Tips and tricks of double‐balloon endoscopic retrograde cholangiopancreatography (with video)

Although endoscopic retrograde cholangiopancreatography (ERCP) is technically difficult in patients with altered gastrointestinal tract, double‐balloon endoscopy (DBE) allows endoscopic access to pancreato‐biliary system in such patients. Balloon dilation of biliary stricture and extraction of bile duct stones, placement of biliary stent in patients with Roux‐en‐Y or Billroth‐II reconstruction, using DBE have been reported. However, two major technical parts are required for double‐balloon ERCP (DB‐ERCP). One is insertion of DBE and the other is an ERCP‐related procedure. The important point of DBE insertion is a sure approach to the afferent limb with Roux‐en‐Y reconstruction or Braun anastomosis. Short type DBE with working length 152 cm is beneficial for DB‐ERCP because it is short enough for most biliary accessory devices. In this paper, we introduce our tips and tricks for successful DB‐ERCP.     

Direct cholangioscopy combined with double-balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography

Double-balloon enteroscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is an effective endoscopic approach for pancreatobiliary disorders in patients with altered gastrointestinal anatomy. Endoscopic interventions via DBE in these postoperative settings remain difficult because of the lack of an elevator and the use of extra-long ERCP accessories. Here, we report the usefulness of direct cholangioscopy with an ultra-slim gastroscope during DBE-assisted ERCP. Three patients with choledocholithiasis in postoperative settings (two patients after Billroth II gastrojejunostomy and one patient after Roux-en-Y gastrojejunostomy) were treated. DBE was used to gain access to the papilla under carbon dioxide insufflation, and endoscopic sphincterotomy was performed with a conventional sphincterotome. For direct cholangioscopy, the enteroscope was exchanged for an ultra-slim gastroscope through an incision in the overtube, which was inserted directly into the bile duct. Direct cholangioscopy was used to extract retained bile duct stones in two cases and to confirm the complete clearance of stones in one case. Bile duct stones were eliminated with a 5-Fr basket catheter under direct visual control. No adverse events were noted in any of the three cases. Direct cholangioscopy with an ultra-slim gastroscope facilitates subsequent treatment within the bile duct. This procedure represents another potential option during DBE-assisted ERCP.     

Double balloon endoscopy increases the ERCP success rate in patients with a history of Billroth II gastrectomy

AIM:To evaluate the effect of double balloon endoscope(DBE)on the endoscopic retrograde cholangio-pancreatography(ERCP)success rate in patients with a history of BillrothⅡ(BⅡ)gastrectomy.METHODS:From April 2006 to March 2007,32 patients with a BⅡgastrectomy underwent 34 ERCP attempts.In all cases,the ERCP procedures were started using a duodenoscope.If intubation of the afferent loop or reaching the papilla failed,we changed to DBE for the ERCP procedure(DBE-ERCP).We assessed the success rate of afferent loop intubation,reaching the major papilla,selective cannulation,possibility of therapeutic approaches,procedure-related complications,and the overall success rate.RESULTS:Among the 32 patients with a history of BⅡgastrectomy,the duodenoscope was successfully passed up to the papilla in 22 patients(69%),and cannulation was successfully performed in 20 patients(63%).Six patients(2 with failure in afferent loop intubation and 4 with failure in reaching the papilla)underwent DBE-ERCP.The DBE reached the papilla in all the 6 patients(100%)and selective cannulation was successful in 5 patients(83%).Four patients(67%)who had common bile duct stones were successfully treated.One patient underwent diagnostic ERCP only and the other one,in whom selective cannulation failed,was diagnosed with papilla cancer proven by biopsy.There were no complications related to the DBE.The overall ERCP success rate increased to 88%(28/32).CONCLUSION:The overall ERCP success rate increases with DBE in patients with a previous BⅡgastrectomy.     

