Endoclip papilloplasty for a patulous and incompetent biliary papilla

A 78-year-old woman with choledocholithiasis (Fig. 1) underwent an extensive endoscopic sphincterotomy for large stone extraction. Concerned about the possibility of recurrent cholangitis and subsequent recurrent stone formation, we proceeded with a novel procedure, which we called endoclip papilloplasty: zipper closure of the patulous papilla with endoclips (Figure 2, Figure 3; Video 1, available online at www.VideoGIE.org).Figure 2Papilla before ERCP.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3ERCP procedure: A, stones were extracted by lithotomybasket. B, Placement of 7F suspended overlength single-pigtail biliary stent (7F × 20 cm). C, Zipper closure with Micro-Tech endoclips of the patulous papilla was finished.View Large Image Figure ViewerDownload Hi-res image Download (PPT) During ERCP, a large periampullary diverticulum and a protruding ampulla were noted. A generous biliary sphincterotomy (>1 cm) was performed to facilitate large stone extraction by use of a lithotripsy basket and a stone extraction balloon. After all stone fragments were cleared from the bile duct, a 7F single-pigtail biliary stent was placed (suspended overlength biliary stent, 7F × 20 cm). Because of a concern about recurrent cholangitis and subsequent recurrent stone formation, endoclip papilloplasty was performed (Fig. 3). After ERCP, no adverse events occurred. Three weeks later, the stent was removed, and the papilla appeared competent (Fig. 4). To evaluate the sphincter-preserving effect, sphincter of Oddi (SO) manometry was performed, including basal pressure (BP), phasic contraction amplitude (PCA), and common bile duct (CBD) pressure (CBDP). The CBDP, BP, and PCA had recovered to 2 mm Hg, 11 mm Hg, and 27 mm Hg, respectively. Seven months later, the patient’s liver function was normal and the papilla had an improved appearance (Fig. 5). At the same time, the CBD returned to 1.0 cm. There were no stones in the CBD and recurrent cholangitis or papillary stenosis did not occur, indicating that the sphincter pressure and function were preserved.Figure 5The papilla had an improved appearance after 7 months.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Biliary sphincterotomy has been a standard therapeutic procedure for bile duct stones since 1973. Because most centers cannot perform lithotripsy, a large endoscopic sphincterotomy (EST) is required for large stones. Risk factors for recurrence of primary bile duct stones are bile duct diameter after cholelithotomy and periampullary diverticulum.1Kim D.I. Kim M.H. Lee S.K. et al.Risk factors for recurrence of primary bile duct stones after endoscopic biliary sphincterotomy.Gastrointest Endosc. 2001; 54: 42-48Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar, 2Uchiyama K. Onishi H. Tani M. et al.Long-term prognosis after treatment of patients with choledocholithiasis.Ann Surg. 2003; 238: 97-102Crossref PubMed Google Scholar The loss of SO function may cause bactobilia and recurrence after EST.3Skar V. Skar A.G. Midtvedt T. et al.Bacterial growth in the duodenum and in the bile of patients with gallstone disease treated with endoscopic papillotomy (EPT).Endoscopy. 1986; 18: 10-13Crossref PubMed Scopus (40) Google Scholar To our knowledge, a method that could optimally replace SO function has not been reported. Our team reported several patients who had undergone endoclip papilloplasty first in China.4Huang Yonghui Wang Kun Zhang Hejun et al.A preliminary study of sphincter-preserving effect of SureClip from MicroTech on duodenal papilla occlusion [in Chinese].Chin J Dig Endosc. 2018; 35: 823-827Google Scholar In this patient, all stones were completely removed without any post-ERCP adverse events. This procedure may preserve the sphincter pressure, maintaining its antireflux function. Post-EST stenosis after large or generous EST is rarely reported. In this patient, post-EST stenosis was not observed 7 months postoperatively. Because the ampulla was redundant and protruding, the method accelerated healing of the papilla. The outcomes of the procedure are unclear in patients with a flat and small ampulla, and the use of clips for closure may be challenging. Further investigation is warranted to clarify the outcomes. All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3Nzk2OGQwOTQyYTdlMzYyZGIxMTc2M2UxNzg1M2IzOSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4MjQzOTE0fQ.qtXflsfKIEVnxxj_dJYR0vfbosrehXJO2yu-TX506jp_90WyijOG24uf4R8BRMqF1aCMEfyXllOJCUTv0JlzFiJVJs3KGr8sYFOHl_jbgvxnUp7i3BBxyDwVnLS3ouaU-VH7xVYteo4GVaGH5mHCvoUYlw2CaHOn99sjZIeS4Uh071nfCaZPBNlyWDhCzZYnYdXmBxVEnbg4S36GwLgcHkibGiwtY7s5ZN5g7yhBZE9N9nnru-ch0ID8M56kFvM-0gsKlpIAOeL3CHdMRpSsKKCR0dmgweSt-FNc8VjrzpUousAGfjVDuVLToeakr0_phnxl2LoG6mi7sGk2FVYM4w Download .mp4 (63.78 MB) Help with .mp4 files Video 1Endoclip papilloplasty: zipper closure of the patulous papilla with endoclips for sphincter preservation after extensive endoscopic sphincterotomy. Endoclip papilloplasty for a patulous and incompetent biliary papilla: a therapeutic misadventureVideoGIEVol. 4Issue 10PreviewWith great interest, we have read the video case report by Fan et al,1 “Endoclip papilloplasty for a patulous and incompetent biliary papilla” published in the July 2019 issue of VideoGIE. The authors describe the use of clips for a patulous papilla closure to reduce the possibility of recurrent cholangitis and stone formation after an extensive endoscopic sphincterotomy (ES) for large stone extraction. Three weeks after clipping, the authors claim that the papilla appeared competent and the pressure of sphincter of Oddi (SO) had recovered. Full-Text PDF Open Access