Precut fistulotomy – widening its limits

Selective cannulation of the common bile duct (CBD) is the most important and challenging step in a biliary endoscopic retrograde cholangiopancreatography (ERCP) [1] [2]. 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 [3]. 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 [2]. 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 [2] [4].

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.

Fig. 1 Needle-knife fistulotomy (NKF): basic and advanced maneuvers in challenging settings. a NKF performed at a distance from the papilla. b NKF performed in a patient with pancreatic cancer infiltrating the ampulla. c NKF performed in a patient with cholangitis secondary to limited hemobilia. d NKF performed in a patient with an intradiverticular papilla with the papillary orifice not visible from the duodenum, with the assistance of a biopsy forceps.

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 [5]. 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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• References

• 1 Lopes L, Dinis-Ribeiro M, Rolanda C. Safety and efficacy of precut needle-knife fistulotomy. Scand J Gastroenterol 2014; 49: 759-765
• 2 Testoni PA, Mariani A, Aabakken L. et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2016; 48: 657-683
• 3 Testoni PA, Testoni S, Giussani A. Difficult biliary cannulation during ERCP: how to facilitate biliary access and minimize the risk of post-ERCP pancreatitis. Dig Liver Dis 2011; 43: 596-603
• 4 Lopes L, Dinis-Ribeiro M, Rolanda C. Early precut fistulotomy for biliary access: time to change the paradigm of “the later, the better”?. Gastrointest Endosc 2014; 80: 634-641
• 5 DaVee T, Garcia JA, Baron TH. Precut sphincterotomy for selective biliary duct cannulation during endoscopic retrograde cholangiopancreatography. Ann Gastroenterol 2012; 25: 291-302