Cap-assisted ERCP in patients with a Billroth II gastrectomy

BACKGROUND: ERCP is difficult in patients with a Billroth II gastrectomy because of anatomical changes. OBJECTIVE: Cap-assisted ERCP can improve the cannulation rate and the success rate of stone removal. DESIGN: Case series. SETTING: A tertiary referral center. PATIENTS AND INTERVENTIONS: Ten consecutive patients with bile-duct stones (9) or a distal common bile duct stricture (1), who had previously undergone Billroth II gastrectomy and were referred for ERCP, were analyzed for the outcome of their ERCP. All procedures were carried out with a cap-fitted regular forward-viewing endoscope. MAIN OUTCOME MEASUREMENTS: Ability to perform afferent loop intubation and bile-duct cannulation. RESULTS: Of 10 patients in whom ERCP was attempted, afferent loop intubation and selective bile-duct cannulation were achieved in all patients (100%). Endoscopic sphincterotomy (EST) was successful in all 10 patients (100%). All stones were removed by EST alone in 7 patients and by both EST and endoscopic papillary balloon dilation in 2 patients. There were no serious complications in the patients. LIMITATIONS: Small sample size, single-center experience. CONCLUSIONS: Diagnostic and therapeutic ERCP with a cap-fitted regular forward-viewing endoscope was successful in all patients with a prior Billroth II gastrectomy. The high rate of successful ERCP was achieved by improving afferent loop intubation and bile-duct cannulation with a cap-fitted endoscope.     

EXPERIENCES OF BILIARY INTERVENTIONS USING SHORT DOUBLE‐BALLOON ENTEROSCOPY IN PATIENTS WITH ROUX‐EN‐Y ANASTOMOSIS OR HEPATICOJEJUNOSTOMY

Background: The efficacy of double‐balloon enteroscopy (DBE) for biliary interventions has been shown in patients with surgical anatomy. However, the use of available endoscopic retrograde cholangiography accessories during this procedure is limited because of the length of the conventional instrument (200 cm). The aim of this study was to evaluate the feasibility of short DBE for managing biliary disorders in patients with a Roux‐en‐Y gastrectomy or hepaticojejunostomy (HJ). Patients and Methods: Using a short enteroscope (152 cm) and commercially available endoscopic retrograde cholangiography accessories, biliary interventions were performed in six patients with Roux‐en‐Y reconstruction or HJ anastomosis. Results: A total of 12 biliary interventions were performed; balloon dilations of the HJ anastomosis or intrahepatic ducts (four patients), nasobiliary drainages (three patients), bile duct stone removal after endoscopic papillary large balloon dilation with or without small sphincterotomy (two patients), and a biliary stent placement (one patient). One patient showed retroperitoneal air following endoscopic papillary large balloon dilation, but recovered conservatively. Conclusions: Biliary interventions via DBE using a short enteroscope are feasible in patients with surgical anatomy.     

Double balloon enteroscopy for endoscopic retrograde cholangiopancreaticography after Roux-en-Y reconstruction: case series and review of the literature

BACKGROUND: Endoscopic access to the biliary system can be difficult in patients with surgically altered anatomy, such as a Roux-en-Y reconstruction. Double balloon enteroscopy (DBE) is a relatively new procedure that enables access to the small bowel. DBE has recently been advocated as a method for endoscopic retrograde cholangiopancreaticography (ERCP) in patients with surgical reconstructions, with the potential to perform diagnostic and therapeutic interventions. METHODS: In three patients with a hepaticojejunostomy and Roux-en-Y reconstruction, the experiences using DBE to perform ERCP are described. The literature on DB-ERCP in patients with a Roux-en-Y reconstruction was reviewed. RESULTS: In all patients, the Roux limb was entered and a diagnostic cholangiography was carried out. In one patient, endoscopic therapy could be performed, consisting of balloon dilation of a stenotic biliodigestive anastomosis, repeated balloon dilation of biliary strictures and removal of bile casts. CONCLUSION: This series confirms recent data emerging from the literature that double balloon enteroscopy is a safe and feasible technique to obtain biliary access in patients with surgically altered anatomical configurations, such as those with a Roux-en-Y reconstruction. The diagnostic and therapeutic potential of DB-ERCP is great, and the utility of the procedure could be further improved if customised accessories become more widely available.     

