Needle-knife Precut Sphincterotomy Research Articles

The "squeezing with forceps" method for emergency endoscopic removal of an impacted pancreatic stone in the papilla of a patient on antithrombotic therapy.

Endoscopic pancreatic sphincterotomy or needle-knife precut sphincterotomy is an essential procedure when removing a large impacted pancreatic stone in the papilla [1] [2] [3]. However, sometimes it is not feasible to perform such procedures, especially in emergency settings in patients receiving antithrombotic therapy. Herein, we report an alternative method that can be used for emergency endoscopic removal of an impacted pancreatic stone in the papilla of patients undergoing antithrombotic therapy.

Identification of risk factors involved in recurrence after common bile duct stone removal with ERCP: A retrospective observational study.

Recurrent stone detection is common after endoscopic treatment of common bile duct stones (CBDS). This study aimed to identify the risk factors for recurrence of CBDS.We retrospectively evaluated 14 patients who underwent endoscopic treatment for CBDS. Risk factors for single and multiple recurrent CBDSs were evaluated using logistic regression analysis.Endoscopic and needle-knife precut sphincterotomy was performed in 506 and 112 patients, respectively. There was 1 recurrence in 85 patients (13.8%), 2 recurrences in 23 patients (3.7%), and 3 recurrences in 9 patients (1.5%). According to the multivariate analyses, being older than 65 years (odds ratio [OR] 1.084, P = .000), concomitant heart disease (OR 2.528, P = .002), concomitant lung disease (OR 1.766, P = .035), a large common bile duct diameter (OR 1.347, P = .000), presence of cholelithiasis (OR 1.752, P = .018), stent (OR 1.794, P = .023), or T-tube placement in the common bile duct (OR 47.385, P = .000), and prolongation of the procedure (OR 1.037, P = .000) increased the risk of recurrence, while having undergone cholecystectomy due to gallstones (OR 1.645, P = .042). The mean stone diameter (P = .059), nitroglycerin use (P = .129), and periampullary diverticulum (P = .891) did not increase the risk of recurrent CBDS.The probability of multiple recurrences after the first recurrence of CBDS increased with age >65 years, concomitant heart/lung diseases, stent/T-tube placement in the common bile duct, a wide common bile duct (≥10 mm), and cholelithiasis.

Management of biliary diseases after the failure of initial needle knife precut sphincterotomy for biliary cannulation

Endoscopic retrograde cholangiopancreatography is not always successful even with needle knife precut sphincterotomy (NKPS). How to manage these patients with initial NKPS failure has not been well studied. We report the outcomes of patients who received endoscopic and non-endoscopic rescue treatment after the initial NKPS failure. During the 15 years from 2004 to 2018, 87 patients with initial NKPS failure received interval endoscopic treatment (IET group, n = 43), percutaneous transhepatic biliary drainage (PTBD group, n = 25), or bile duct surgery (BDS group, n = 19) were retrospectively studied. Compared with the PTBD group, the prevalence of choledocholithiasis was higher (69.8% vs. 16.0%, p < 0.001), and malignant bile duct stricture were lower (20.9% vs. 76.0%, p < 0.001) in the IET group. Furthermore, the IET group had a significantly longer time interval between the first and second treatment procedures (4 days vs. 2 days, p = 0.001), a lower technique success rate (79.1% vs. 100%, p = 0.021), and a shorter length of hospital stay (7 days vs. 18 days, p < 0.001). Compared to the BDS group, the only significant finding was that the patients in the IET group were older. Although not statistically significant, the complication rate was lowest in the IET group (7.0%) while highest in the BDS group (15.8%). Complications in the IET group were also mild, as compared with the other two groups. In conclusion, IET should be considered after initial failed NKPS for deep biliary cannulation before contemplating more invasive treatment such as BDS. PTBD may be the alternative therapy for patients with malignant biliary obstruction.

Causes and Countermeasures of Difficult Selective Biliary Cannulation: A Large Sample Size Retrospective Study.

