Flail, flay, or fail: needle-knife versus transpancreatic sphincterotomy to access the difficult-to-cannulate bile duct during ERCP

Abstract Background Selective deep biliary cannulation is the first and the most important step before further biliary therapy. Transpancreatic sphincterotomy(TPS), and needle knife fistulotomy(NKF) were commonly used in patients with difficult cannulation, but few studies compare the outcome between TPS and NKF. Aims To investigate the success rate and complications of NKF and TPS in patients with difficult biliary access. Methods A total of 78 patients who met the criteria of difficult cannulation in the National Taiwan University hospital from October 2015 to October 2017 were retrospectively reviewed. Their baseline demographics, success rate of biliary cannulation, and the rate of adverse events were assessed. Results 31 patients and 47 patients underwent TPS and NKF for difficult biliary access, respectively. The characteristics of the 2 groups were similar, but patients in TPS group had more frequent pancreatic duct cannulation. Bile duct cannulation was successful in 23 patients (74.2 %) in the TPS group and 39 (83.0%) in the NKF group (P=0.34). There was no difference between the TPS and NKF in the rate of adverse events, including post-ERCP pancreatitis (PEP) (16.1% vs. 6.4%, p = 0.17), and hemorrhage (3.2% vs. 8.5%, p = 0.35). No perforation occurred. Conclusions Both TPS and NKF have good biliary access rate in patient with difficult cannulation. TPS has acceptable successful rate and similar complication rate, compared with NKF.

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Comparison between transpancreatic sphincterotomy and needle-knife fistulotomy in difficulty biliary access, a retrospective study in Taiwan

10.21203/rs.2.15791/v1 ◽

2019 ◽

Author(s):

Kai-Shun Liang ◽

Chieh-Chang Chen ◽

Wei-Chih Liao ◽

Yu-ting Kuo ◽

Liang-Wei Tseng ◽

...

Keyword(s):

Retrospective Study ◽

Bile Duct ◽

Adverse Events ◽

Complication Rate ◽

University Hospital ◽

Access Methods ◽

Biliary Cannulation ◽

Access Rate ◽

Needle Knife ◽

Transpancreatic Sphincterotomy

Abstract Background Selective deep biliary cannulation is the first and the most important step before further biliary therapy. Transpancreatic sphincterotomy(TPS), and needle knife fistulotomy(NKF) were commonly used in patients with difficult cannulation, but few studies compare the outcome between TPS and NKF. Aims To investigate the success rate and complications of NKF and TPS in patients with difficult biliary access. Methods A total of 78 patients who met the criteria of difficult cannulation in the National Taiwan University hospital from October 2015 to October 2017 were retrospectively reviewed. Their baseline demographics, succesfs rate of biliary cannulation, and the rate of adverse events were assessed. Results 31 patients and 47 patients underwent TPS and NKF for difficult biliary access, respectively. The characteristics of the 2 groups were similar, but patients in TPS group had more frequent pancreatic duct cannulation. Bile duct cannulation was successful in 23 patients (74.2 %) in the TPS group and 39 (83.0%) in the NKF group (P=0.34). There was no difference between the TPS and NKF in the rate of adverse events, including post-ERCP pancreatitis (PEP) (16.1% vs. 6.4%, p = 0.17), and hemorrhage (3.2% vs. 8.5%, p = 0.35). No perforation occurred. Conclusions Both TPS and NKF have good biliary access rate in patient with difficult cannulation. TPS has acceptable successful rate and similar complication rate, compared with NKF.

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Comparison between transpancreatic sphincterotomy and needle-knife fistulotomy in difficulty biliary access, a retrospective study in Taiwan

10.21203/rs.2.15791/v3 ◽

2020 ◽

Author(s):

Kai-Shun Liang ◽

Chieh-Chang Chen ◽

Wei-Chih Liao ◽

Yu-ting Kuo ◽

Liang-Wei Tseng ◽

...

