Needle-knife Sphincterotomy Research Articles

What is the factor of post ERCP pancreatitis for cannulation by trainees in naïve papilla

Access to the pancreatic or the bile duct is paramount to the success of diagnostic and therapeutic ERCP. Selective cannulation may be difficult because of the small size of the papilla and anatomic factors such as peripapillary diverticulum and gastrectomy with Billroth-II anastomosis. Currently, one of the techniques for gaining access in such cases is the pre-cut technique with a catheter that has a thin wire at the tip (needle knife). A less well-described pre-cut technique involves initial cannulation of the pancreatic duct with a “traction-type” papillotome and then incision through the “septum” toward the bile duct. The aim of this randomized trial was to compare the success and the complication rates of needle-knife sphincterotomy and transpancreatic sphincterotomy in achieving cannulation of an otherwise inaccessible bile duct.Sixty-three consecutive patients with inaccessible bile ducts underwent pre-cut sphincterotomy either by needle-knife sphincterotomy (n = 34) or transpancreatic septotomy (n = 29). In patients with an accessible pancreatic duct who undergo needle-knife sphincterotomy, a short (2-3 cm) stent (5F-7F) was placed in the pancreatic duct to act as a guide and to reduce the risk of post-procedure pancreatitis. All patients were hospitalized overnight for observation after pre-cut sphincterotomy. The outcomes measured were success rate and complications. Indications for pre-cut sphincterotomy were the following: suspected choledocholithiasis, 11 patients (17.5%); obstructive jaundice with negative CT findings, 19 patients (29.2%), or with positive CT findings, 13 patients (20.6%); abdominal pain with elevated biochemical tests of liver function, 15 patients (23.8%); and miscellaneous, 5 patients (7.9%).In 55 of 63 (87%) patients, the bile duct was selectively cannulated after pre-cut sphincterotomy. On a pre-protocol basis, the bile duct was cannulated in 29 of 29 (100%) patients randomized to transpancreatic septotomy sphincterotomy and 26 of 34 (77%) patients who underwent needle-knife sphincterotomy (p = 0.01). There were 7 complications, including bleeding (n = 2) and acute pancreatitis (n = 5). Complications were less frequent in the transpancreatic septotomy sphincterotomy group (1/29; 3.5%) compared with the needle-knife sphincterotomy group (6/34; 17.7%).Transpancreatic pre-cut sphincterotomy can be performed with a high degree of success in patients with inaccessible obstructed bile ducts. Compared with standard needle-knife sphincterotomy, transpancreatic septotomy sphincterotomy has a significantly higher rate of bile duct cannulation and a lower complication rate.

A modern approach to ERCP: maintaining efficacy while optimising safety.

Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging and complications such as post-ERCP pancreatitis (PEP) remain a concern. Modern ERCP techniques aim to maintain efficacy and improve safety. There are limited data regarding efficacy and safety of ERCP carried out by a newly qualified practitioner using modern techniques. The aim of the present study was to conduct an ERCP practice audit and compare it with an Australian national survey in order to review the evidence base underlying modern ERCP practice. All ERCP carried out by a newly qualified practitioner, using prospectively collected data, from September 2011 to May 2015, were audited. Outcomes were compared to an Australia-wide survey of ERCP practice. A literature review was carried out regarding recent developments in ERCP practice. Audit results correlated well with national data. All 478 ERCP were therapeutic and had pre-procedure imaging. Wire-guided biliary cannulation was used. Success rate was 97%. Overall adverse-event rate was 0.8%. Choledocholithiasis was the predominant indication (72%). Biliary cannulation was successful in 338 of 348 naiive papillae. Of these, there were 53 (16%) difficult cannulations but the needle-knife sphincterotomy (NKS) rate was low compared to national data (13% vs 33%). Rate of dual-wire cannulation technique was higher (87% vs 30%). Pancreatic duct stenting (done in 32 cases [70% of dual-wire cannulation cases]) and rectal indomethacin (25%) were used to reduce PEP risk. A newly qualified ERCP proceduralist achieved high success rates with minimal adverse events using modern techniques. Practice was consistent with national data, although dual-wire cannulation technique was preferred to NKS. Evidence base for modern ERCP techniques was reviewed. ERCP efficacy and safety should be monitored by practice audit.

Current situation of endoscopic biliary cannulation and salvage techniques for difficult cases: Current strategies in Japan.

