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Video of Issue Technique for underwater cannulation following endoscopic submucosal dissection including papilla
Shintaro Kawasaki1orcid, Teppei Masunaga2orcid, Motohiko Kato1orcid

DOI: https://doi.org/10.5946/ce.2025.416
Published online: March 30, 2026

1Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan

2Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan

Correspondence: Motohiko Kato Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan E-mail: motohikokato@keio.jp
• Received: November 9, 2025   • Revised: November 30, 2025   • Accepted: December 1, 2025

© 2026 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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Laterally spreading duodenal tumors, including those in the papilla, remain technically challenging to treat. We previously reported the feasibility of performing endoscopic submucosal dissection including papilla (ESDIP).1 Endoscopic naso-biliary drainage (ENBD) and endoscopic naso-pancreatic drainage (ENPD) have been suggested to prevent delayed adverse events after ESDIP.2 However, it is not routinely easy to safely cannulate transected bile and pancreatic ducts in a large mucosal defect following ESDIP.
We present a case in which the visual field was successfully secured, and cannulation achieved using an underwater technique. We adopted an ESDIP treatment approach for a 67-year-old male with a 20 mm papillary-involving tumor. En bloc resection was performed with no complications. After ESDIP, we performed the underwater cannulation technique. First, an endoscopic flushing pump OFP-2 (Olympus) was connected to the duodenal scope (TJF-Q290V, Olympus) using an irrigator instrument channel valve (JSS), allowing continuous water irrigation even while a catheter is inserted into the working channel (Fig. 1). Second, all residual air was aspirated, and the duodenal lumen was filled with water. We successfully cannulated pancreatic and bile ducts and placed ENPD and ENBD tubes (Fig. 2, Video 1). The postoperative course was uneventful and no delayed adverse events occurred. Underwater cannulation offers three potential benefits after ESDIP. First, it reduces bleeding by diluting digestive secretions leaking from the transected bile and pancreatic ducts. Second, it reduces patient body movements by alleviating abdominal distension and discomfort compared to air insufflation. Air/CO₂ insufflation can raise intraluminal pressure to nearly 40 mmHg,3 whereas underwater conditions keep it below 10 mmHg, passively determined by water column depth. This markedly reduced pressure minimizes discomfort and unexpected movements, providing a safer and more stable environment for cannulation and reducing the risk of retroperitoneal gas leakage. Finally, magnified visualization in water can facilitate accurate cannulation by enhancing fine structure recognition.
Video 1. Successful underwater cannulation of bile and pancreatic ducts after endoscopic submucosal dissection of the papilla.
A video related to this article can be found online at https://doi.org/10.5946/ce.2025.416.
Fig. 1.
(A–C) A duodenal scope was connected to an endoscopic flushing pump (OFP-2) with an irrigator instrument channel valve that enabled us to irrigate with water even when a catheter was inserted in the instrument channel.
ce-2025-416f1.jpg
Fig. 2.
(A) Twenty-millimeter laterally spreading duodenal tumor including papilla. (B) The en bloc specimen resected by endoscopic submucosal dissection including papilla. (C) Underwater endoscopic image showing visualization of bile and pancreatic duct orifices before cannulation. Yellow arrowhead, bile duct orifice; green arrowhead, pancreatic duct orifice. (D) Successful image capture of underwater bile and pancreatic duct cannulation.
ce-2025-416f2.jpg
  • 1. Yahagi N, Takatori Y, Sasaki M, et al. Feasibility of endoscopic submucosal dissection including papilla (with video). Dig Endosc 2025;37:402–410.ArticlePubMed
  • 2. Fukuhara S, Kato M, Iwasaki E, et al. External drainage of bile and pancreatic juice after endoscopic submucosal dissection for duodenal neoplasm: Feasibility study (with video). Dig Endosc 2021;33:977–984.ArticlePubMedPDF
  • 3. Yamada T, Hirota M, Tsutsui S, et al. Gastric endoscopic submucosal dissection under steady pressure automatically controlled endoscopy (SPACE); a multicenter randomized preclinical trial. Surg Endosc 2015;29:2748–2755.ArticlePubMedPDF

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      Technique for underwater cannulation following endoscopic submucosal dissection including papilla
      Image Image
      Fig. 1. (A–C) A duodenal scope was connected to an endoscopic flushing pump (OFP-2) with an irrigator instrument channel valve that enabled us to irrigate with water even when a catheter was inserted in the instrument channel.
      Fig. 2. (A) Twenty-millimeter laterally spreading duodenal tumor including papilla. (B) The en bloc specimen resected by endoscopic submucosal dissection including papilla. (C) Underwater endoscopic image showing visualization of bile and pancreatic duct orifices before cannulation. Yellow arrowhead, bile duct orifice; green arrowhead, pancreatic duct orifice. (D) Successful image capture of underwater bile and pancreatic duct cannulation.

      Fig. 1.

      Fig. 2.

      Technique for underwater cannulation following endoscopic submucosal dissection including papilla
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