ENDOSCOPIC PAPILLECTOMY - A NOVEL-APPROACH TO DIFFICULT CANNULATION

Background-Selective cannulation of the biliary and pancreatic ducts i s considered to be the most difficult and rate limiting aspect of diag nostic endoscopic retrograde cholangiopancreatography (ERCP). Aims/Met hods-A novel technique for difficult cannulation is described and its potential role in relieving malignant duodenal obstruction secondary t o ampullary carcinoma. A diagnostic endoscopic papillectomy was perfor med in 10 patients in whom previous attempts at cannulation had failed . Five patients had exophytic ampullary carcinomas, one had carcinoma of the head of pancreas, two had an oedematous ampulla secondary to lo w common bile duct stones, while two had protuberant ampullae with ect opic orifices, The technique entails snaring the ampulla flush with th e duodenal wall using a polypectomy snare and in a similar fashion to polypectomy removing the ensnared ampulla with diathermy using a coagu lation current. The underlying exposed ducts can then be cannulated wh ile the ensnared ampulla can be retrieved to aid histological diagnosi s. Results-Successful cannulation was achieved In all 10 cases with si gnificant haemorrhage in one patient (10%). Four of the snared ampulla ry carcinomas (80%) were retrieved enabling a histological diagnosis t o be made. Conclusions-This study demonstrates the potential role for endoscopic papillectomy as a means of cannulation in difficult circums tances, however larger comparative studies are required.