Ultrasonography-Guided Corticosteroid Injection Combined with Versus Without Needle Knife Release of A1 Pulley for Trigger Finger

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Salvage Techniques for Difficult Biliary Cannulation: A Retrospective Study of 1021 Endoscopic Retrograde Cholangiopancreatography Cases in a Tertiary Referral Center

Although some salvage techniques have been developed to overcome difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP), few reports analyzed the choice of techniques and their clinical outcomes in large cohorts. This study aimed to evaluate the outcomes of biliary cannulation in patients with initial treatment papillae. We retrospectively identified 1021 patients who underwent initial ERCP from January 2013 to March 2020. We investigated background factors, treatment details, success rates, and adverse event rates. Then we analyzed a series of treatment processes, including salvage techniques such as double guidewire technique (DGT), needle knife pre-cutting (NKP), and transpancreatic pre-cut papillotomy (TPPP). The initial ERCP success rate was 94.3%, and the eventual success rate was 98.3%. Salvage techniques were required in 380 of 1021 patients (37.2%), associated with long oral protrusion (OR, 2.38; 95% CI, 1.80–3.15; p < 0.001). A total of 503 cases (49.3%) had long oral protrusions, 47.5% of which required the salvage techniques, much higher than 27.5% of not-long cases. Patients with long oral protrusions had a higher frequency of NKP. In conclusion, patients with long oral protrusions frequently required salvage techniques. Appropriate strategies and salvage techniques may help to overcome many difficult biliary cannulation cases.

Initial experience with a homemade “hybrid-tome” for needle-knife precut in patients with difficult biliary cannulation

Background and study aims Current clinical guidelines recommend needle-knife precut (NKP) as the primary and best method for performing a biliary cannulation (BC) when simple techniques fail and the criteria are met for difficult BC (DBC). However, many endoscopists avoid or defer early NKP in favor of alternative, simpler techniques that have not been shown to be either safer or more effective. Our goal is to test a device that provides the needle-knife papillotome (NKPT) with traction capability and which can facilitate the learning and execution of NKP. Patients and methods This was a descriptive bicentric observational study of a personal cohort of patients undergoing early NKP to analyse the efficacy and safety of the technique with a “hybrid-tome” (HT) built using the isolated core of a NKPT and a conventional canulotome. Results Over a 4-year period, we performed 43 NKPs with the HT, achieving BC in one or two steps in all cases. The 100 % technical success was matched by a 95 % clinical success rate. We recorded 11 adverse events (23 %): five hemorrhages, four pancreatitis, and two cholangitis. In addition to the objective data, we confirmed that HT facilitates alignment with the duodenal papilla and the execution of pre-cutting, especially if the papilla is intradiverticular or hidden by folds. Conclusions The HT tested seems to help trained endoscopists to perform NKP, especially in some anatomic situations, which can improve compliance with the guidelines recommended for early NKP in patients with DBC.

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

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.

DIFFICULT BILIARY CANNULATION: SHOULD WE ALWAYS TRY A SECOND ERCP AFTER A FAILED NEEDLE-KNIFE FISTULOTOMY?

ABSTRACT BACKGROUND: A successful bile duct cannulation is a prerequisite for the realization of endoscopic retrograde cholangiopancreatography (ERCP). When biliary cannulation is not possible, needle-knife fistulotomy (NKF) can be performed. However, when biliary access is not successfully achieved even after performing NKF, it is possible to interrupt the procedure, and repeat the ERCP after a short interval. OBJECTIVE: The aim of this study is to analyze if repeating an ERCP after a short interval of 48 hours is effective in achieving biliary access after an initial NKF was unsuccessfully performed. METHODS: A total of 1024 patients with a naive papilla, that underwent ERCP between the years of 2009-2019, were retrospectively reviewed. Difficult biliary cannulation was identified in 238 of these cases and NKF was performed. Success of biliary cannulation, NKF success at the first and second ERCPs, the associations between the type of the papilla, biliary dilatation, and overall success of NKF and adverse events rates were evaluated. RESULTS: Biliary access was initially achieved in 183 (76.8%) cases. Of the 55 (23.1%) remaining cases a second attempt was performed after 48 hours, and biliary access was successfully achieved in 46 (83.6%) of them. The overall success of NKF after the first and second ERCP, the success rate was 96.2%. Papilla located out of its normal position was related to a minor chance of success at NKF (P<0.05). CONCLUSION: We conclude that when biliary access is not achieved after the performance of a NKF, a second attempt is safe and effective and should be attempted.

Developing a Needle-Knife Surgical Device

Introduction: Nowadays, a new era of orthopedic surgery is taking place. Procedures like video surgery, ultrasound-guided interventions, invasive pain interventions, orthopedic procedures, hydro dissection, dry needling, thermography-assisted pain management, and modern acupuncture started to be widely performed1,2. Background: In 2011 and 2012, Ravaglia & Cliquet presented papers on an Arthroscopic Needle-Knife Surgical Prototype Device (ANKSD)2 in Prague, TWC 20112, and in Dubai, OWC 20123. It was a paper presenting a prototype of a needle-knife for orthopedic procedures based on an 18G11/2 needle. Ravaglia and Cliquet wrote the paper “Comparison of two different needles used as knife on knee arthroscopic portal scalpel procedures”4, which was presented at the XXVI SICOT Triennial World Congress, in Guangzhou, China, in 2015. This research compares arthroscopic portal incisions using an 18G11/2 needle or a metal guide intravenous catheter 14Gx2. They concluded that there were no differences in complications such as infections, wound healing, hematoma, and skin healing time. After this, these researchers started a virtual development of a new needle-knife surgical device. Objective: The aim of the project is a virtual development of a needle-knife surgical device to be useful for minimally invasive ultrasound-assisted orthopedic surgical procedures, videos arthroscopic portals augmentation, and other surgical procedures. Method: Three different needle devices were compared. One is a base model 1 and the other two are experimental models (2 and 3). They are based on a metal guide for intravenous catheter 14Gx2''. The base one model 1 is the metal guide for intravenous catheter 14Gx2''; the experimental model 2 is a flat beveled edge, and experimental model 3 is a board bevel edge6,7,8,9,10,11,12,13,14,15,16. They are all graduated, parylene-coated, with a stop handle needle guard. The devices are multifunctional: Infusion, aspiration, and surgical sever.The devices were developed by 3D Design 3D STEP Standard Format, Catia V5 Format, and 2D Format Design and 3D Model. They were performed through simulation (Software Simulia Abaqus). They were biomechanically simulated with Virtual Biomechanical Strength Simulation17,18,19,20. The Strengths were assessed by Needle Strength Analysis (CAE Simulation)21.Results: For the displacement result, stiffness assessment, we have 7.48 mm for the baseline needle, 8.08mm for model 2, an increase of 8%, and for model 3 we have 7.75 mm, an increase of 3.6%. Conclusion: These devices seem suitable for echo-assisted orthopedic surgery interventions and other procedures according to virtual analysis. Further in vivo procedures shall be performed.