Risk factors for postoperative pancreatitis associated with diagnostic and therapeutic endoscopic retrograde cholangiopancreatography

OBJECTIVE : To investigate the risk factors for postoperative pancreatitis following endoscopic retrograde cholangiography (ERC), endoscopic retrograde pancreatography (ERP), endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST) and endoscopic biliary stenting. METHODS : Four hundred and twelve patients referred to the endoscopy unit were divided into seven groups: (i) double ducts (pancreatic duct and biliary duct) contrast media filling group (ERCP group); (ii) biliary duct contrast media filling group (ERC group); (iii) pancreatic duct contrast media filling group (ERP group); (iv) ERCP plus biliary stenting group (ERCP + stent group); (v) ERC plus stenting group (ERC + stent group); (vi) ERCP plus EST and stone extraction (SE) group (ERCP + EST + SE group); and (vii) ERC plus EST and SE group (ERC + EST + SE group). Differences in postoperative serum amylase at 4 and 24 h, as well as clinical symptoms, were compared among the different groups. RESULTS : The incidence of postoperative hyperamylasemia at 4 and 24 h was 17.7 and 4.4%, respectively. The overall incidence of postoperative acute pancreatitis was 3.9% and the ERP group had the highest incidence of postoperative acute pancreatitis among the seven groups. CONCLUSIONS : Repeated pancreatic duct contrast filling during ERCP manipulation is the main risk factor for postoperative pancreatitis and therapeutic ERCP, such as EST, stenting and SE, does not increase the incidence of postoperative pancreatitis.     

诊断与治疗性逆行胰胆管造影并发胰腺炎危险因素分析

目的：探讨诊断性胰、胆管显影与胆道支架、乳头括约肌切开取石术等治疗抗逆行胰、胆管造影（ERCP）,对术后并发胰腺炎的影响。方法：412例ERCP操作分为7组,诊断性ERCP为胆胰双管显影（ERCP）组、单纯胆管显影（ERC）组组与单纯管显影（ERP）组,治疗组ERCP分为双管显影加支架术（ERCP＋支架）组、ERC＋支架组、ERCP＋乳头肌切开（EST）取石组及ERC＋EST取石组,比较各组术后4h、24h血清淀粉酶及临床症状改变。结果：术后4h、24h高淀粉酶血症发生率为17．7％及4．4％,并发急性胰腺炎的发生率为3．95,各组中以ERP组发病率为最高。结论：在ERCP操作中,反复胰管造影是并发术后胰腺炎主要危险因素,EST、支架治疗并不增加胰腺炎的发病率。     

SMALL SPHINCTEROTOMY COMBINED WITH ENDOSCOPIC PAPILLARY LARGE BALLOON DILATION IN PATIENTS WITH BILLROTH II GASTRECTOMY

Background: The difficulty in orienting a duodenoscope or sphincterotome in Billroth II gastrectomy patients with an afferent loop is well known to experienced biliary endoscopists. In patients who have large biliary stones, stone retrieval is technically difficult, particularly when a mechanical lithotriptor is required. To address this issue a new technique was developed to gain greater access to the common bile duct. Methods: This new technique, small endoscopic sphincterotomy combined with endoscopic papillary large balloon dilation (SES + EPLD), was carried out in eight cases with Billroth II reconstruction. First, endoscopic sphincterotomy (ES) with a small incision was performed with a capped forward‐viewing endoscope. Then, endoscopic papillary dilation was performed with a large balloon to slowly match the size of the bile duct. Stones were then retrieved from the biliary duct with a balloon and a basket. Results: Stone retrieval was successful in all cases. Dilating the papillary orifice with a large balloon made it possible to remove large stones smoothly without crushing them. After dilation with the large balloon, there were some instances of oozing, but no perforations near the papilla. Conclusions: SES + EPLD was effective for the retrieval of large biliary stones without the use of mechanical lithotripsy for B‐II reconstruction cases. This new method, incorporating a slow dilation of the papilla up to a large diameter, could provide a larger opening than a large ES. This method of stone retrieval is easy to perform and may be able to play a role in the treatment of large and multiple bile duct stones with B‐II gastrectomy.     

十二指肠乳头括约肌小切开联合气囊扩张治疗难治性胆总管结石的疗效评价

目的 探讨乳头括约肌小切开联合气囊扩张治疗难治性胆总管结石的效果和安全性.方法 将2008年3月至2009年12月收治的难治性胆总管结石患者随机分为两组,分别为乳头括约肌切开组及乳头括约肌小切开联合气囊扩张组,比较两组间结石取净率、取石次数、机械碎石使用率、并发症发生率.结果 两组间结石取净率、早期并发症发生率,差异无统计学意义（2/61比2/62,6/61比4/62;P＞0.05）;乳头括约肌切开组需多次及需要使用机械碎石才能取净结石的比例以高于乳头括约肌小切开联合气囊扩张组,率差异有统计学意义（15/61比5/62,12/6l比4/62;P＜0.05）.结论 乳头括约肌小切开联合气囊扩张与乳头括约肌切开两种方法同样安全有效;乳头括约肌小切开联合气囊扩张操作更简便.     