In the pancreatobiliary session at Endoscopic Forum Japan (EFJ) 2015, current trends of routine biliary cannulation techniques and salvage techniques for difficult biliary cannulation cases were discussed. Endoscopists from nine Japanese high-volume centers along with two overseas centers participated in the questionnaires and discussion. It was concluded that, currently, in Western countries, the wire-guided cannulation (WGC) technique is favored during initial cannulation attempts. However, the conventional technique using an endoscopic retrograde cholangiopancreatography catheter with contrast medium injection is still used as first choice at most Japanese high-volume centers. The WGC technique is used as the second choice at some institutions only. After failed biliary cannulation attempts, the initial salvage option preferred in most centers includes pancreatic guidewire placement, followed by precut techniques as the second salvage choice. Among several precut techniques, the free-hand needle knife sphincterotomy with cutting upwards from the pancreatic duct is most popular. Endoscopic ultrasonography-guided rendezvous technique is also carried out as a final salvage option at select institutions.

Diffuse intestinal pneumatosis after an Endoscopic Retrograde Cholangiopancreatography: A paradigmatic case for an old pathogenetic dilemma

[1] Sezgin O, Tezel A, Sahin B. Limited duodenal pneumatosis during needle-knife sphincterotomy. Endoscopy 1999;31:S54. An 83 year-old man with severe jaundice due to an advanced ancreatic adenocarcinoma was referred to our hospital to undergo ndoscopic Retrograde Cholangiopancreatography (ERCP). In his ast history a chronic bronco-pulmonary obstructive disease COPD) was present. At admission he was in poor general condition resenting signs of malnutrition (albumin 1.8 g/dl). Before ERCP the atient experienced transient hypotension requiring colloid infuion and etilefrine chloride administration. Sphincterotomy and tent placement allowed biliary drainage. Few hours after ERCP he patient complained of abdominal pain, vomiting and hypotenion. Duodenal perforation was suspected and a CT-scan showed a iffuse intestinal pneumatosis (IP) from the esophagus to the jejual walls (Fig. 1) associated with severe gastric dilation. Gastric ecompression, antibiotics and 48-hours of bowel rest led to partial ymptoms relief. After 24 hours a CT-scan showed complete IP reslution (Fig. 2) but progressive renal failure occurred. The patient ied for the consequences of multi-organ failure.

Su1631 Needle-knife Sphincterotomy vs. Guidewire-Assisted Transpancreatic Sphincterotomy for Difficult Biliary Cannulation

Needle-knife sphincterotomy (NKS) is a commonly used precut technique for difficult biliary cannulation. Guidewire-assisted transpancreatic sphincterotomy (GATS), as an alternative method for bile duct entry when conventional biliary cannulation failed, has been debated on its success rate of cannulation and its complications, such as increased incidence of pancreatitis. This study was aimed to compare success rate, and complications of NKS and GATS for difficult biliary cannulation.

Endoskopik yöntemle tedavi edilen bir duodenal duplikasyon kisti olgusu

Ondokuz yafl›nda genç bayan hasta tekrarlayan kar›n a¤r›s› flikayeti ile bafl-vurdu. Abdominal ultrasonografi ve tomografi tetkikleri sonucunda duode-num 2. ve 3. k›s›mlar› aras›nda 3 cm'lik bir duplikasyon kisti tespit edildi. Bu nadir hastalık için iki ayrı seansta endoskopik sfinkterotomi ve snare polipektomi yöntemleri başarı ile uygulandı

Early 'shallow' needle-knife papillotomy and guidewire cannulation: an effective and safe approach to difficult papilla.

Needle-knife sphincterotomy (NKS), known as 'precut', is used worldwide to facilitate access to the common bile duct when standard cannulation has failed. This procedure is considered hazardous because it is burdened with high procedural related complications (bleeding and perforation). Its right timing is still debated. In this study we report our results using a modified precut approach, early shallow needle-knife papillotomy (eSNKP) coupled with guidewire cannulation in case of difficult papilla. We evaluated its safety and effectiveness. From 2012 to 2014, 1034 patients underwent therapeutic ERCP. A total of 138 of them presented difficult papilla and were treated with eSNKP performed after 5 failed attempts of standard guidewire cannulation. Deep biliary cannulation rate was recorded, as well as intraoperative and postoperative complication rate. Successful biliary deep cannulation was achieved in 132/138 patients (95.7%) by means of eSNKP. In 6 patients (4.3%), cannulation failed even after eSNKP. ERCP was newly performed 72 hours later with successful and immediate guidewire biliary cannulation. Overall morbidity was 10.1% (14/138). No perforation occurred. Minor bleeding occurred in 4/138 cases (2.9%) and 10/138 patients (7.2%) developed mild pancreatitis. In case of difficult papilla, eSNKP followed by guidewire cannulation increases the successful deep biliary cannulation with low rate of complications.

