Gastrointestinal Endoscopy
Volume 70, Issue 5 , Page 1049, November 2009

Periampullary diverticulum: an indicator of easy or difficult cannulation?

Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan

Article Outline

 

To the Editor:

We read with interest the article by Panteris et al1 on the success or difficulty of cannulation and complication rates in patients with and without periampullary diverticula (PAD). After patients with undetectable papilla were excluded, there was no significant difference between the 2 groups, concluding that the presence of PAD was not associated with difficult cannulation or complications and might be an indicator of easier cannulation. We believe that the main drawback of this study is the exclusion of patients with undetectable papilla, which misleads the journal readers.

The presence of PAD has been thought to make ERCP technically difficult and may increase the risk of complications, but the results of studies are conflicting.2, 3 Although a paradiverticular papilla is usually easy to cannulate, an intradiverticular papilla poses a problem in identifying and properly orienting the papilla for cannulation and significantly increases the postsphincterotomy bleeding rate.2, 4, 5 To keep the papilla outside the diverticulum, several techniques were developed for adequate cannulation and safe sphincterotomy, including simultaneous application of a guidewire, a biopsy forceps, or another cannula adjacent to a cannula; use of a front-viewing endoscope; placement of a pancreatic stent or guidewire; and an EUS-guided technique.4, 5, 6, 7, 8

In this study by Panteris et al,1 the incidence of undetectable papilla significantly increased in patients with PAD, which was suspected to be attributed to the possible location of the papilla inside the diverticulum (intradiverticular papilla). If patients with undetectable papilla were included, unsuccessful cannulation was significantly noted in patients with PAD. Moreover, the cannulation success rate was low and the cannulation difficulty rate was high in patients with the identified papilla within or through the PAD compared with that outside the PAD. We therefore believe that they should highlight the intradiverticular papilla as an indicator of difficult cannulation.

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References 

  1. Panteris V, Vezakis A, Filippou G, et al. Influence of juxtapapillary diverticula on the success or difficulty of cannulation and complication rate. Gastrointest Endosc. 2008;68:903–910
  2. Zoepf T, Zoepf DS, Arnold JC, et al. The relationship between juxtapapillary duodenal diverticular and disorders of the biliopancreatic system: analysis of 350 patients. Gastrointest Endosc. 2001;54:56–61
  3. Matsushita M, Uchida K, Nishio A, et al. Small papilla: another risk factor for post-sphincterotomy perforation. Endoscopy. 2008;40:875–876
  4. Mangiavillano B, Arcidiacono PG, Carrara S, et al. EUS-guided rendezvous technique for difficult cannulation of an intradiverticular papilla. Endoscopy. 2008;40:E87–E88
  5. García-Cano J. ERCP cannulation of a hidden papilla within a duodenal diverticulum. Endoscopy. 2008;40:E53
  6. Matsushita M, Hajiro K, Takakuwa H, et al. ERCP for intradiverticular papilla continues to be a challenge. Gastrointest Endosc. 1999;50:734
  7. Matsushita M, Uchida K, Okazaki K. EUS-guided suprapapillary puncture for safe selective biliary access. Gastrointest Endosc. 2007;66:865–866
  8. Lai R, Freeman ML. Endoscopic ultrasound-guided bile duct access for rendezvous ERCP drainage in the setting of intradiverticular papilla. Endoscopy. 2005;37:487–489

PII: S0016-5107(09)00444-1

doi:10.1016/j.gie.2009.03.016

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    Antonios Vezakis, Vasilios Panteris
    Gastrointestinal Endoscopy November 2009 (Vol. 70, Issue 5, Pages 1049-1050)

Gastrointestinal Endoscopy
Volume 70, Issue 5 , Page 1049, November 2009

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