内镜下逆行胰胆管造影术治疗老年胆总管巨大结石40例

目的探讨内镜下逆行胰胆管造影术(ERCP)治疗老年胆总管巨大结石的可行性及安全性。方法 40例老年胆总管巨大结石患者完善术前准备,密切监护下经十二指肠镜先行ERCP,发现胆总管结石后行内镜下十二指肠乳头括约肌切开(EST)和机械碎石(EML)取石,视具体情况留置鼻胆管引流及支架置入引流。结果 40例患者37例取石获得成功,成功率92.5%;其中10例经过二次取石。所有患者腹痛症状明显改善,皮肤巩膜黄染迅速消褪,发热患者48 h内体温趋于正常。术后并发轻型胰腺炎4例,乳头肌切口创面轻度渗血2例,均经内科保守治疗痊愈,未发生肠穿孔、胆道撕脱等严重并发症和死亡。结论 ERCP治疗老年胆总管巨大结石是一种安全、有效的治疗方法,应考虑作为治疗的首选方案。     

Endoscopic retrograde cholangiopancreatography in patients with Billroth II gastroenterostomy

BACKGROUND AND AIM: Endoscopic retrograde cholangiopancreatography (ERCP) is more complicated in patients with Billroth II gastroenterostomy (B II GE) especially in those associated with Braun anastomosis (BA). The aim of the present study was to review experience of ERCP in patients with B II GE. METHODS: The records of patients with B II GE who had undergone an ERCP within the last 2.5 years were retrospectively evaluated. RESULTS: Fifty-two patients with simple B II GE and seven with additional BA underwent ERCP within this period. The probability of common bile duct cannulation and success of endoscopic treatment was 43/52 (83%) and 2/7 (29%) in the respective groups. The reasons for failure were long afferent loop in patients with BA; for the nine patients with B II GE the reasons for failure were tumoral infiltration at the orifice of afferent loop in one patient, peripapillary tumoral invasion in two patients, failure of entrance to the afferent loop due to angulation in two patients, and long afferent loop in the remaining four patients. Overall, perforation developed in 10.2% (6/59 of the patients. Two of these patients died (2/59, 3.4%) and one (1/59, 1.7%) had concomitant pancreatitis. CONCLUSIONS: Although ERCP is successful in a large proportion of patients with B II GE, it carries significant risks such as perforation. ERCP must be performed by experienced endoscopists at institutions that have suitable facilities to manage endoscopy-related complications.     

Diagnostic and therapeutic ERCP in hepatic hydatid disease

BACKGROUND: This retrospective study evaluated the use of diagnostic and therapeutic ERCP in pre- and postoperative patients with hepatic hydatid disease. METHODS: For 8 years, ERCP was performed in 39 patients with hepatic echinococcal disease. Indications in the preoperative group of patients (n = 19) included a cholestatic enzyme profile in all cases; jaundice or acute cholangitis also was present in, respectively, 14 and 7 cases. In the postoperative group (n = 20), indications for ERCP included persistent external biliary fistula after surgery in 10 patients, jaundice in 8, acute cholangitis in 7, and right upper quadrant pain in 2 patients. RESULTS: ERCP findings in the preoperative group included cystobiliary fistula (9 patients), external compression of the hepatic biliary system (5), hydatid vesicles and/or membranes within the biliary tract (3), intrahepatic duct stricture (1), and a normal cholangiogram (4). The most common ERCP finding in the postoperative group was external biliary fistula (10 patients); other findings consisted of hydatid cyst material within the bile duct (4), bile duct stenosis (2), cystobiliary fistula and hydatid cyst material in the bile duct (1), cystobiliary fistula (1), hydatid membranes in the gallbladder (1), extrinsic compression to bile ducts (1), and a normal cholangiogram (1). In the preoperative group, endoscopic sphincterotomy was performed in 11 patients, with balloon catheter extraction in 2; complete resolution of findings was achieved in 10 cases. In the postoperative group, sphincterotomy (with balloon or basket extraction as needed) was performed in 19 patients, stents were placed in 2 patients, 1 patient underwent balloon dilatation, and 1 had nasobiliary drainage; there was complete resolution of the findings in 14 of the 20 patients. CONCLUSIONS: ERCP and related therapeutic maneuvers are safe and valuable in the pre- and postoperative management of patients with hepatic hydatid disease.     