Endoscopic Needle Knife Sphincterotome-an Alternative for Retrieval of an Entrapped Nasogastric Tube.

Knowledge of the use of a nasogastric tube (NG) is integral in medical practice as a whole and more so in gastrointestinal diseases because of its wide range of uses. Accidental fixation of the nasogastric tube during surgery is a rare complication. Various methods have been described for retrieval of an entrapped, retained or stapled nasogastric tube. We describe here a novel technique in which an endoscopic needle knife sphincterotome using a side-view endoscope was used successfully to cut the knots and release the entrapped NG tube. Although stress should always be laid on prevention, the flexible endoscopic approach is a small-duration procedure, a minimally invasive, cost-effective technique for the removal of a nasogastric tube that avoids the need of redo surgery and unnecessary exposure to anaesthesia.

A Novel Round Insulated Tip Papillotome as an Alternative to the Classic Needle-Knife for Precut Sphincterotomy in Endoscopic Retrograde Cholangiopancreatography.

Objective. The purpose of this study was to investigate the efficacy and safety of a new round insulated tip papillotome (r-ITP) as compared to that of the classic needle-knife sphincterotome (NKS) in difficult-to-cannulate endoscopic retrograde cholangiopancreatography (ERCP) patients. Materials and Methods. Patients with no exclusion criteria and an intact papilla referred for ERCP were invited to participate in the study. “Difficult-to-cannulate” patients, defined as failure to achieve deep biliary cannulation within five minutes from the first touch of papilla, with no more than ten attempts permitted, were randomly assigned for precut sphincterotomy using either the classic NKS or r-ITP. Results. Seventy and 69 patients were randomly assigned to the NKS and r-ITP groups, respectively. The groups were comparable regarding age, sex, indications, and associated conditions. There was no statistically significant difference in terms of successful cannulation or post-ERCP complications between the two groups. Only five patients (3.6%) developed mild to moderate post-ERCP pancreatitis and two had mild bleeding. No perforations or deaths were encountered. Conclusions. Although the round insulated tip papillotome was not shown to be superior to the classic NKS concerning efficacy and safety when used by an experienced endoscopist, it remains a simple, safe, and efficacious alternative.

Double Wire-Guided Technique Improves Biliary Cannulation Rates in Difficult ERCP: 3-Year Experience

Introduction: Post-ERCP complications increase with repeated attempts at cannulation. We aimed to evaluate a number of advanced biliary cannulation techniques when standard approach fails. Methods: One thousand four hundred fifty-four consecutive patients underwent ERCP between May 2010 and July 2013 at our institution; their medical records were evaluated for demographic data, procedure indication, biliary cannulation technique used, cannulation success rate, and complications. Guidewire-assisted (GA) cannulation with no contrast injection until deep biliary cannulation was considered a standard technique. Double wire-guided (DWG) cannulation, transeptal papillary septotomy (TPS), and/or needle knife sphincterotomy (NKS) were considered advanced biliary cannulation techniques. In DWG cannulation, the bile duct is cannulated alongside a wire placed in the pancreatic duct (PD), using PD wire as a guide. In TPS-assisted biliary cannulation, a partial septotomy is performed after sphinctertome is introduced into the common channel of the papilla. Sphinctertome is then reintroduced and GA cannulation reattempted. A stepwise approach was applied: when standard technique failed, DWG cannulation was usually attempted first if PD wire was in place; if that failed, TPS or NKS was performed. Alternatively, TPS or NKS were performed alone. Results: The overall biliary cannulation success rate was 99.2% (1442/1454). Advanced techniques were used in 10% (150/1454) cases, with a 92% (138/150) success rate. Alone DWG technique was used in 69/150, TPS alone in 18/150, and NKS alone in 41/150; multiple techniques were used in 22/150. Overall DWG technique was applied in 90/150 procedures. Most common indication for ERCP requiring advanced techniques was jaundice secondary to stone disease or malignancy; average age was 50 years; 995/459 were female/male. DWG cannulation was successful in 76% (68/90). TPS was then used in 17/22 cases where DWG technique failed, and resulted in 94% (16/17) successful biliary cannulation. TPS alone was successful in 83% (15/18) cases; success rate of NKS alone was 85% (35/41). There was a trend towards increased use of TPS in the last 2 years reviewed. The overall rate of post-ERCP pancreatitis was 0.7% (6/1454), and all cases were mild. One case of pneumoperitoneum occurred after NKS and was treated conservatively. Of the 12 patients who failed advanced techniques on the first attempt, 4 were successfully cannulated with standard technique during repeat procedure. Conclusion: In our experience, the proposed stepwise approach to biliary cannulation using the double wire-guided technique is both safe and effective.

