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Brief Report Successful intubation of the periampullary diverticulum in post-Billroth II method-reconstructed intestinal tract using clip-and-snare method with a pre-looping technique
Makoto Yamamotoorcid, Kunihiro Tsujiorcid, Shigetsugu Tsujiorcid, Shigenori Wakitaorcid, Hiroyoshi Nakanishiorcid, Haruhiko Shugoorcid, Naohiro Yoshidaorcid, Hisashi Doyamaorcid

DOI: https://doi.org/10.5946/ce.2025.060
Published online: June 9, 2025

Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan

Correspondence: Kunihiro Tsuji Department of Gastroenterology, Ishikawa Prefectural Central Hospital, 2-1, Kuratsukihigashi, Kanazawashi, Ishikawa 920-8530, Japan E-mail: kt98052@yahoo.co.jp
• Received: February 23, 2025   • Revised: March 16, 2025   • Accepted: March 22, 2025

© 2025 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Successful bile duct intubation is essential for the completion of endoscopic retrograde cholangiopancreatography (ERCP) but may be challenging. Intubation difficulty varies according to patient factors, and the presence of a reconstructed intestine or diverticulum is a major factor that increases intubation difficulty.1-3 In this study, we report a case of post-Billroth II reconstruction of the intestine with a periampullary diverticulum that was successfully intubated using the clip-and-snare method with a pre-looping technique (CSM-PLT).4 The CSM-PLT is an endoscopic submucosal dissection (ESD) traction method that is unique in its ability to fine-tune traction effectively.
A 70-year-old man was diagnosed with advanced gastric cancer 5 years prior and subsequently underwent distal gastrectomy with Billroth II reconstruction. Postoperative recurrence was observed, and the patient was treated with chemotherapy; however, six months later, a malignant biliary stricture developed owing to metastases. ERCP was performed to treat jaundice. The duodenal papilla was easily reached without anastomotic stenosis with the microscope (PCF-H290TI; Olympus Medical Systems). The papilla was accompanied by a large periampullary diverticulum that could not be observed in the endoscopic field of view because of the lateral marginal opening of the diverticulum. The straight-view microscope was unable to operate the two devices effectively using the one-channel method5; therefore, we used the ZEOCLIP traction method.6 Intubation was attempted using a 0.035-inch catheter (MTW; ABIS Inc.) and a 0.025-inch guidewire (Visiglide 2; Olympus Medical Systems). Using wire-guided cannulation, the axis of the cannula direction could not be aligned correctly with the axis of the bile duct because the traction vector was completely fixed by the clipped points. This did not result in effective traction, and bile duct intubation was not achieved (Fig. 1). Consequently, percutaneous transhepatic biliary drainage was performed, followed by the placement of an uncovered metallic stent, after which chemotherapy was resumed. However, six months later, the patient developed bile duct stenosis again owing to disease progression, and ERCP was performed. The same endoscope, 0.035-inch catheter, and 0.025-inch guidewire were used as in the previous examination. Developing an effective field of view was considered challenging using the ZEOCLIP traction method; therefore, the CSM-PLT (SnareMater; Olympus Medical Systems) was used, which can adjust the traction vector to improve it. The CSM-PLT was placed on the slightly anorectal side of the papilla within the diverticulum and made visible by pulling the snare. The snare was slightly adjusted so that the instrumental channel and common bile duct axis were in a straight line. When the guidewire was placed in the pancreatic duct using the CSM-PLT, the bile duct was successfully intubated using the pancreatic duct guidewire method (Fig. 2). Common bile duct cholangiography revealed an obstruction in the previously implanted stent. A guidewire broke through the stenosis, and an uncovered metallic stent (ZEOSTENT-V, 10×80 mm) was implanted. The patient was discharged without any postoperative complications and received chemotherapy.
In this study, we report a case of post-Billroth II reconstruction of a periampullary diverticulum that was successfully intubated using CSM-PLT. To the best of our knowledge, intubation using this technique has not been previously reported. ERCP for gastrointestinal reconstruction differs from that for the normal intestine, and the enteral loop is challenging to identify, especially with a duodenal scope with ERCP, because of the difficulty in capturing the view of direction.7 Therefore, we often used a direct-view scope. However, the papilla is difficult to view from the front. The CSM-PLT was used to overcome these issues.
The CSM-PLT is a traction method for ESD that uses a snare developed by Yoshida et al.4 A brief description of the CSM-PLT is as follows: With the snare ligated to the hood at the endoscope tip, the endoscope is inserted into the lesion, and a clip device is inserted through the accessory channel of the endoscope. The clip is placed in the traction area and ligated using the snare, allowing the manipulation of the lesion through the snare from outside the endoscope (Fig. 3). An advantage of CSM-PLT over the conventional traction method in bile duct cannulation is that it can be operated independently of the scope, as traction is performed from outside the scope. In addition, it is superior in improving the visibility of the main papilla and adjusting the position and angle suitable for bile duct intubation according to the performer’s intention through subtle adjustment of the force point. Third, attraction and repulsion can be applied using an elastic snare. Fourth, the snare can be easily released by opening, leaving only the clip that can be reapplied to correct the traction site. Finally, no special equipment or advanced techniques are required for this procedure.
The presence of a periampullary diverticulum increases the difficulty and incidence of illnesses associated with ERCP, particularly when the papilla is not visible, which is often technically difficult.5 Various methods have been devised for the treatment of papillae with periampullary diverticula and have been successful in many cases of difficult intubation. The two devices in the one-channel method5 and double-catheter method8 involve inserting two biopsy forceps or cannulas through the same accessory channel, fixing one device in the direction that facilitates the approach of the papilla, and intubating the bile duct with the other device. Although this method can pull the hidden papilla with biopsy forceps to obtain a frontal view, it requires high skill because of the simultaneous operation of two interfering devices. In addition, its use is limited to endoscopes whose accessory channels can accommodate the two devices. In the submucosal injection method,9 hyaluronic acid is injected locally near the papillae and is used to shift the papillae toward the frontal view through the submucosal injection of sodium hyaluronate. The advantages of this method are the relative simplicity of submucosal injections and the ability to fix the unsupported papilla with hyaluronic acid. However, the papilla turns in an unexpected direction because of the injection, and the procedure cannot be performed again under similar conditions. In the ZEOCLIP traction method,6 which was attempted in this case, the clip is fixed near the papilla and bowel wall, and traction is applied to the S-O clip. Fine-tuning the traction vector is difficult because the fulcrum and force points are fixed. In this study, a PCF-H290TI scope was used. Therefore, the operation of the two devices using the one-channel method was restricted, and the conventional traction method using ZEOCLIP did not provide effective traction.
In this case, the CSM-PLT was more successful than the ZEOCLIP traction method because the common bile duct axis could be fine-tuned to the cannula using CSM-PLT. Moreover, the snare is ligated to the clip and can easily be unligated; its impact on the patient’s side is limited to clip ligation and traction. Therefore, we consider this an advantage over the conventional ZEO clip traction method. However, this study had some limitations. The prerequisite for the CSM-PLT is that the endoscope should be inserted into the papilla, and whether reproducibility can be achieved in R-Y-reconstructed intestines is unclear. Furthermore, the operability of endoscopes with balloon-associated endoscopy is anticipated to vary depending on whether the snare is passed inside or outside the overtube. In addition, owing to the traction method for gastric ESD, the CSM-PLT could be applied using a straight-viewing scope; however, whether it can be used in ERCP using a side-viewing scope is unclear, and future studies are needed.
In this study, a patient with a post-Billroth II-reconstructed intestine with a periampullary diverticulum was successfully intubated using CSM-PLT. In conclusion, CSM-PLT is advantageous over the conventional clip ligation method, and we expect that this method will be applied in the future. The Institutional Review Board of Ishikawa Prefectural Central Hospital approved this study. Informed consent from the patient was obtained for all medical procedures and publication of this report.
Fig. 1.
(A) Duodenal papilla with periampullary diverticulum (indicated by white arrowhead) difficult to view anteriorly. (B) Frontal view of a periampullary diverticulum. (C) Traction method with S-O clip method and visible papilla (indicated by yellow arrowhead). (D) Axis adjustment was difficult during intubation.
ce-2025-060f1.jpg
Fig. 2.
(A) Traction image with clip-and-snare method with a pre-looping technique. (B) Image during intubation, frontal view of the papilla is obtained by subtle positioning. (C) Radioscopy image before traction (clip indicated by arrowhead). (D) Radioscopy image after traction (clip indicated by arrowhead).
ce-2025-060f2.jpg
Fig. 3.
(A) Snare ligated to the end of the scope. (B) Clip on one side of the lesion. (C) Snare released, moved to the clip, and re-ligated to the clip. (D) The clip-and-snare method with a pre-looping technique is completed by hitting the clip, and the snare can be operated independently of the endoscope.
ce-2025-060f3.jpg
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  • 2. Hidenobu O, Hikaru H, Yuki I, et al. The use of a traction device called the S-O clip facilitated cannulation of the bile duct with an intradiverticular papilla. Gastroenterol Endosc 2020;62:165–172.Article
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  • 4. Yoshida N, Doyama H, Ota R, et al. The clip-and-snare method with a pre-looping technique during gastric endoscopic submucosal dissection. Endoscopy 2014;46 Suppl 1 UCTN:E611–E612.ArticlePubMed
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  • 9. Hideaki H, Yasushi K, Takanori S. The use of submucosal injection facilitates cannulation for the bile duct with periampullary diverticulum. Gastroenterol Endosc 2015;57:1392–1397.Article

