{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,12]],"date-time":"2026-08-12T23:28:56Z","timestamp":1786577336205,"version":"build-2736575974"},"reference-count":12,"publisher":"Georg Thieme Verlag KG","issue":"CP","license":[{"start":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T00:00:00Z","timestamp":1785369600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Endosc Int Open"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Background and Study Aims A papilla located on the left wall of a periampullary diverticulum creates a mechanically unfavourable axis for biliary cannulation that is not readily corrected from the conventional endoscopist position. We describe the Extreme Anticlockwise Bileduct Cannulation Diverticulum (ABCD) technique, where \u201cExtreme\u201d qualifies the degree of anticlockwise rotation applied\u2014an endoscopist-repositioning manoeuvre designed to address this constraint without additional instrumentation.<\/jats:p>\n                  <jats:p>Patients and Methods Following observations in two index cases, the technique was adopted pre-emptively in consecutive patients with a confirmed left-wall periampullary papilla. Twenty-four patients were prospectively enrolled between July 2021 and February 2026. The endoscopist repositioned to the patient\u2019s head end and applied extreme anticlockwise duodenoscope rotation to realign the instrument axis. The primary outcome was successful biliary cannulation. Adverse events were graded using the Cotton consensus criteria.<\/jats:p>\n                  <jats:p>Results Successful biliary cannulation was achieved in 23\/24 patients (95.8%), all within 5 min of adopting the repositioned stance. Primary guidewire cannulation was achieved in 20\/24 (83.3%); the remaining three required needle-knife fistulotomy, performed from the same repositioned stance. Trainees were involved in 22 cases and cannulated independently in 16 (72.7%). Then, 3 of 24 patients (12.5%) experienced post-sphincterotomy bleeding, graded as AGREE Grade I. No post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis or other major complications were observed.<\/jats:p>\n                  <jats:p>Conclusions The Extreme ABCD technique is a simple, equipment-independent repositioning strategy for ERCP in left-wall periampullary diverticular anatomy. In this prospective series, it was associated with a high rate of biliary cannulation without rescue accessories and was feasible in a supervised training environment. Multicentre evaluation is warranted.<\/jats:p>","DOI":"10.1055\/a-2916-0033","type":"journal-article","created":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T23:11:38Z","timestamp":1785453098000},"source":"Crossref","is-referenced-by-count":0,"special_numbering":"S","title":["Extreme Anticlockwise Endoscopist Repositioning for Biliary Cannulation in Left-wall Periampullary Diverticulum"],"prefix":"10.1055","volume":"14","author":[{"given":"Wai Liam","family":"Lam","sequence":"additional","affiliation":[{"name":"University Hospitals of North Midlands NHS Trust, England, United Kingdom of Great Britain and Northern Ireland","place":["Stoke-on-Trent"],"department":["Department of Gastroenterology and Endoscopy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nasir","family":"Javed","sequence":"additional","affiliation":[{"name":"University Hospitals of North Midlands NHS Trust, England, United Kingdom of Great Britain and Northern Ireland","place":["Stoke-on-Trent"],"department":["Department of Gastroenterology and Endoscopy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0363-6277","authenticated-orcid":false,"given":"Muhammed","family":"Saad","sequence":"additional","affiliation":[{"name":"University Hospitals of North Midlands NHS Trust, England, United Kingdom of Great Britain and Northern Ireland","place":["Stoke-on-Trent"],"department":["Department of Gastroenterology and Endoscopy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shabbir","family":"Jivanjee","sequence":"additional","affiliation":[{"name":"University Hospitals of North Midlands NHS Trust, England, United Kingdom of Great Britain and Northern Ireland","place":["Stoke-on-Trent"],"department":["Department