Thread a needle with two hands: inner countertraction using clip with rubber band facilitates difficult pancreatic cannulation during ERCP

Difficult biliary or pancreatic cannulation during endoscopic retrograde cholangiopancreatography (ERCP) is among the leading causes of failed operations [1]. Inspired by the application of traction in endoscopic treatment of early gastrointestinal tumors [2], we have developed clip-and-rubber-band traction to accomplish difficult pancreatic cannulation during ERCP (▶Video 1). An elderly woman was diagnosed with an uncinate process tumor of the pancreas by endoscopic ultrasound-guided fineneedle biopsy. To relieve the high pressure of the extremely dilated pancreatic duct, ERCP was considered to perform pancreatic duct drainage. Unfortunately, a long, rugose, and pendulous papilla with a stiff and constrictive orifice was revealed under duodenoscopy (▶Fig. 1 a), resulting in the failure of conventional cannulation because the papillary orifice could not be reached or entered (▶Fig. 1b). Consequently, the clip-and-rubberband traction technique was used to rescue the difficult ERCP. After an endoclip holding a rubber band was anchored to the inferior border of the papillary orifice, a second endoclip was introduced to pick up the rubber band and fix it to the opposite wall of the duodenum (▶Fig. 1 c). As the papilla was completely lifted upright with the countertraction device and the papillary orifice was well exposed, the sphincterotome with a guidewire was successfully inserted into the pancreatic duct within seconds (▶Fig. 1d). After the stenosis of the pancreatic duct head was thoroughly dilated with dilating bougies, a 7-Fr × 7-cm plastic stent was smoothly placed into the pancreatic duct body with fluent drainage of pancreatic juice (▶Fig. 1 e). Compared with the external means of traction including clip with line [2], snare [3] and forceps [4] in ERCP, internal countertraction has several remarkable advantages. It does not interfere ERCP instruments, and it is inexpensive, easily accessible, and simple and convenient to manipulate. This technique is very promising for improving the success rate of difficult biliary or pancreatic cannulation during ERCP in the future.