Guidewire-assisted transpancreatic sphincterotomy for difficult biliary cannulation: a prospective randomized controlled trial.

Precut techniques have been used to facilitate biliary cannulation during difficult endoscopic retrograde cholangiopancreatography. Presently, needle-knife sphincterotomy (NKS) is a commonly used precut technique. Since its first description, transpancreatic sphincterotomy, as an alternative method for bile duct entry when conventional biliary cannulation failed, has been debated on its success rate of cannulation and its complications, such as increased incidence of pancreatitis. Guidewire techniques are another effective method to improve the success rate of selective bile duct cannulation. This is a single-center prospective randomized controlled trial aimed to compare success rate, cannulation time, and complications of guidewire-assisted transpancreatic sphincterotomy (GATS) and NKS for difficult biliary cannulation. Between July 2010 and October 2013, consecutive patients who failed in the standard biliary cannulation were randomly assigned to the GATS and NKS groups. The outcome measures included success rate, cannulation time, and complications. A total of 149 patients were enrolled and analyzed: 73 in the GATS group and 79 in the NKS group. The characteristics of the 2 groups were similar. Bile duct cannulation was successful in 70 patients (95.9%) in the GATS group and 64 (84.2%) in the NKS group (P=0.018). The median cannulation time spent in precut was 193 seconds in the GATS group and 485 seconds in the NKS group (P<0.001). There was no difference between the groups for the incidence of complications, pancreatitis, and hemorrhage (9.6% vs. 10.5%, 6.8% vs. 6.6%, 1.4% vs. 3.9%, respectively). No perforation occurred. GATS compared with NKS increases biliary cannulation rate and requires less cannulation time during difficult biliary access. This technique is not associated with an increased risk for complications. It seems to be an effective and safe alternative for biliary access during difficult endoscopic retrograde cholangiopancreatography.

Needle Knife Sphincterotomy for Biliary Access at ERCP: Experience At Two United States Academic Tertiary Referral Centers

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a highly effective modality for the management of various panctreaticobiliary disorders. Cannulation of the desired duct is an essential first step towards a successful ERCP. Standard methods of biliary cannulation have been reported to fail in 15-20% of cases. When conventional methods fail, a needle knife or access sphincterotomy (NKS) can be used to achieve bile duct access. Our goal was to evaluate the overall success and complication rates associated with NKS at our institutions, including those cases that were referred after primary biliary cannulation failure at other institutions. Methods: Retrospective review of all patient records where NKS was performed as part of the ERCP procedure at the University of Rochester Medical Center (URMC) and at Geisinger Health System between 4/30/2003 and 5/15/2014 (n=611). Billing records and ERCP databases were used to acquire relevant information. Initial biliary cannulation was attempted using standard techniques; if unsuccessful, a NKS was performed to achieve deep biliary cannulation. In some cases, a pancreatic duct stent was placed before the use of NKS. Results: In 611 patients where NKS was performed during ERCP, the initial success rate for deep biliary cannulation was 85.1%. Repeat ERCP attempt within 7 days resulted in an overall success rate of 93%. There were a total of 48 complications (7.9%): 33 post-ERCP pancreatitis (5.4%), 9 post-sphincterotomy bleeds (1.5%), 4 perforations (0.7%), 1 hepatic abscess (0.2%), and 1 pneumothorax (0.2%). All complications were managed non-surgically. There were no deaths directly associated with the ERCP or NKS procedures. For those patients who were referred after initial failed ERCP at an outside institution and who underwent NKS (n=55), the overall success rate of biliary cannulation was 92.7%. The complication rate in this group was 7.3% (2 post-ERCP pancreatitis, 1 bleed, 1 perforation). In those patients where a pancreatic duct stent was placed prior to NKS (n=159) compared to those with no stent placed (n=452), there was higher rate of overall success rate (96.9% vs. 91.6 %; p=0.03). The overall complication rate for the pancreatic stent group was 10.7% and, for those without pancreatic stent placement was 6.9% (p=0.12). Conclusion: In patients who undergo ERCP at a tertiary referral center, NKS is highly effective with an acceptable complication profile. This is true even in patients where biliary access has previously failed at an outside institution. The use of pancreatic duct stent placement prior to NKS does improve overall biliary cannulation rates without significantly impacting the risk of complications.