Selective biliary cannulation is a difficult part of endoscopic retrograde cholangiopancreatography (ERCP). Therefore, endoscopists have focused on how to improve the cannulation success rate and reduce the postoperative complication rate. This study aims to provide practical advice on safe operation for endoscopists. Data from the ERCP database of our medical center from January 2008 to December 2017 were retrospectively reviewed. All patients underwent ERCP for the first time. Data pertaining to diseases, anatomic factors, difficult cannulation rates, cannulation success rates, and postoperative complication rates for various assistive cannulation techniques were analyzed by using the Pearson χ2 tests and Fisher exact tests. The difficult cannulation rate was 8.1%. The main influencing factors were benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy. The postoperative complication rates and overall cannulation success rates of 7 assistive techniques were not statistically different (P>0.05), but the overall complication rates were statistically different (P<0.05). Needle-knife precut sphincterotomy had the highest rate of complications. Benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy were the main factors of difficult selective biliary cannulation. The overall incidence of needle-knife precut sphincterotomy complications was higher than that of other techniques, but various assistive techniques were safe and effective in our single center.

Outcomes of precut sphincterotomy techniques in cases of difficult biliary access

GoalsOur study aims to define success and complication rates of precut sphincterotomy with the needle-knife and transpancreatic papillary septotomy (TPS) techniques as experienced at a single, high-volume endoscopy centre.BackgroundComplication rates...

Clinical effect of different methods for endoscopic precut sphincterotomy in difficult intubation during endoscopic retrograde cholangiopancreatography: A comparative analysis

Objective To investigate the clinical characteristics of different methods for endoscopic precut sphincterotomy in difficult intubation during endoscopic retrograde cholangiopancreatography (ERCP) . Methods A retrospective analysis was performed for the clinical data of 185 patients who underwent ERCP and precut sphincterotomy in The Second Affiliated Hospital of Kunming Medical University from May2015 to December 2018. According to the method for endoscopic precut sphincterotomy, these patients were divided into needle-knife precut sphincterotomy (NKP) group with 73 patients, needle-knife fenestration (NKF) group with 24 patients, transpancreatic precut sphincterotomy (TPS) group with 30 patients, and arch-knife precut sphincterotomy group (Erlangen group) with 58 patients. These four precut methods were analyzed in terms of advantages and disadvantages, influence on the success rate of intubation, and increase or reduction in complications. An analysis of variance was used for comparison of normally distributed continuous data between multiple groups, and the least significant difference t-test was used for comparison within each group; the Kruskal-Wallis H test was used for comparison of non-normally distributed continuous data between multiple groups, and the Nemenyi method was used for further comparison between two groups.The chi-square test was used for comparison of categorical data between multiple groups, and a logistic regression analysis was used to determine risk factors and perform a multivariate analysis. Results The NKF and TPS groups had a significantly higher success rate of intubation than the NKP group (both P 57 years (OR = 0. 094, 95% CI: 0. 028-0. 316, P 57 years (OR = 0. 065, 95% CI: 0. 017-0. 256, P < 0. 001) was an independent protective factor against the risk of PEP, while total time of operation (OR = 1. 040, 95% CI: 1. 007-1. 074, P = 0. 016) was an independent risk factor for PEP. Conclusion TPS may be safer and more effective than NKP and Erlangen under certain conditions. Age and total time of operation may influence the incidence rate of complications.

Application of needle-knife precut papillotomy in difficult common bile duct cannulation of endoscopic retrograde pancreatic duct radiography

Objective To investigate the effects and safety of needle-knife precut papillotomy in difficult common bile duct cannulation of endoscopic retrograde pancreatic duct radiography(ERCP). Methods The data of 104 cases treated with needle-knife precut papillotomy were retrospectively analyzed.The effect of pre incision and short-term complications were observed, and compared with 1326 cases(conventional group) of conventional selective intubation in the same period of ERCP. Results Successful cannulation of the bile duct was achieved in 97 of 104 patients who underwent needle-knife precut papillotomy, the total success rate was achieved in 93.3%.The complications of needle-knife precut papillotomy occurred in 8 patients(7.7%), including mild bleeding in 4 cases, mild pancreatitis in 2 cases and billiary infection in 2 cases.There were 1326 cases conventional selective intubation in the same period of ERCP, and 98 cases(7.4%) with complication.There was no significant difference in the incidence of complications between the needle knife cut group and the conventional selective intubation group(χ2=0.055, P>0.05 ). Conclusion In case of difficult common bile duct cannulation of ERCP, needle-knife precut sphincterotomy surgery can be safely and effectively catch the high -ERCP the success of treatment, is worthy of wider application. Key words: Endoscopic retrograde pancreatic duct radiography; Difficult common bile duct cannulation; Needle-knife precut papillotomy