Difficult bile duct stones

Opinion statement Bile duct stones are routinely removed at time of endoscopic retrograde cholangiopancreatography (ERCP) after biliary sphincterotomy with standard balloon or basket extraction techniques. However, in approximately 10% to 15% of patients, bile duct stones may be difficult to remove due to challenging access to the bile duct (periampullary diverticulum, Billroth II anatomy, Roux-en-Y gastrojejunostomy), large (> 15 mm in diameter) bile duct stones, intrahepatic stones, or impacted stones in the bile duct or cystic duct. The initial approach to the removal of the difficult bile duct stone is to ensure adequate biliary sphincter orifice diameter with extension of biliary sphincterotomy or balloon dilation of the orifice. Mechanical lithotripsy is a readily available adjunct to standard stone extraction techniques and should be available in all ERCP units. If stone extraction fails with these maneuvers, two or more bile duct stents should be inserted, and ursodiol added to aid in duct decompression, stone fragmentation, and stone dissolution. Follow-up ERCP attempts to remove the difficult bile duct stones may be performed locally if expertise is available or alternatively referred to a tertiary center for advanced extracorporeal or intracorporeal fragmentation (mother-baby laser or electrohydraulic lithotripsy) techniques. Nearly all patients with bile duct stones can be treated endoscopically if advanced techniques are utilized. For the rare patient who fails despite these efforts, surgical bile duct exploration, percutaneous approach to the bile duct, or long-term bile duct stenting should be discussed with the patient and family to identify the most appropriate therapeutic option. A thoughtful approach to each patient with difficult bile duct stones and a healthy awareness of the operator/endoscopy unit limitations is necessary to ensure the best patient outcomes. Consultation with a dedicated tertiary ERCP specialty center may be necessary.     

Double-balloon-enteroscopy-based endoscopic retrograde cholangiopancreatography in post-surgical patients

AIM: To evaluate double balloon enteroscopy (DBE) in post-surgical patients to perform endoscopic retrograde cholangiopancreatography (ERCP) and interventions. METHODS: In 37 post-surgical patients, a stepwise approach was performed to reach normal papilla or enteral anastomoses of the biliary tract/pancreas. When conventional endoscopy failed, DBE-based ERCP was performed and standard parameters for DBE, ERCP and interventions were recorded. RESULTS: Push-enteroscopy (overall, 16 procedures) reached entera...     

内镜十二指肠乳头切开术治疗十二指肠乳头旁憩室合并胆总管结石

目的 探讨内镜乳头括约肌切开术(EST)对十二指肠乳头旁憩室合并胆总管结石治疗的方法及价值.方法 我院2005年1月至2009年4月282例EST病例,其中38例为十二指肠乳头旁憩室合并胆总管结石患者,回顾性分析十二指肠憩室对这些病例的ERCP成功率、EST及其并发症的影响.结果 该组38例十二指肠乳头旁憩室合并胆总管...     

Endoscopic retrograde cholangiography and laparoscopic cholecystectomy: stones,stents and sphincterotomy

