Early institution of pre-cutting for difficult biliary cannulation: a prospective study comparing conventional vs. a modified technique

doi:10.1016/j.gie.2005.05.022

Gastrointestinal Endoscopy

Volume 62, Issue 5, November 2005, Pages 669-674

https://doi.org/10.1016/j.gie.2005.05.022 Get rights and content

Background

Pre-cutting techniques have been used to gain biliary access at the expense of an increased complication rate. This may be because of the multiple attempts to achieve cannulation by using standard methods before pre-cutting and causing excess edema and papillary trauma. There are limited data on the early use of pre-cutting techniques.

Methods

We performed a prospective study of the early introduction of needle-knife techniques in patients with difficult biliary cannulation. Standard biliary cannulation was attempted with a sphincterotome and a guidewire. If this failed within 10 minutes or if there were more than 5 pancreatic cannulations, the needle-knife technique was used. Either a standard method of pre-cutting (below-upward) from the papillary orifice or the modified technique of pre-cutting (above-downward), stopping short of the papillary orifice, was adopted, as per the discretion of the endoscopist. If pre-cutting failed, the cannulation was reattempted 24 to 48 hours later.

Results

A total of 346 therapeutic biliary ERCP procedures were performed between April and August 2003. Of these, 70 patients (20%) (mean age, 54 years; 38 men) underwent needle-knife pre-cut sphincterotomy (16 with the standard technique). In 58 patients (83%), the procedure was successful with the initial pre-cutting, making the total success at initial ERCP 334/346 (96.5%). Nine patients in whom pre-cut failed, returned for a second-attempt ERCP, with 7 completed successfully. The total success rate of pre-cutting was 65/70 (93%). The overall success rate of biliary cannulation, after two ERCP attempts, was 341/346 (98.5%). Six patients had mild bleeding, and one had mild pancreatitis. There was no difference in these complications between the two types of pre-cut techniques.

Conclusions

The early use of needle knife for difficult biliary cannulation is safe and effective, irrespective of the technique used.

Section snippets

Patients and methods

This is a single-blinded (patient only), prospective study assessing the success and the complication rates of pre-cut techniques, instituted early in difficult biliary cannulation. Consecutive consenting patients referred for therapeutic ERCP between April 2003 and August 2003 were included in the study. All cases were commenced with a standard double-lumen sphincterotome preloaded with contrast. If required, a guidewire was used to aid biliary cannulation. If biliary access failed after 10

Results

Between April 2003 and August 2003, we performed 346 therapeutic biliary ERCP procedures. Of these, needle-knife pre-cut to access the biliary tree was performed in 70 patients (20%). The mean age (range) for the entire group was 54 years (25-87 years), with 38/70 being men.

The type of needle-knife cut and the indications for therapeutic ERCP are outlined in Table 1.

Potential contributing factors to failed biliary cannulation included a periampullary diverticulum in 10, malignant infiltration

Discussion

“Pre-cut” was first introduced by Siegel² and later was popularized by Huibregtse and Soehendra.3, 4 Subsequently, two kinds of specialized accessories have become available for pre-cut, namely the short-nosed Erlangen-type sphincterotome designed by Soehendra⁴ and the needle-knife papillotome designed by Huibregtse.³ The application of these techniques has been criticized because of the high complication rates documented in some series.