Comparison of sequential pancreatic duct guidewire placement technique and needle knife precut sphincterotomy for difficult biliary cannulation

Pancreatic duct guidewire placement (PDGP) includes double guidewire technique (DGT) and transpancreatic sphincterotomy (TPS). DGT can be switched to TPS with ease due to the existing guidewire in the pancreatic duct. In this study, we aimed to combine DGT and TPS as a single technique, named sequential PDGP, and to compare its performance with needle knife precut sphincterotomy (NKPS) in treating difficult biliary cannulation (BC). A total of 83 patients with difficult BC were enrolled in this study. Of these, 63 underwent sequential PDGP and 20 underwent NKPS. Cannulation success rate, cannulation time and endoscopic retrograde cholangiopancreatography (ERCP)-related complications were prospectively recorded and compared between the two groups. Successful BC was achieved in 88.9% (56/63) of the patients in the sequential PDGP group compared with 70.0% (14/20) in the NKPS group (P = 0.095). Cannulation time was 7.49 ± 5.03 min in the sequential PDGP group and 10.60 ± 7.24 min in the NKPS group (P = 0.086). Post-ERCP pancreatitis occurred in 12.7% of patients in the sequential PDGP group and 10.0% in the NKPS group (P = 1.000). There was no significant difference in the rates of other complications (bleeding, perforation and cholangitis) between the two groups. Sequential PDGP is a safe and effective alternative method to NKPS in cases of difficult BC. In those with failed standard cannulation, sequential PDGP can be considered when the guidewire is inadvertently inserted into the pancreatic duct or can be placed in the pancreatic duct without difficulty.

Su1628 A Comparative Study of Strategies for Prevention of Post-ERCP Pancreatitis After Early Needle Knife Precut Sphincterotomy

Su1628 A Comparative Study of Strategies for Prevention of Post-ERCP Pancreatitis After Early Needle Knife Precut Sphincterotomy

A novel dry model for practicable sphincterotomy and precut needle knife sphincterotomy.

Aim. We aimed to develop a simulation dry model for endoscopic sphincterotomy (ES) and needle knife precut sphincterotomy (NKP) and to evaluate its usefulness as a training simulator. Materials and Methods. An endoscopic retrograde cholangiopancreatography trainer was used as a duodenum, bile duct, and papilla simulator. A simulated papilla was created with a piece of rolled uncured ham, and ES and NKP were performed. Hands-on training was carried out using this model, and success and failure of the procedures were evaluated. A questionnaire survey was conducted among the participants to assess the performance and usefulness of the dry model for ES and NKP training. Results. Twenty-two endoscopists participated in the hands-on training using this dry model. ES was successful in 33 out of 34 attempts (97%) whereas NKP was successful in all 7 attempts (100%). Based on the results of the questionnaire survey, the median score for realism was 7 (range: 2–9) for ES and 8 for NKP on a scale of 1 to 10. Conclusions. The dry model using an uncured ham provides a condition closely similar to actual clinical practice and is useful as a training model for ES and NKP.

Sphincterotomy of the Minor Papilla

Minor papilla sphincterotomy remains the mainstay of endoscopic therapy for symptomatic pancreas divisum and is also required when pancreatic therapy cannot be performed through the major papilla. Endoscopic sphincterotomy is technically feasible in 50–86% of patients, and can be performed by means of a pull-type or a needle-knife sphincterotome. The latter method has three variants: sphincterotomy over a pancreatic stent, wire-assisted access sphincterotomy, and needle-knife precut sphincterotomy. Although the complication rate of minor papilla endoscopic therapy ranges from 0% to 50%, with a post-endoscopic retrograde cholangiopancreatography pancreatitis rate ranging from 0% to 34%, minor papilla sphincterotomy provides high clinical response rates in patients with pancreas divisum and recurrent acute pancreatitis. Because of its technical difficulty and higher complication rate, minor papilla sphincterotomy should be performed only by expert endoscopists with experience in therapeutic pancreatic endoscopy. Technical details about minor papilla cannulation and sphincterotomy are provided in this article. This article is part of an expert video encyclopedia.

