Precut fistulotomy – widening its limits
08 March 2018 (online)
Selective cannulation of the common bile duct (CBD) is the most important and challenging step in a biliary endoscopic retrograde cholangiopancreatography (ERCP)  . However, in the first ERCP, even in experienced hands, biliary cannulation may fail in up to 15 % – 35 % of cases when using standard methods alone . In this subset of patients, additional cannulation techniques are needed to access the CBD in order to continue with the ERCP. Precut is the most common strategy used by experienced endoscopists, when conventional methods have failed . Needle-knife fistulotomy (NKF) and conventional precut are the two most common variants. Recently published guidelines recommend opting for NKF, as evidence suggests a lower risk of adverse events, especially pancreatitis, when used early in the biliary cannulation algorithm  .
This video report aims to demonstrate basic and advanced NKF maneuvers in challenging and hazardous settings, with an emphasis on the need to adapt to the patients’ individual anatomy ([Fig. 1], [Video 1]). Consequently, even some of the most difficult biliary cannulation cases can have their problems managed by ERCP alone (in the same session), instead of being referred for endoscopic ultrasound or percutaneous biliary drainage.
Video 1 Use of needle-knife fistulotomy in highly challenging and demanding clinical settings.
In each case, the NKF procedure was performed using a needle-knife, in a freehand fashion, making a puncture in the papilla above the orifice, and then cutting on the CBD axis, while maintaining a free distance from the papillary orifice . All procedures were performed by an experienced endoscopist (L. L.).
NKF is probably an obligatory technique to be included in the toolbox of every future advanced ERCP endoscopist. However, given its potential complications and the skills required to be proficient, it should probably be reserved for skilled endoscopists in high-volume ERCP centers.
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