LAUSR

A 75-year-old man attended the emergency department complaining of upper abdominal colic accompanied by nausea and cold sweating for 24 hours. Physical examination found that there was mild tenderness and tension in the upper region of his abdomen. Several of his liver function test and blood chemistry values were abnormal: neutrophil count 7710/μL (reference 2000–7000/μL), total bilirubin 2.1mg/dL, direct bilirubin 1.3mg/dL, pancreatic lipase 2085 IU/L. In addition, acute inflammatory markers, including procalcitonin (0.63ng/mL), IL-6 (287pg/mL), and C-reactive protein (59.1mg/mL), were all elevated. A nonenhanced abdominal computed tomography scan indicated the presence of an 8-mm stone in the distal common bile duct (▶Fig. 1). Endoscopic retrograde cholangiopancreatography (ERCP) was performed on the second day after admission. The duodenoscope reached the descending duodenum smoothly. However, as the angle between the bile duct and cannulation was almost a right angle, possibly caused by a diverticulum, an experienced endoscopist failed to complete biliary cannulation after several attempts (▶Fig. 2). Several days later, a second try was made, this time using magnets to help to tackle the difficult papilla (▶Video 1). A magnetic bead was fixed next to the papilla and a powerful magnet placed externally (▶Fig. 3 a, b). Through the attraction between the magnets, the angle was changed and the biliary cannulation was then successfully performed (▶Fig. 3 c, d). Following cannulation, the sphincter was cut about 5mm using blended current. Finally, the stone was extracted using a stone basket, and the filling defect disappeared (▶Fig. 3 e, f). There were no complications. Reports exist of magnets playing an important role in endoscopic surgery [1, 2]. In the present case, biliary cannulation that was difficult using the conventional E-Videos