Selective Biliary Cannulation for a Papilla in the 9 o’clock Position Using Pull and Rotatable Sphincterotome

Abstract

A 50-year-old woman visited the emergency room of Daejeon Eulji University Hospital with the primary complaint of right upper-quadrant pain. Her past medical history included a Billroth II operation with Braun anastomosis for stomach cancer. Upon physical examination, the patient had blood pressure of 100/50 mmHg, pulse rate of 116/min, respiratory rate of 18 breaths/min, and body temperature of 37.1°C. Laboratory tests indicated that the patient had a white blood cell count of 4,940/μL, hemoglobin concentration of 12.8 g/dL, platelet count of 52,000/μL, total bilirubin concentration of 1.75 mg/dL, aspartate aminotransferase level of 126 IU/L, alanine aminotransferase level of 450 IU/L, alkaline phosphatase level of 153 IU/L, amylase level of 248 U/L, lipase level of 668 U/L, and C-reactive protein level of 0.75 mg/dL. An abdominal computed tomography scan showed that the patient had biliary tree dilatation and gallbladder distension due to distal common bile duct (CBD) stones. Gallbladder stones and pericholecystic infiltration were also observed (Fig. 1). The next day, we performed endoscopic retrograde cholangiopancreatography (ERCP) for CBD stone removal. Using a cap-fitted forward-viewing endoscope (Olympus GIF Q260, Olympus Optical Co., Tokyo, Japan), the papilla was located at the 9 o’clock position (Fig. 2A). On fluoroscopy, the endoscope showed a figure 8 shape different from that in a normal Billroth II operation (Fig. 2B). We then attempted to unsuccessfully manipulate the endoscope and fix the papilla at the 12 o’clock position. To facilitate the use of a rotatable sphincterotome, the endoscope was replaced with a doublechannel endoscope (GIF-2T240, Olympus Optical Co., Tokyo, Japan) but the papilla remained at the 9 o’clock position. A sphincterotome (TRUEtome; Boston ScienReceived May 31, 2019 Revised Jun. 18, 2019 Accepted Jul. 23, 2019