Needle-knife sphincterotomy over a pancreatic stent (NKPS) in difficult biliary cannulation but incidental selective pancreatic duct (PD) cannulation

Needle-knife sphincterotomy over a pancreatic stent (NKPS) in difficult biliary cannulation but incidental selective pancreatic duct (PD) cannulation

Su1728 Needle Knife Sphincterotomy for Biliary Access At ERCP: a Tertiary Referral Center Experience

Su1728 Needle Knife Sphincterotomy for Biliary Access At ERCP: a Tertiary Referral Center Experience

Endoscopic papillary large balloon dilation for the retrieval of bile duct stones after prior Billroth II gastrectomy

Background/Aims:Endoscopic retrieval of large common bile duct (CBD) stones is often difficult in patients who have undergone Billroth II gastrectomy, as anatomic alterations may present technical barriers to successful cannulation and increase procedure-related complications. Endoscopic papillary large balloon dilation (EPLBD) can be an alternative technique for the removal of difficult stones. Accordingly, the aim of this study was to evaluate the safety and effectiveness of EPLBD for CBD stone extraction in patients with Billroth II gastrectomy.Materials and Methods:From July 2006 to November 2011, 30 patients who underwent EPLBD with limited endoscopic sphincterotomy (EPLBD + ES) or EPLBD alone for the treatment of large CBD stones (≥10 mm) after Billroth II gastrectomy were retrospectively reviewed. A large balloon dilator (12-18 mm) was used to dilate the ampullary orifice.Results:Selective cannulation was successful in 25 patients (83.3%) with a standard catheter. Of the 30 subjects, EPLBD + ES was performed in 19 and EPLBD alone in 11. The mean bile duct diameter was 17.7 ± 4.3 mm (range, 11-31 mm), and mean size of balloon dilation was 14.5 ± 2.6 mm (range, 12-18 mm). Stone removal was successfully completed in 29 patients (96.7%). Successful stone retrieval during the first session was achieved in 27 patients (90.0%). Two cases (6.7%) of mild pancreatitis responded to conservative treatment, and no perforation or mortality was encountered.Conclusions:EPLBD with or without needle knife (NK) sphincterotomy seems to be a safe and feasible modality for CBD stone retrieval in patients with prior Billroth II gastrectomy.

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.

Needle Knife Sphincterotomy and the Risk of Post-ERCP Complications: A Tertiary Center Experience

Purpose: Endoscopic retrograde cholangiographic pancreatography (ERCP) is successful in 90% of patients to achieve biliary cannulation. Needle knife sphincterotomy (NKS) has been advocated in patients which routine cannulation is not possible. Our aim was to evaluate the efficacy of cannulation and complication risk of NKS in our institution. Methods: Retrospective analysis of 706 ERCPs in which NKS was performed from 2001-2011. The cannulation was accomplished with a guide wire and NKS was used in difficult cases to gain access into the biliary duct. If the primary cannulation failed, and the wire went only into the pancreatic duct, pancreatic sphincterotomy was performed and pancreatic duct stent was placed. Results: A total of 706 patients required NKS in our cohort of which 614 (86.9%) had successful biliary cannulation. A total of 318 (45%) patients had pancreatic duct stent placed prior to NKS. In our cohort of patients who underwent NKS, post-ERCP pancreatitis (PEP) was diagnosed in 57, perforation in 6 (0.8) and bleeding in 46 (6.5%) patients. In patients with unsuccessful NKS, the risk of PEP with and without a pancreatic duct stent placement was 12.7% and 6.7% respectively. (P=0.67) In patients with successful NKS with biliary cannulation, the risk of PEP with and without a pancreatic duct stent placement was 9.6% and 6.4%, respectively. (P=0.60) Also, the risk of developing any complication in the successful NKS group did not differ in patients with and without a pancreatic duct stent placed. (14% vs. 11.1%, P=0.56) Conclusion: In patients with failed primary cannulation, NKS is successful in achieving biliary access in most patients. The use of a pancreatic duct stent prior to NKS did not appear to impact the risk of complications