Precut needle-knife sphincterotomy in advanced endoscopy fellowship

Many advanced endoscopists finish their fellowship with very little training on how to perform needle-knife sphincterotomies. It has been described as a procedure not for the faint of heart and a technique that should not be substituted for lack of experience. I recently spoke to John Goff, creator of the transpancreatic septotomy technique, and asked for his thoughts on the subject. His reply was “know your anatomy, know when to stop, know when to regroup and when to try again the next day.” In this month's Fellows' Corner, Drs Anastassiades and Saxena share with us the tips and tricks of successful mastery of the needle-knife technique during advanced fellowship.

Endoscopic Biliary Access

Endoscopic Biliary Access

Sa1505 Needle-Knife Precut Sphincterotomy With a Small Incision Made Possible by Prior Pancreatic Stent Placement Reduces the Complication Rate in Difficult Biliary Cannulation

classified as a figure ‘V’ type in 208 patients with sharp angles between Ab with Ac, while classified as a figure ‘T’ type in 162 patients with right angle, and as a ‘Septal’ type in 39 patients in whom Ac was extremely short. 16 patients showed anomaly arrangement of pancreatico-biliary duct. Results: Classified by the orifice morphology, 307 patients were L/N in Mono group and 151 patients were D in Dual group (p 0.01). L/N would have Mono orifice, which has various bifurcations (OR 10.0). The patients with intra-papillary choledochocele were confirmed in 31 patients only in L/N. The numbers of patients who required MPD/GW assist in this study were 144 with L/N and 47 with D (p 0.01). The incidence of post ERCP pancreatitis (PEP) was 3.6% with L/N and 1.6% with D (p 0.25). Conclusion: Wire Guided Cannulation is popular in performing ERCP recently. However, it’s superiority by Radomized Controlled Studies has still proved controversial. Everyone agrees visible cannulation would promise to make sure the treatment. The reason why there are unexpected variations known for IPB such as figure ‘T’ and choledochocele especially with L/N. If Vater’s ampula would be recognized L/N, a minimal dose injection is recommended in order to visualize the intra-papillary anatomy. That allows achieving a safe and reliable ERCP to avoid PEP.

Failed biliary cannulation: Clinical and technical outcomes after tertiary referral endoscopic retrograde cholangiopancreatography

Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center. Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP. Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary cannulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identifiable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 naïve papilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or post-ERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017). Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.

T1525: Role of Needle Knife Precut Sphincterotomy and Repeated Cannulations of Vater's Papilla in the Occurrence of Post-ERCP Pancreatitis

precut technique is a validated risk factor for post-ERCP pancreatitis (PEP). However, it is unclear if the increased risk for pancreatitis is associated with technique itself or with difficult papillary cannulation, a manoeuvre that often anticipates precut sphincterotomy. The aim of this study was to evaluate the frequency of PEP using early precut technique during ERCP in a large single center series.

Needle-Knife Sphincterotomy for Biliary Cannulation

Conventional techniques for biliary cannulation are unsuccessful in 5% to 10% of patients. Although precut needle-knife sphincterotomy (NKS) can improve the cannulation success rate, this technique has been associated with increased morbidity, particularly postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Investigators examined the relationship between NKS and ERCP complications using data that were collected prospectively from two successive randomized ERCP trials involving 732 patients. PEP was …

Needle-knife sphincterotomy: factors predicting its use and the relationship with post-ERCP pancreatitis (with video)

