Different Strategies for Transpancreatic Septotomy and Needle Knife Infundibulotomy Due to the Presence of Unintended Pancreatic Cannulation in Difficult Biliary Cannulation

BACKGROUND/AIMS: Several precut techniques have been used to gain biliary access for difficult cases. The aim of this study was to evaluate the success and complication rates of two precut techniques, transpancreatic septotomy (TPS) and needle knife infundibulotomy (NKI), in difficult biliary cannulation due to the presence of unintended pancreatic cannulation. METHODS: Eighty-six patients who failed standard biliary cannulation were included. TPS was performed when we failed to achieve biliary access despite 5 minutes of attempted cannulation or when more than three attempted unintended pancreatic cannulations occurred. If deep cannulation was not achieved within 5 minutes for any duct, NKI was performed. If this failed, we crossed over to the other technique in the second attempt. RESULTS: The initial total success rate of biliary cannulation was 88.4% (86.6% for the TPS group and 94.7% for the NKI group, p=0.447). After crossover of the techniques, the final success rate was 95.3%. The complication rate was 20.9% in patients with TPS and 15.8% in patients with NKI (p=0.753). CONCLUSIONS: The use of different strategies based on the presence of unintended pancreatic cannulation may help increase the success rate for difficult biliary cannulation without increasing complication rates.

A Single Institution's Experience of Infundibulotomy in Patients Taking Antiplatelet Agents: Outcomes, Safety and Complications / 대한소화기학회지

BACKGROUND/AIMS: The diagnostic and therapeutic utility of endoscopic retrograde cholangiopancreatography (ERCP) has been well demonstrated for biliary and pancreatic diseases. Biliary access can be allowed by infundibulotomy if failed by using the standard cannulation methods. However, no data are available regarding ERCP-related complications in patients taking antiplatelet agents who are undergoing infundibulotomy. Therefore, we aimed to assess the frequency of ERCP-related complications after infundibulotomy in patients taking antiplatelet agents. METHODS: We performed a retrospective study, and enrolled 835 patients who underwent ERCP at Pusan National University Hospital from January 2011 to December 2012. Seventy-two patients had been taking antiplatelet agents prior to the procedure. Patients were classified into two groups according to the utilization of infundibulotomy: 20 patients underwent infundibulotomy (group 1), and 52 patients did not undergo infundibulotomy (group 2). Complications after ERCP were defined as bleeding, post-ERCP pancreatitis, and perforation according to Cotton's criteria. RESULTS: Between group 1 and 2, there were no significant differences in baseline characteristics. ERCP was successfully performed in all cases. Clinically significant bleeding was observed in one patient in group 1 (5%, 1/20) versus none in group 2. Post-ERCP pancreatitis was observed in 2 patients (10.0%, 2/20) in group 1, and 7 patients (13.5%, 7/52) in group 2 (p=0.691). However, none of these differences were statistically significant. No perforation occurred in both groups. CONCLUSIONS: Considering the low incidence of bleeding after infundibulotomy in patients taking antiplatelet agents, infundibulotomy may be safely performed in this group of patients.

Esfinterotomía de aguja / Needle sphincterotomy

La canulación fallida del conducto biliar común durante la colangiopancreatografía retrógrada endoscópica es del 5 al 20% según la experticia del operador. El uso de guías hidrofílicas y la canulación profunda y selectiva son claves en el adecuado abordaje de la vía biliar. La inadecuada selección del paciente, papilas pequeñas o peridiverticulares, cálculo impactado, disfunción del Oddi o traumatismo repetido durante la canulación son las causas más frecuentes. La esfinterotomía de aguja en sus dos modalidades infundibulotomía y el precorte son técnicas opcionales para el abordaje del conducto biliar ante el fallo de la técnica convencional. Ambas técnicas son igualmente efectivas para el abordaje biliar en coledocolitiasis. La hiperamilasemia es más frecuente en el precorte (17.75%) en infundibulotomía (2.7%). La incidencia de pancreatitis post colangiografía es de 15% posterior a 15 o más intentos de canulación. La pancreatitis en el precorte puede alcanzar el 8% y es rara durante la infundibulotomía. El sangramiento ocurre de forma comparable con ambas técnicas. La esfinterotomía de aguja temprana en la canulación fallida disminuye la ocurrencia de pancreatitis post procedimiento. Debe ser realizada por colangiografistas expertos en la técnica y manejo de las complicaciones y contarse con los equipos y materiales adecuados

The failed cannulation of the common bile duct during endoscopic retrograde cholangiopancreatography is from 5 to 20% depending on operator expertise. The use of hydrophilic guides and the deep and selective cannulation are key to sucessfull access to the bile duct. Inadequate patient selection, small duodenal papilla or peridiverticular, impacted gallstone, Oddi dysfunction or repeated trauma during cannulation are the most common causes of failure. Needle-knife sphincterotomy in its two modalities: infundibulotomy and precut are optional techniques for accessing the bile duct when confronted with the conventional technique failure. Both techniques are equally effective for biliary choledocholithiasis. Hyperamylasemia is more common in the precut (17.75%) infundibulotomy (2.7% ). The incidence of post cholangiography pancreatitis is 15% after 15 or more cannulation attempts. Pancreatitis in precut can reach 8% and is rare during the infundibulotomy. Bleeding occurs in a similar way in both techniques. Early needle-knife use, in failed in cannulation decreases the occurrence of post procedure pancreatitis. It must be perfomed by experts in the technique that are able to manage eventual complications beside having adequate equipment and materials available