Use of Needle Knife and Post-sphincterotomy Bleeding in Advanced Endoscopy Training

Background: The ACG/ASGE Quality in Endoscopy Taskforce recognizes that adverse events are inherent in the performance of ERCP and calls for continuous quality improvement in ERCP programs. Sphincterotomy, a part of the ERCP core curriculum for trainees, may be associated with bleeding complications. Aims: To study factors associated with post-sphincterotomy bleeding (PSB) during advanced endoscopy fellowship training. Methods: Retrospective case series at a tertiary academic center. Patients who underwent ERCP in the academic year 2011-2012 were identified. Cases complicated by PSB were included. Clinical and endoscopic variables were collected. Factors associated with bleeding were explored. Results: Three hundred fifty ERCP procedures were reviewed. Eleven PSB cases were identified. Demographics: 64% female; mean age 63; 73% inpatients. Clinical characteristics: jaundice was the most frequent indication (45%); coagulopathy was present in 27%; 55% were on antiplatelet and/or anticoagulant agents; 27% required ICU stay; rebleeding occurred in two patients (18%); mean number of packed red blood cell units transfused was two; mean hospital stay was 6 days. Technical characteristics: pre-cut needle knife sphincterotomy was performed in 45%; a trainee participated in 91% of PSB cases and in 100% of bleeding cases involving a needle knife; 73% of bleeding cases occurred in the first 6 months of the academic year; immediate bleeding occurred in 55%. Initial endoscopic hemostasis was successful in all cases, and involved epinephrine injection monotherapy in 4 of 11 patients (36%); epinephrine injection and heater probe therapy in four patients (36%); epinephrine injection and clip placement in one patient (9%); and triple combination therapy with epinephrine injection, heater probe, and clip placement in two patients (18%). One of two patients with rebleeding was treated with epinephrine injection and heater probe therapy, and the other patient with epinephrine injection, heater probe, and clip placement. Rescue IR intervention was required in one patient but failed. Hemostasis was achieved on third endoscopy with temporary biliary stent placement. Biliary cannulation and therapeutic ERCP intervention was successful in 100%. Conclusion: The performance of pre-cut needle knife sphincterotomy was a frequent technical factor in post-sphincterotomy bleeding during 1 year of advanced endoscopy training. This technique remains a high-risk procedure. The use of needle knife sphincterotomy by trainees warrants careful monitoring and the development of effective training methods to teach this technique.

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.

Combined precut in difficult biliary cannulation

precut sphincterotomy refers to a variety of endoscopic techniques that are used in order to access the bile duct when conventional methods of cannulation have failed. There are not significant data (such as efficacy, safety) about the use of different techniques of precutting at the same session. We have described our experience with combined precut sphincterotomy (CPS) and we have compared our results to the use of an isolated precut. we have performed 247 precuts of a total of 2.390 ERCPs. Patients were distributed according to the type of precut practiced: Needle-knife, transpancreatic and combined precut sphincterotomies. "Combined precut" consisted in performing first a transpancreatic sphincterotomy and, if the access was not achieved, then performing a needle-knife sphincterotomy in the same session. The data about safety and efficacy were prospectively collected. The complications were defined according to the consensus criteria. we performed precutting techniques in 247 patients. Needle-knife, transpancreatic, and combined precuts were performed in 125 (6.9%), 74 (4.1%) and 48 (2.6%) patients, respectively. Bile duct cannulation was successful in 48 patients (100%) in the group of combined precut, 121 patients (96.8%) in the transpancreatic group, and 67 patients (90.5%) in the needleknife group (p = 0.03). There were not differences in complications rates between the three groups. There was no pancreatitis in the combined precut group. The complications were successfully managed with conservative treatment. combined precut sphincterotomy seems to be a safe and successful technique in those cases of difficult bile duct cannulation.