However, most of the criticisms regarding higher

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Modified double-guidewire technique using a unique double-lumen sphincterotome for difficult biliary cannulation
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Early precut versus primary precut sphincterotomy to reduce post-ERCP pancreatitis: randomized controlled trial (with videos)
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Precut sphincterotomy, usually performed after prolonged and failed cannulation, is considered a risk factor for post-ERCP pancreatitis (PEP). There are limited studies on primary needle-knife precut for the prevention of PEP. The aim of this study was to assess the safety and efficacy of primary precut.
A randomized controlled trial was conducted in a tertiary care setting on patients who underwent ERCP. Patients were randomized to very early precut (group A, precut after 2 failed attempts of wire-guided sphincterotome cannulation) and primary precut (group B, direct needle-knife precut). All procedures were done by an experienced endoscopist. The primary outcome of the study was to compare the incidence of PEP between the 2 groups.
Three hundred three patients were randomized to group A (n = 152, age 48.2 ± 15.4 years, 61 men) and group B (n = 151, age 46.7 ± 13.8 years, 65 men). There was no significant difference in baseline characteristics and indications for ERCP between the 2 groups. Development of PEP (5.2% vs .67%; P = .04) and asymptomatic hyperamylasemia (12.5% vs 2.6%; P = .01) were lower in group B compared with group A. The bile duct cannulation time (13.8 ± 2.2 vs 7.2 ± 1.7 minutes; P = .001) was lower in group B, whereas the overall cannulation success rate (98% vs 98.6%; P = 1.0) was similar in both the groups.
Primary precut by an experienced endoscopist results in low risk of PEP. (Clinical trial registration number: CTRI/2017/08/009510.)
Management of difficult or failed biliary access in initial ERCP: A review of current literature
2019, Clinics and Research in Hepatology and Gastroenterology
Selective bile duct cannulation is the prerequisite for all endoscopic biliary therapeutic interventions, but this cannot always be achieved easily. Despite advances and new developments in endoscopic accessories, selective biliary access fails in 5%–15% of cases, even in expert high volume centers. Various techniques – such as double-guidewire induced cannulation, pre-cut papillotomy or transpancreatic sphincterotomy with or without placement of a pancreatic stent – have been used to improve cannulation success rates. Repeated and prolonged attempts at cannulation increase the risk of pancreatitis. Repeating the ERCP within a few days after initial failed pre-cut is a successful strategy and should be tried before contemplating more invasive, alternative interventions such as percutaneous-endoscopic or endoscopic ultrasound guided rendezvous procedure, percutaneous transhepatic or surgical intervention. However, standard guidelines or sequential protocol has not been existed up to now. In certain circumstances, there are unique clinical indications for which invasive, alternative interventions should be preferred. We present and discuss the methods that can be used in difficult or failed initial ERCP, therefore to provide practical advice for endoscopists, especially those who are inexperienced.
Comparison of efficacy and safety of transpancreatic septotomy, needle-knife fistulotomy or both based on biliary cannulation unintentional pancreatic access and papillary morphology
2019, Hepatobiliary and Pancreatic Diseases International
Citation Excerpt :
Furthermore, the recent study suggests that it appears to be effective and safe to perform a second ERCP on patients with initial failure of biliary cannulation more than 4 days after precutting if feasible [1]. The overall success rate of biliary cannulation in our study compares favorably to those reported in other studies with TPS, NKF or both for precutting [12–16,20,29]. The high success rates of biliary cannulation reflect the efficacy of the precut strategy depending on whether inadvertent pancreatic duct cannulation occurred combined with the papillary morphology.
Precut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography (ERCP). However, scarce data are available on different precut techniques for difficult biliary cannulation. This study aimed to evaluate the efficacy and safety of transpancreatic septotomy (TPS), needle-knife fistulotomy (NKF) or both based on the presence of unintentional pancreatic access and papillary morphology.
Between March 2008 and December 2016, 157 consecutive patients undergoing precutting for an inaccessible bile duct during ERCP were identified. Precut techniques were chosen depending on repetitive inadvertent pancreatic cannulation and the papillary morphology. We retrospectively assessed the rates of cannulation success and procedure-related complications among three groups, namely TPS, NKF, and TPS followed by NKF.
The baseline characteristics of the three groups were comparable. The overall success rate of biliary cannulation reached 98.1%, including 111 of 113 (98.2%) with TPS, 35 of 36 (97.2%) with NKF and 8 of 8 (100%) with NKF following TPS, without significant difference among groups. The incidences of total complications and post-ERCP pancreatitis were 9.6% and 7.6%, respectively. There was a trend towards less frequent post-ERCP pancreatitis after NKF (0%) compared with 11 cases (9.7%) after TPS and one case (12.5%) after NKF following TPS, but not significantly different (P = 0.07). No severe adverse event occurred during this study period.
The choice of precut techniques by the presence of unintended pancreatic access and the papillary morphology brought about a high success rate without increasing risk in difficult biliary cannulation.
Difficult Cannulation and Sphincterotomy
2019, Clinical Gastrointestinal Endoscopy
Endoscopic retrograde cholangiopancreatography (ERCP) requires several years of dedicated training and continuous refinement of knowledge and skill. With the dissemination of endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP), ERCP has evolved from a diagnostic to an almost purely therapeutic procedure. General issues on cannulation have already been highlighted in Chapter 40. This chapter concentrates on variations of standard techniques to overcome challenges to standard cannulation and sphincetrotomy, including in patients with anatomic variations, gastric outlet obstruction, and surgically altered anatomy.
Emergency endoscopic needle-knife precut papillotomy in acute severe cholangitis resulting from impacted common bile duct stones at duodenal papilla
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In our study, the success rate of NKPP and CBD cannulation was 100%. The total complication rate was 4.2% (5/118), with two cases of hemorrhage and three of acute pancreatitis, which did not differ significantly from the literature [14–16,18,19]. There was no procedure-related mortality.
To evaluate the efficacy and safety of emergency endoscopic needle-knife precut papillotomy in acute severe cholangitis resulting from impacted common bile duct stones at duodenal papilla.
Between January 2010 and January 2015, 118 cases of acute severe cholangitis with impacted common bile duct stones at the native papilla underwent emergency endoscopic retrograde cholangiopancreatography (ERCP) and early needle-knife precut papillotomy in a tertiary referral center. Precut techniques were performed according to the different locations of stones in the duodenal papilla. Clinical data about therapy and recovery of the 118 patients were recorded and analyzed.
One hundred and eighteen patients underwent emergency ERCP within 24 h after hospitalization, with a total success rate of 100%. The mean operating time was 6.4 ± 4.1 min. Postoperative acute physiology and chronic health evaluation (APACHE) II scores, white blood cell count and liver function improved significantly. The complication rate was 4.2% (5/118); two with hemorrhage and three with acute pancreatitis. There was no procedure-related mortality.
Emergency endoscopic needle-knife precut papillotomy is effective and safe for acute severe cholangitis resulting from impacted common bile duct stones at the duodenal papilla.

View all citing articles on Scopus

: Meeting presentation at Australian Gastroenterology Week, October 7-10, 2003, Brisbane, Australia (J Gastroenterol Hepatol 2003;18[suppl]: B47).

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Original ArticleEarly institution of pre-cutting for difficult biliary cannulation: a prospective study comparing conventional vs. a modified technique

Background

Methods

Results

Conclusions

Section snippets

Patients and methods

Results

Discussion

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

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Gastrointest Endosc

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Am J Gastroenterol

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Original Article
Early institution of pre-cutting for difficult biliary cannulation: a prospective study comparing conventional vs. a modified technique