Digestive Diseases and Sciences

, Volume 57, Issue 11, pp 2982–2987 | Cite as

Additional Biliary Cannulation Methods in Patients with Juxtapapillary Duodenal Diverticula

  • Erkan Parlak
  • Aydın Şeref KöksalEmail author
  • Selçuk Dişibeyaz
  • Bahattin Çiçek
  • Serkan Uysal
  • Nurgül Şaşmaz
  • Burhan Şahin
Original Article


Background and Aims

Juxtapapillary diverticula (JPD) can increase the difficulty of biliary cannulation. A number of additional methods have been defined in case of failed cannulation attempt by standard technique. We aimed to investigate the more commonly preferred and practical additional methods among them.


A total of 1,205 endoscopic retrograde cholangiopancreatographies (ERCP) performed during a study period of 14 months were prospectively entered into a database. Of these, 222 (18 %) had JPD (123 women, 99 men, mean age 69 years) and 983 had no diverticula (523 women, 460 men, mean age 57 years). Additional cannulation methods used in patients with JPD were recorded. Biliary cannulation time, total procedure time, use of pre-cut papillotomy, and therapeutic success of ERCP were compared between the groups as well.


Biliary cannulation was performed by standard technique in 210 patients with JPD (94.5 %). Cannulation was achieved by placement of a guidewire into the pancreatic duct in 6 (2.7 %) and use of two devices in one channel in 2 (0.9 %) patients. There was no significant difference between the total procedure time and therapeutic success of ERCP between the groups. Cannulation time was significantly longer in patients with JPD. Pre-cut papillotomy was performed less in patients with JPD.


Presence of JPD does not decrease the therapeutic success of ERCP. Placement of a guidewire in the pancreatic duct or use of two-devices-in-one-channel are practical, successful, safe, and preferred methods which can be used in patients with failed cannulation by standard technique.


Duodenum Diverticula Cannulation ERCP 


Conflict of interest

All the authors have no conflicts of interest.


