Around the World: duodenoscope maneuver to permit an en face papillary view and short duodenoscope position in the setting of duodenal compression.

Background and Aims: Deformities of the first portion (D1) or second portion (D2) of the duodenum can limit duodenoscope orientation and stability at the major papilla (MP) for cannulation during ERCP. We present a technique, "Around the World," for improving orientation of the MP and duodenoscope stability during ERCPs performed amid D1/D2 deformities. Methods: Advance the duodenoscope to the third portion or fourth portion of the duodenum. With unlocked dials, reduce to the short position by rotating the right-left dial clockwise while withdrawing the endoscope and applying clockwise torque to the shaft until a 180° rotation of the shaft and 360° rotation of the control section are achieved. Resolve the resultant external loop by disconnecting the endoscope and unraveling the umbilical cord. Results: Two patients with pancreatic masses causing biliary obstruction underwent ERCPs, during which D1/D2 deformities were noted, and the MP was initially in a suboptimal orientation for cannulation or not visualized. Around the World was performed, improving orientation of the MP and facilitating successful ERCP each time. Conclusions: If D1/D2 deformity is present during ERCP and the orientation of the MP is suboptimal, not visualized, or the duodenoscope position is unstable, Around the World can improve endoscope position to optimize trajectory for cannulation.