In the absence of precut needle-knife sphincterotomy (NKS), failure of biliary cannulation may occur in up to 10% of cases. There are few prospective evaluations of the safety and efficacy of NKS, and studies of its early use in difficult cannulation have been inconclusive. Whether precut NKS after failure of primary biliary cannulation is independently associated with post-ERCP pancreatitis (PEP) remains controversial. To examine the relationship between NKS and PEP. Analysis of prospectively collected data from two randomized trials of ERCP techniques, with PEP as the primary endpoint measure. Tertiary-care academic medical center. This study involved 732 patients from two successive, prospective, randomized trials of naïve papilla cannulation between November 2001 and April 2006. Patients with pancreatic or ampullary cancer were excluded. Naïve papilla cannulation, NKS, primary guidewire versus contrast-assisted cannulation, and glyceryl trinitrate patch versus placebo. PEP and procedure-related complications. NKS was performed in 94 of 732 patients (12.8%) and was successful in achieving bile duct access in 80 of 94 patients (85%). Cannulation success in the entire group was 717 of 732 patients (97.7%). The overall frequency of PEP following NKS was 14.9% (14 of 94 patients) compared with 6.1% (39 of 638 patients) without NKS (P < .001). The incidence of PEP increased with an increasing number of attempts at cannulating the papilla. Pancreatic stents were inserted in 22 patients, 5 of whom developed pancreatitis. In multivariate analysis, independent predictors of PEP were as follow: female sex (odds ratio [OR] = 3.5, P = .028), suspected sphincter of Oddi dysfunction (SOD) (OR = 9.7, P < .001), partial pancreatic drainage (OR = 4.8, P = .011), 10 to 14 attempts at papilla cannulation (OR = 4.4, P = .031), and >/=15 attempts at papilla cannulation (OR = 9.4, P = .013). NKS was not an independent predictor of PEP. There were no perforations, no major bleeding, and no cases of severe pancreatitis in the NKS group. Nonrandomized for NKS intervention. The number of attempts at cannulating the papilla is independently associated with PEP, and the risk increases with an increasing number of attempts. NKS is not an independent predictor of PEP.

Effect of Precut Sphincterotomy on Biliary Cannulation Based on the Characteristics of the Major Duodenal Papilla

Therapeutic endoscopic retrograde cholangiopancreatography requires selective cannulation of the relevant ductal system. The aim of this study was to evaluate the efficacy and safety of 3 different precutting techniques for difficult bile duct access on the basis of the characteristics of the major duodenal papilla (MDP). The patients were classified into small MDP, large MDP, or swollen MDP groups on the basis of the characteristics of the MDP. The precutting technique was based on MDP characteristics: transpancreatic sphincterotomy for small MDPs, needle-knife precut sphincterotomy for large MDPs, and needle-knife fistulotomy for swollen MDPs. The success rate of bile duct cannulation and the complication rates were compared. A total of 86 patients (58 men; mean age, 76 years) with difficult bile duct cannulation required precutting technique; 48 had transpancreatic sphincterotomy, 30 had needle-knife precut sphincterotomy, and 8 had needle-knife fistulotomy. With precutting, the procedure was successful in 46 of 48 (96%), 27 of 30 (90%), and 8 of 8 patients (100%), respectively. The overall success rate of biliary cannulation after 2 endoscopic retrograde cholangiopancreatography attempts was 100%. The overall complication rate was 4.7% (4 of 86) (2 mild bleeding and 2 mild pancreatitis). Selection of the precutting technique on the basis of the characteristics of the MDP resulted in a high degree of success and a low complication rate in cases of difficult bile duct cannulation.

Risk for Post-ERCP Pancreatitis After Needle Knife Precut Sphincterotomy Following Repeated Cannulation Attempts

The aim of this study was to determine the risk and identify the factors associated with post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in patients who undergo needle knife precut sphincterotomy (NKS). In addition, we evaluated the effect of gabexate for the prevention of post-ERCP pancreatitis. NKS, after repeated cannulation attempts during ERCP, is known to increase the risk of post-ERCP pancreatitis. However, the specific risk factors for post-ERCP pancreatitis have not been identified, and the preventive role of protease inhibitors, such as gabexate, has not yet been established. The medical records of 200 patients who underwent NKS, after repeated cannulation attempts during ERCP, were reviewed retrospectively. The potential risk factors for post-ERCP pancreatitis were investigated. The effect of gabexate infused after the ERCP procedure was also evaluated. Thirteen (6.5%) patients out of 200 developed post-ERCP pancreatitis. Sex, age, the presence of pancreatitis at procedure, underlying disease, direction of the sphincterotomy, success or failure of cannulation after NKS, diameter of common bile duct, pancreatic duct status, and the presence of acinar filling were not associated with the risk of pancreatitis. Gabexate infusion after ERCP increased the incidence of ERCP-associated pancreatitis. We could not identify any risk factors associated with the development of post-ERCP pancreatitis in patients who underwent NKS after repeated cannulation attempts during ERCP. However, gabexate administered after the ERCP procedure was found to increase the incidence of pancreatitis.