Keyword(s):

Retrospective Study ◽

Bile Duct ◽

Adverse Events ◽

Pancreatic Duct ◽

Complication Rate ◽

University Hospital ◽

Biliary Cannulation ◽

Access Rate ◽

Needle Knife ◽

Transpancreatic Sphincterotomy

Abstract Background Selective deep biliary cannulation is the first and the most important step before further biliary therapy. Transpancreatic sphincterotomy(TPS), and needle knife fistulotomy(NKF) were commonly used in patients with difficult cannulation, but few studies compare the outcome between TPS and NKF.Methods A total of 78 patients who met the criteria of difficult cannulation in the National Taiwan University hospital from October 2015 to October 2017 were retrospectively reviewed. Their baseline demographics, success rate of biliary cannulation, and the rate of adverse events were assessed.Results 31 patients and 47 patients underwent TPS and NKF for difficult biliary access, respectively. The characteristics of the 2 groups were similar, but patients in TPS group had more frequent pancreatic duct cannulation. Bile duct cannulation was successful in 23 patients (74.2 %) in the TPS group and 39 (83.0%) in the NKF group (P=0.34). There was no difference between the TPS and NKF in the rate of adverse events, including post-ERCP pancreatitis (PEP) (16.1% vs. 6.4%, p = 0.17), and hemorrhage (3.2% vs. 8.5%, p = 0.35). No perforation occurred.Conclusions Both TPS and NKF have good biliary access rate in patient with difficult cannulation. TPS has acceptable successful rate and similar complication rate, compared with NKF.

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Biliary cannulation in endoscopic retrograde cholangiography: How to tackle the difficult papilla

Digestive Diseases ◽

10.1159/000515692 ◽

2021 ◽

Author(s):

Mark op den Winkel ◽

Jörg Schirra ◽

Christian Schulz ◽

Enrico N. De Toni ◽

Christian J. Steib ◽

...

Keyword(s):

Biliary Drainage ◽

Guide Wire ◽

A Priori ◽

Endoscopic Retrograde Cholangiography ◽

Endoscopic Retrograde ◽

Biliary Cannulation ◽

Increased Risk ◽

Difficult Biliary Cannulation ◽

Needle Knife ◽

Transpancreatic Sphincterotomy

Background: In the setting of a naïve papilla, biliary cannulation is a key step in successfully performing endoscopic retrograde cholangiography (ERC). Difficult biliary cannulation (DBC) is associated with an increased risk of post-ERCP-pancreatitis and failure of the whole procedure. Summary: Recommendations for biliary cannulation can be divided in (a) measures to reduce the likelihood of a difficult papilla-situation a priori and (b) rescue techniques in case the endoscopist is actually facing DBC. (a): careful inspection of the papillary anatomy and optimizing its accessibility by scope-positioning is fundamental. A sphincterotome in combination with a soft-tip hydrophilic guide-wire rather than a standard catheter with a standard guide-wire should be used. (b): The most important rescue techniques are needle-knife precut, double-guidewire technique and transpancreatic sphincterotomy. In few cases, anterograde techniques are needed. To this regard, the EUS-guided biliary drainage (EUS-BD) followed by rendezvous is increasingly used as an alternative to percutaneous-transhepatic biliary drainage. Key Messages: Biliary cannulation can be accomplished with alternative retrograde or less frequently by salvage-anterograde techniques, once conventional direct cannulation attempts have failed. Considering recent favorable data for the early use of transpancreatic sphincterotomy, an adopted version of the 2016 European-Society-for-Gastrointestinal-Endoscopy (ESGE)-algorithm on biliary cannulation is proposed.

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Needle knife recanalization of a complete post-transplant bile duct stricture

Endoscopy ◽

10.1055/a-1353-4734 ◽

2021 ◽

Author(s):

Ramzi Mulki ◽

Mohamed Abdelfatah

Keyword(s):

Bile Duct ◽

Bile Duct Stricture ◽

Post Transplant ◽

Needle Knife ◽

Duct Stricture

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Troubleshooting Difficult Bile Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or EUS-Guided Rendezvous Technique?