Endoscopic retrograde cholangiopancreatography (ERCP) is clearly a useful adjunct in the management of patients undergoing laparoscopic cholecystectomy who have common bile duct stones. Whether endoscopic sphincterotomy plus laparoscopic cholecystectomy is superior to traditional open cholecystectomy and bile duct exploration is a question which remains to be answered by prospective, randomized trials. The immense popularity of laparoscopic cholecystectomy may prohibit such a study in the USA. In expert hands, endoscopic stone extraction is usually successful, so ERCP can be deferred until after cholecystectomy unless there is serious suspicion of a duct stone preoperatively. Actual clinical practice will depend, however, on the skill of the surgeon, the skill of the endoscopist, and the commitment to removing the gallbladder laparoscopically. It would seem prudent for surgeons to continue to direct their energy toward conquering the common bile duct via the laparoscope, and leave ERCP and stone extraction in the realm of the endoscopist who has been extensively trained in this difficult technique. Proficiency at ERCP, sphincterotomy and stone extraction requires considerable training, and the procedure should not be attempted by individuals who have performed fewer than 100 ERCPs and 25 individually supervised sphincterotomies, according to the ASGE Standards of Training 1992. As experience with video endoscopic surgery increases and technology improves, it will become possible to remove most duct stones at the time of cholecystectomy, thus obviating the need for endoscopic sphincterotomy.In addition, ERCP should be regarded as the treatment of choice for postoperative cystic duct stump leaks. Studies have shown that any type of biliary decompression, i.e. sphincterotomy, stents or nasobiliary catheters, will be successful. The authors recommend that, in the absence of duct stones, stenting or nasobiliary catheters be used as they are less invasive. Bile duct leaks may also be managed endoscopically, but success depends on the individual characteristics of the duct injury. The decision to manage late onset strictures endoscopically should be individualized, and consideration of local endoscopic expertise, operative risk, interval between surgery and stricture, and the patient's wishes should be made.     

Tips for double balloon enteroscopy in patients with Roux‐en‐Y reconstruction and modified Child surgery

Pancreatobiliary disease in patients with altered anatomic intestine is one of the most difficult cases for pancreatobiliary endoscopic therapies and diagnosis. There are two major challenges to overcome to complete the procedure. The first challenge is the deep insertion to the blind end. The second challenge is the endoscopic retrograde cholangiopancreatography (ERCP)‐related intervention. Impairing either success means the incompletion of the procedure. The double balloon enteroscope (DBE), which has been recently developed, enabled the deep intubation to the blind end. Especially, using the scopes with a short working length allowed us to perform the ERCP‐related interventions with a high success rate. Generally, ERCP using double balloon endoscope (DB‐ERCP) in patients with altered gastrointestinal anatomy has been established. We introduce our standard technique for DB‐ERCP and provide several tips for insuring a successful procedure.     

Choledochal cyst type I: successful endoscopic balloon dilatation of the distal common bile duct and sphincter of Oddi: a case report

A 12-year-old boy with a choledochal cyst type I is reported with clinical features of abdominal pain, postprandial vomiting, weight loss and fatigue since 3 months. Diagnosis was made by ultrasound and confirmed by computer-assisted tomography (CAT) and endoscopic retrograde cholangiography (ERC). Instead of the usual surgical treatment balloon dilatation of the sphincter of Oddi and the distal common bile duct was performed by endoscopic means. The patient was relieved from his complaints, gained weight and felt healthy again. Sonographic and endoscopic reexamination had proven that the diameter of the common bile duct had diminished from 3,0 to 2,6 cm. Endoscopic balloon dilatation of choledochal cysts type I may be a valuable alternative to surgical treatment.     

Endoscopic papillary large balloon dilation for large common bile duct stones

Endoscopic papillary large balloon dilation (EPLBD) involves endoscopic biliary sphincterotomy (EBS) followed by balloon dilation using a 12–20-mm balloon to remove large or difficult stones from the common bile duct. The complications and limitations of endoscopic biliary sphincterotomy (EBS) are well known. Endoscopic papillary balloon dilation (EPBD) with a smaller diameter balloon but without sphincterotomy is widely used in a number of regions of the world for removal of routine bile duct stones and has been investigated as an alternative to EBS. EPBD, however, appears to be associated with an increased risk of pancreatitis. EPLBD differs from EPBD as it involves EBS followed by large balloon dilation. EPLBD would theoretically combine advantages of sphincterotomy and balloon dilation by increasing efficacy at stone extraction while minimizing complications of both EBS and EBD. A review of the available literature for EPBLD shows that it is relatively safe and effective. A high success rate (up to 95%) has been described for stone removal using EPLBD, with a low complication rate. Unlike EPBD, EBLBD does not appear to be associated with a higher risk of post-ERCP pancreatitis, probably because of separation of the biliary and pancreatic sphincters after EBS. EPLBD appears to be a reasonable option for removal of large or difficult common bile duct stones. This technique may be especially helpful in patients with difficult papillary anatomy, such as those with small papillae, intra- or peri-diverticular papilla. Its role in patients with coagulopathy or other risks for bleeding remains to be investigated.