of Gastroenterology and Endoscopy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kar","family":"Lau","sequence":"additional","affiliation":[{"name":"University Hospitals of North Midlands NHS Trust, England, United Kingdom of Great Britain and Northern Ireland","place":["Stoke-on-Trent"],"department":["Department of Gastroenterology and Endoscopy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roderick","family":"Prawiradiradja","sequence":"additional","affiliation":[{"name":"University Hospitals of North Midlands NHS Trust, England, United Kingdom of Great Britain and Northern Ireland","place":["Stoke-on-Trent"],"department":["Department of Gastroenterology and Endoscopy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Damien","family":"Durkin","sequence":"additional","affiliation":[{"name":"University Hospitals of North Midlands NHS Trust, England, United Kingdom of Great Britain and Northern Ireland","place":["Stoke-on-Trent"],"department":["Department of Gastroenterology and Endoscopy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-6222-8816","authenticated-orcid":false,"given":"Srisha","family":"Hebbar","sequence":"additional","affiliation":[{"name":"University Hospitals of North Midlands NHS Trust, England, United Kingdom of Great Britain and Northern Ireland","place":["Stoke-on-Trent"],"department":["Department of Gastroenterology and Endoscopy"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"194","published-online":{"date-parts":[[2026,8,12]]},"reference":[{"key":"ref1","doi-asserted-by":"crossref","first-page":"282","DOI":"10.4253\/wjge.v8.i6.282","article-title":"Endoscopic retrograde cholangiopancreatography in periampullary diverticulum: the challenge of cannulation","volume":"8","author":"A Y Altonbary","year":"2016","journal-title":"World J Gastrointest Endosc"},{"key":"ref2","first-page":"782","article-title":"Endoscopic biliary intervention using traction devices for periampullary diverticulum","volume":"64","author":"R Inoue","year":"2019","journal-title":"Dig Dis Sci"},{"key":"ref3","doi-asserted-by":"crossref","first-page":"1095","DOI":"10.1055\/a-0919-4154","article-title":"How to facilitate cannulation of an intradiverticular papilla: a technique with two devices in one channel using paediatric forceps","volume":"51","author":"J-M Gonzalez","year":"2019","journal-title":"Endoscopy"},{"key":"ref4","first-page":"777","article-title":"Usefulness of the two-devices-in-one-channel technique for difficult bile duct intubation","volume":"55","author":"T Kaneko","year":"2022","journal-title":"Clin Endosc"},{"key":"ref5","first-page":"184","article-title":"Cannulation in patients with large periampullary diverticulum using SpyBite miniforceps","volume":"51","author":"M Balkrishanan","year":"2018","journal-title":"Clin Endosc"},{"key":"ref6","doi-asserted-by":"crossref","first-page":"824","DOI":"10.1055\/s-0043-111010","article-title":"A new 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periampullary duodenal diverticula at endoscopic retrograde cholangiopancreatography: a proposed classification of periampullary duodenal diverticula","volume":"16","author":"J Boix","year":"2006","journal-title":"Surg Laparosc Endosc Percutan Tech"},{"key":"ref10","doi-asserted-by":"crossref","first-page":"2403","DOI":"10.3748\/wjg.v26.i19.2403","article-title":"Clinical significance of different periampullary diverticulum classifications for endoscopic retrograde cholangiopancreatography cannulation","volume":"26","author":"P Li","year":"2020","journal-title":"World J Gastroenterol"},{"key":"ref11","doi-asserted-by":"crossref","first-page":"446","DOI":"10.1016\/j.gie.2009.10.027","article-title":"A lexicon for endoscopic adverse events: report of an ASGE workshop","volume":"71","author":"P B Cotton","year":"2010","journal-title":"Gastrointest Endosc"},{"key":"ref12","doi-asserted-by":"crossref","first-page":"1078","DOI":"10.1016\/j.gie.2021.11.038","article-title":"Novel classification for adverse events in GI endoscopy: the AGREE classification","volume":"95","author":"K Nass","year":"2021","journal-title":"Gastrointest Endosc"}],"container-title":["Endoscopy International 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