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      Successful intubation of the periampullary diverticulum in post-Billroth II method-reconstructed intestinal tract using clip-and-snare method with a pre-looping technique
      Image Image Image
      Fig. 1. (A) Duodenal papilla with periampullary diverticulum (indicated by white arrowhead) difficult to view anteriorly. (B) Frontal view of a periampullary diverticulum. (C) Traction method with S-O clip method and visible papilla (indicated by yellow arrowhead). (D) Axis adjustment was difficult during intubation.
      Fig. 2. (A) Traction image with clip-and-snare method with a pre-looping technique. (B) Image during intubation, frontal view of the papilla is obtained by subtle positioning. (C) Radioscopy image before traction (clip indicated by arrowhead). (D) Radioscopy image after traction (clip indicated by arrowhead).
      Fig. 3. (A) Snare ligated to the end of the scope. (B) Clip on one side of the lesion. (C) Snare released, moved to the clip, and re-ligated to the clip. (D) The clip-and-snare method with a pre-looping technique is completed by hitting the clip, and the snare can be operated independently of the endoscope.

      Fig. 1.

      Fig. 2.

      Fig. 3.

      Successful intubation of the periampullary diverticulum in post-Billroth II method-reconstructed intestinal tract using clip-and-snare method with a pre-looping technique
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