Post written by Mark Henrik Bonnichsen, MBBS (Hon), from the Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.

We describe a case of a 77-year-old woman who underwent ERCP for choledocholithiasis and surveillance MRCP for an intraductal papillary mucinous neoplasm. MRCP also showed an incidental choledochocoele. At ERCP, the choledochocoele made visualization of the major papilla for selective biliary cannulation difficult.

Given the potential risk of bleeding and perforation with freehand precut needle-knife fistulotomy and the experience in our unit in endoscopic submucosal dissection (ESD), the decision was made to use a clip-and-line traction method.

A line, a 0.025-inch VisiGlide guidewire (Olympus Corporation, Tokyo, Japan), was tied to one of the jaws of an opened hemostatic clip (Resolution 360; Boston Scientific, Marlborough, Mass, USA) and then closed and inserted via the working channel of the duodenoscope. The clip was advanced, opened, and deployed onto the choledochocoele at the point at which traction would not increase too much tension on the duodenal wall. Gentle traction on the line from the assistant exposed the major papilla.

Initial wire pass was into the pancreatic duct, and a decision was made to insert a pancreatic stent to facilitate biliary cannulation. This was successful and followed by sphincterotomy and balloon trawl removal of the common bile duct stone.

Anatomic variations of the distal bile duct and major papilla as well as impaired visualization of the papilla are not uncommonly encountered scenarios and can make biliary access difficult. We present a novel technique with equipment that is widely available and easy to use. This may help in difficult cases when a choledochocoele is noted on preprocedural imaging or when other factors impair visualization of the major papilla.

We feel other endoscopists may benefit from use of this technique, but it also serves as a reminder that techniques used in other therapeutic procedures such as tissue resection and ESD may be useful in complex cases in pancreaticobiliary endoscopy.

My deepest gratitude extends to all collaborators and co-authors.

A, Major papilla underneath a choledochocoele. B, Sphincterotome used to attempt to expose major papilla. C, Clip-and-line traction method setup. D, Clip deployment onto choledochocoele. E, View of the major papilla after clip and traction. F, Extraction of stone with extraction balloon.

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