Traction-assisted Endoscopic Retrograde Cholangiopancreatography Using an S-O Clip for Difficult Biliary Cannulation in Billroth II Reconstruction With Tumor-associated Distortion.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is technically challenging, especially when the papilla is poorly oriented relative to the endoscope. We report a case of traction-assisted ERCP using an S-O clip for difficult biliary cannulation in a patient with Billroth II reconstruction and tumor-associated distortion. A patient with a history of distal gastrectomy with Billroth II reconstruction for gastric cancer presented with obstructive jaundice caused by recurrent gastric cancer with biliary stricture. During double-balloon enteroscopy-assisted ERCP, marked papillary malorientation due to distortion of the afferent limb made standard biliary cannulation difficult. To improve papillary visualization, an S-O clip was placed on a mucosal fold on the oral side of the papilla, and the loop was anchored to the anal-side intestinal wall to create clip-to-wall traction. This maneuver improved frontal visualization of the papillary orifice and stabilized the biliary axis, allowing successful biliary cannulation with an MTW ERCP catheter and guidewire. Endoscopic sphincterotomy and plastic stent placement were then completed without adverse events. Although similar traction-assisted ERCP techniques have been reported, this case highlights the usefulness of the method in tumor-associated distortion, where traction did not dramatically reposition the papilla but provided sufficient frontal visualization for biliary cannulation. Traction-assisted ERCP may be a useful adjunctive technique in selected cases with altered anatomy and compromised papillary orientation.