A Role of Endoscopic Balloon Dilatation after Partial Infundibulotomy in Billroth II Patients / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is difficult to perform in patients with a Billroth II anastomosis due to the anatomical alterations. This study evaluated retrospectively the efficacy and safety of endoscopic balloon dilatation after a partial infundibulotomy with a needle knife in patients who had undergone a Billroth II operation. METHODS: Between January 1, 2004 and December 31, 2005, 11 patients, who had undergone a prior Billroth II gastrectomy, underwent ERCP because of a suspicion of pancreatobiliary diseases. Infundibulotomy was performed using a needle knife sphincterotome. After a partial infundibulotomy, a dilation balloon was passed over a prepositioned guidewire and placed in the biliary orifice. Under endoscopic and fluoroscopic control, the balloon was then inflated with diluted contrast over a period of 1 to 2 minutes. RESULTS: A total of 10 patients (7 male and 3 female) were enrolled in this study. Eight had common bile duct stones, 1 bile duct cancer, and 1 pancreatic cancer. The common bile duct was dilated by a balloon. The calculi were removed in 6 patients, and a common bile duct stent was implanted in two cases via endoscopy. No complications such as acute pancreatitis or apparent infections of the biliary tracts were encountered in these cases except for mild fever, temporary high serum levels of aminotransferase and amylase after ERCP in 3 cases. No severe bleeding or perforation occurred in patients undergoing balloon dilatation. CONCLUSIONS: An infundibulotomy with balloon dilatation is a valuable alternative to endoscopic sphinterotomy in the treatment of patients with bile duct diseases, who have undergone prior Billroth II gastrectomies.

A Role of Endoscopic Balloon Dilatation after Partial Infundibulotomy in Billroth II Patients / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is difficult to perform in patients with a Billroth II anastomosis due to the anatomical alterations. This study evaluated retrospectively the efficacy and safety of endoscopic balloon dilatation after a partial infundibulotomy with a needle knife in patients who had undergone a Billroth II operation. METHODS: Between January 1, 2004 and December 31, 2005, 11 patients, who had undergone a prior Billroth II gastrectomy, underwent ERCP because of a suspicion of pancreatobiliary diseases. Infundibulotomy was performed using a needle knife sphincterotome. After a partial infundibulotomy, a dilation balloon was passed over a prepositioned guidewire and placed in the biliary orifice. Under endoscopic and fluoroscopic control, the balloon was then inflated with diluted contrast over a period of 1 to 2 minutes. RESULTS: A total of 10 patients (7 male and 3 female) were enrolled in this study. Eight had common bile duct stones, 1 bile duct cancer, and 1 pancreatic cancer. The common bile duct was dilated by a balloon. The calculi were removed in 6 patients, and a common bile duct stent was implanted in two cases via endoscopy. No complications such as acute pancreatitis or apparent infections of the biliary tracts were encountered in these cases except for mild fever, temporary high serum levels of aminotransferase and amylase after ERCP in 3 cases. No severe bleeding or perforation occurred in patients undergoing balloon dilatation. CONCLUSIONS: An infundibulotomy with balloon dilatation is a valuable alternative to endoscopic sphinterotomy in the treatment of patients with bile duct diseases, who have undergone prior Billroth II gastrectomies.

Efficacy of Needle-knife Infundibulotomy in Failed Cannulation on Endoscopic Retrograde Cholangiopancreatography / 대한소화기내시경학회지

BACKGROUND/AIMS: Cannulation failure to biliary tract has been reported in 10% of patients who are performed diagnostic and therapeutic ERCP. Infundibulotomy by use of needle knife is cutting a bulbar part of protruding papilla, which has merit to avoid complete destruction of sphincter of Oddi and serious side effects than general precutting method. We want to know effectiveness and safety of infundibulotomy. METHODS: From January 1997 to December 1998, 36 patients who failed cannulation over three times trial by conventional method are included to this study. We compared the success rate of cannulation and procedure related complication according to bile duct dilatation, periampullary diverticulum and shape of ampulla of Vater. RESULTS: 1) Success rate of cannulation to bile duct is 81% (29/36). 2) All patients in group of bile duct dilatation (14) are succeed to cannulation, which is significantly high compare to other group (p=0.0288). 3) There was no statistical difference in success rate according to presence of periampullary diverticulum. 4) In groups of bulging prominent papilla are succeed in 23 among 26 patients, which is tendency of high in patients than other group (p=0.0760). 5) Total occurrence of procedure related complication was 33% (12/36). 6) The complication rate was not different in two groups according to cannulation success 7) The complication rate was tendency of high in patients without bile duct dilatation (p=0.0756). CONCLUSIONS: Infundibulotomy by use of needle knife is effeetive and safe cannulation method to patient who failed cannulation to bile duct. Success of cannulation is low and occurrence of complication is tendency of high in patient without bile duct dilation, which propose endoscopists attention in selection of indications.

Early experience of endoscopic infundibulotomy / 대한비뇨기과학회지

Over the last few years. the managements of urologic diseases have been changed rapidly to less invasive procedures, especially endourologic surgery. Recently. we experienced a case of caliceal in fundibular stricture due to renal tuberculosis and a case of caliceal diverticulum containing stones which were treated endourologically. In latter case. we also performed electrofulguration of the wall of the diverticulum. The techniques used and results achieved in 2 patients who have been success fully managed are discussed.