  1. 1.
    Osnes M, Lotveit T, Larson S, Aune S. Duodenal diverticula and their relationship to age, sex, and biliary calculi. Scand J Gastroenterol. 1981;16:103–107.PubMedGoogle Scholar
  2. 2.
    Mesh E, Friedman E, Czerniak A, Bat L. The association of biliary and pancreatic anomalies with periampullary duodenal diverticula. Arch Surg. 1987;122:1055–1057.CrossRefGoogle Scholar
  3. 3.
    Kimura W, Nagai H, Kuroda A, Muto T. No significant correlation between histologic changes of the papilla of Vater and juxtapapillary diverticulum. Scand J Gastroenterol. 1992;27:951–956.PubMedCrossRefGoogle Scholar
  4. 4.
    Leinkram C, Roberts-Thompson IC, Kume GA. Juxtapapillary diverticula: association with gallstones and pancreatitis. Med J Aust. 1980;1:209–210.PubMedGoogle Scholar
  5. 5.
    Lotveit T, Osnes M, Larson S. Recurrent biliary calculi: duodenal diverticula as a predisposing factor. Ann Surg. 1982;196:30–32.PubMedCrossRefGoogle Scholar
  6. 6.
    Egawa N, Kamisawa T, Tu Y, Sakaki N, Tsuruta K, Okamoto A. The role of juxtapapillary duodenal diverticulum in the formation of gallbladder stones. Hepatogastroenterology. 1998;45:917–920.PubMedGoogle Scholar
  7. 7.
    Egawa N, Anjiki H, Takuma K, Kamisawa T. Juxtapapillary duodenal diverticula and pancreatobiliary disease. Dig Surg. 2010;27:105–109.PubMedCrossRefGoogle Scholar
  8. 8.
    Skar V, Skar AG, Bratlie J, Osnes M. Betaglucuronidase activity in the bile of gallstone patients both with and without duodenal diverticula. Scand J Gastroenterol. 1989;24:205–212.PubMedCrossRefGoogle Scholar
  9. 9.
    Løtveit T, Osnes M, Aune S, Larsen S. Studies of the choledocho-duodenal sphincter in patients with and without juxta-papillary duodenal diverticula. Scand J Gastroenterol. 1980;15:875–880.PubMedCrossRefGoogle Scholar
  10. 10.
    Chang-Chien CS. Do juxtapapillary diverticula of the duodenum interfere with cannulation at endoscopic retrograde cholangiopancreatography? A prospective study. Gastrointest Endosc. 1987;33:298–300.PubMedCrossRefGoogle Scholar
  11. 11.
    Vaira D, Dowsett JF, Hatfield AR, et al. Is duodenal diverticulum a risk factor for sphincterotomy? Gut. 1989;30:939–942.PubMedCrossRefGoogle Scholar
  12. 12.
    Hall RI, Ingoldby CJH, Denyer ME. Periampullary diverticula predispose to primary rather than secondary stones in the common bile duct. Endoscopy. 1990;22:127–128.PubMedCrossRefGoogle Scholar
  13. 13.
    Leivonen MK, Halttunen JAA, Kivilaakso EO. Duodenal diverticulum at endoscopic retrograde cholangiopancreatography: analysis of 123 patients. Hepatogastroenterology. 1996;43:961–966.PubMedGoogle Scholar
  14. 14.
    Kirk AP, Summerfield JA. Incidence and significance of juxtapapillary diverticula at endoscopic retrograde cholangiopancreatography. Digestion. 1980;20:31–35.PubMedCrossRefGoogle Scholar
  15. 15.
    Cotton PB, Lehman G, Vennes JA, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc. 1991;37:383–391.PubMedCrossRefGoogle Scholar
  16. 16.
    Tham TC, Kelly M. Association of periampullary duodenal diverticula with bile duct stones and with technical success of endoscopic retrograde cholangiopancreatography. Endoscopy. 2004;36:1050–1053.PubMedCrossRefGoogle Scholar
  17. 17.
    Toth E, Lindström E, Tork FT. An alternative approach to the inaccessible intradiverticular papilla. Endoscopy. 1999;31:554–556.PubMedCrossRefGoogle Scholar
  18. 18.
    Tantau M, Person B, Burtin P, Boyer J. Duodenal diverticula and ERCP: a new trick. Endoscopy. 1996;28:326.PubMedCrossRefGoogle Scholar
  19. 19.
    Jujita N, Noda Y, Kobayashi G, Kimura K, Yago A. ERCP for intradiverticular papilla: two-devices-in-one-channel method. Endoscopic retrograde cholangiopancreatography. Gastrointest Endosc. 1998;48:517–520.CrossRefGoogle Scholar
  20. 20.
    Külling D, Haskell E. Double endoscope method to access intradiverticular papilla. Gastrointest Endosc. 2005;62:811–812.PubMedCrossRefGoogle Scholar
  21. 21.
    Scotiniotis I, Ginsberg GG. Endoscopic clip-assisted biliary cannulation: externalization and fixation of the major papilla from within a duodenal diverticulum using the endoscopic clip fixing device. Gastrointest Endosc. 1999;50:431–433.PubMedCrossRefGoogle Scholar
  22. 22.
    Huang CH, Tsou YK, Lin CH, Tang JH. Endoscopic retrograde cholangiopancreatography (ERCP) for intradiverticular papilla: endoclip-assisted biliary cannulation. Endoscopy. 2010;42:E223–E224.PubMedCrossRefGoogle Scholar
  23. 23.
    Draganov P, Devonshire DA, Cunningham JT. A new technique to assist in difficult bile duct cannulation at the time of endoscopic retrograde cholangiopancreatography. JSLS. 2005;9:218–221.PubMedCentralPubMedGoogle Scholar
  24. 24.
    Sherman S, Hawes RH, Lehman GA. A new approach to performing endoscopic sphincterotomy in the setting of a juxtapapillary diverticulum. Gastrointest Endosc. 1991;37:353–355.PubMedCrossRefGoogle Scholar
  25. 25.
    Lai R, Freeman ML. Endoscopic ultrasound-guided bile duct access for rendezvous ERCP drainage. Endoscopy. 2005;37:487–489.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Erkan Parlak
    • 1
  • Aydın Şeref Köksal
    • 1
    • 2
    Email author
  • Selçuk Dişibeyaz
    • 1
  • Bahattin Çiçek
    • 1
  • Serkan Uysal
    • 1
  • Nurgül Şaşmaz
    • 1
  • Burhan Şahin
    • 1
  1. 1.Department of GastroenterologyTürkiye Yüksek İhtisas HospitalAnkaraTurkey
  2. 2.AnkaraTurkey

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