of Vater was fixed at the front. The CBD was then easily intubated.
Cases of difficult CBD intubation during ERCP have been reported [1]. The traction device (S-O clip) can also be used in complex cases with diverticular papillae during conventional ERCP [2]. CBD intubation using this device for diverticular papilla in Roux-en-Y reconstruction has also been reported [3]. However, our patient had a postoperative bile duct flexure rather than a diverticular papilla, distinct from the previous case. The traction device technique used in our case is summarized in [Fig. 5].
Fig. 5 A summary of the traction technique used in our patient.
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