Gastroenterology Insights ◽

10.3390/gastroent12040039 ◽

2021 ◽

Vol 12 (4) ◽

pp. 405-422

Author(s):

Ting-Ting Chan ◽

Marcus C. H. Chew ◽

Raymond S. Y. Tang

Keyword(s):

Bile Duct ◽

Endoscopic Ultrasound ◽

Biliary Drainage ◽

Percutaneous Biliary Drainage ◽

Rendezvous Technique ◽

Surgically Altered Anatomy ◽

Appropriate Treatment ◽

Benign Pathology ◽

Cannulation Technique ◽

Needle Knife

Despite experienced hands and availability of various well-designed catheters and wires, selective bile duct cannulation may still fail in 10–20% of cases during endoscopic retrograde cholangiopancreatography (ERCP). In case standard ERCP cannulation technique fails, salvage options include advanced ERCP cannulation techniques such as double-guidewire technique (DGW) with or without pancreatic stenting and precut papillotomy, percutaneous biliary drainage (PBD), and endoscopic ultrasound-guided Rendezvous (EUS-RV) ERCP. If the pancreatic duct is inadvertently entered during cannulation attempts, DGW technique is a reasonable next step, which can be followed by pancreatic stenting to reduce risks of post-ERCP pancreatitis (PEP). Studies suggest that early precut papillotomy is not associated with a higher risk of PEP, while needle-knife fistulotomy is the preferred method. For patients with critical clinical condition who may not be fit for endoscopy, surgically altered anatomy in which endoscopic biliary drainage is not feasible, and non-communicating multisegmental biliary obstruction, PBD has a unique role to provide successful biliary drainage efficiently in this particular population. As endoscopic ultrasound (EUS)-guided biliary drainage techniques advance, EUS-RV ERCP has been increasingly employed to guide bile duct access and cannulation with satisfactory clinical outcomes and is especially valuable for benign pathology at centres where expertise is available. Endoscopists should become familiar with each technique’s advantages and limitations before deciding the most appropriate treatment that is tailored to patient’s anatomy and clinical needs.

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A simple and novel marking method for correctly identifying the precutting direction to achieve safe and efficacious precut sphincterotomy (with video)

Endoscopy International Open ◽

10.1055/a-0752-9755 ◽

2019 ◽

Vol 07 (01) ◽

pp. E3-E8

Author(s):

Kazumasa Nagai ◽

Akio Katanuma ◽

Kuniyuki Takahashi ◽

Kei Yane ◽

Toshifumi Kin ◽

...

Keyword(s):

Bile Duct ◽

Technical Success ◽

Tertiary Referral ◽

Endoscopic Retrograde ◽

Incision Length ◽

Tertiary Referral Center ◽

Preliminary Study ◽

Needle Knife ◽

The Right ◽

Precut Sphincterotomy

Abstract Background and study aims Failure to recognize the right direction and precise incision length during precutting has been reported. To address these concerns, we developed a marking method that places a marking on the cutting endpoint before starting precutting. This preliminary study aimed to assess the effectiveness and safety of precut sphincterotomy using our new marking method. Patients and methods Between April 2015 and May 2017, 21 patients from our tertiary referral center were included in this study. Precut sphincterotomy using our marking method was employed for difficult common bile duct cannulation cases. Before starting precutting, a marking was placed slightly before the upper margin of the bulge of the papilla in the 11- to 12-o’clock direction as a cutting endpoint by cauterization with a needle knife. Results Technical success was obtained in all 21 procedures. There were no post-endoscopic retrograde cholangiopancreatography (ERCP) complications except for one mild case of post-ERCP pancreatitis. Conclusion Our new marking method before precutting enabled precise incision and quick bile duct cannulation without causing severe complications.

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