Transpancreatic Precut Sphincterotomy for Cannulation of Inaccessible Common Bile Duct

Abstract

Obstruction of the biliary tract can lead to severe complications. The common treatment of patients with biliary tract obstruction is the decompression by endoscopic procedures. However, cannulation of the common bile duct can be difficult under certain instances because of anatomical variations or obstruction at the biliary entrance level. Needle-knife or precut sphincterotomy has been described as technique to facilitate biliary access in patients with difficult bile duct cannulation. In the current study, we evaluated success and complication rates of a wire-guided transpancreatic precut technique at our hospital. Between January 2003 and June 2006, a total of 108 patients with jaundice but with inaccessible bile ducts using classic techniques (failed primary cannulation or failed needle-knife papillotomy) underwent a wire-guided transpancreatic precut sphincterotomy. Precuts were performed using a soft guide wire placed in the pancreatic duct without injection of contrast fluid into the pancreatic duct. We studied cannulation success and complications associated with postprocedural hospitalization. Bile duct cannulation was successful in 103 (95.4%) of the 108 patients. Five patients (4.6%) required a percutaneous transhepatic biliary drainage. In 108 patients, there were 12 patients (11.1%) with procedure-related complications including acute pancreatitis (n = 6) and bleeding (n=6). Four patients had a mild and transient pancreatitis (pain improvement after 2 days), 2 had severe pancreatitis that was reversible after 7 days of conservative treatment. In 4 cases, a blood transfusion (each with 2 erythrocyte concentrates) became necessary. Perforations and other severe procedure-related deaths did not occur. Transpancreatic precut sphincterotomy using a soft guide wire is a safe and effective procedure in patients with difficult bile duct access where classic sphincterotomy or needle-knife procedures fail.