title: Increased selective biliary cannulation rates in the setting of periampullary diverticula: main pancreatic duct stent placement followed by pre-cut biliary sphincterotomy.
abstract: BACKGROUND
  Selective biliary cannulation is often difficult when there is a periampullary diverticulum, especially when the papilla is within the diverticulum. We report eight such cases in which a new technique was used to achieve biliary access.
  
  
  METHODS
  Among 4138 ERCPs, there were 246 cases (5.9%) with periampullary diverticula. Biliary cannulation initially failed in eight patients (3.3%), five of whom had previously undergone six failed attempts at other institutions. A technique was used whereby the papilla was kept out of the diverticulum by placement of a pancreatic duct stent. Needle-knife sphincterotomy was then performed followed by attempts to achieve biliary access.
  
  
  RESULTS
  Biliary entry was immediately successful in five patients and successful at a second ERCP in two (overall success 87.5%). Two patients developed post-ERCP pancreatitis.
  
  
  CONCLUSIONS
  When the papilla is within the periampullary diverticulum, placement of a main pancreatic duct stent keeps the papilla out of the diverticulum, thereby facilitating pre-cut needle-knife sphincterotomy and selective biliary cannulation.
authors.affiliation: Indiana University Medical Center, Indianapolis, USA.
authors.forename: E L
authors.initials: EL
authors.lastname: Fogel
authors.forename: S
authors.initials: S
authors.lastname: Sherman
authors.forename: G A
authors.initials: GA
authors.lastname: Lehman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater / Q000601:surgery*; D003137:Common Bile Duct Diseases / Q000150:complications / Q000601:surgery; D004240:Diverticulum / Q000150:complications / Q000601:surgery*; D004378:Duodenal Diseases / Q000150:complications / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010183:Pancreatic Ducts / Q000601:surgery*; D011379:Prognosis; D016717:Sphincterotomy, Endoscopic / Q000295:instrumentation / Q000379:methods*; D015607:Stents