- Email: [email protected]
Precut papillotomy via fine-needle knife papillotome: a safe and effective technique
0016-5107/86/3206-0403$02.00/0 GASTROINTESTINAL ENDOSCOPY Copyright © 1986 by the American Society for Gastrointestinal Endoscopy
New Methods-New Materials Precut papillotomy via fine-needle knife papillotome: a safe and effective technique K. Huibregtse, MD R. M. Katon, MD G. N. J. Tytgat, MD
Endoscopic sphincterotomy is now an established method for removal of common bile duct calculi and treatment of ampullary stenosis, the sump syndrome, and certain cases of ampullary carcinoma. It is also generally performed prior to biliary endoprosthesis placement. I -:l Despite refinements in fiberscopes and techniques, selective bile duct cannulation is unsuccessful in 10% to 15% of cases, even in the hands of experienced endoscopists. 4 When biliary cannulation fails, a precut papillotome is employed by some endoscopists. 5 This papillotome consists of a I-em wire which can be bowed and extends to the tip of the catheter. A short incision is made in the 11 or 12 o'clock position in an attempt to cut the roof off the common channel to facilitate access to the common bile duct. This device may be associated with pancreatitis or perforation and is generally thought to be rather risky.4 Cotton5 states that "precutting should not be used by beginners; it is an uncontrolled process and may leave the patients worse off than before." Other authors have utilized a straight 5-mm wire papillotome (needle knife) to gain access to the biliary tract when direct cannulation fails. 6 - s This technique involves the creation of an artificial choledochoduodenal fistula proximal to the papilla itself by making a 1- to 1.5-cm long incision in the bulging intraduodenal common duct. This technique has not had widespread popularity due to its difficulty and potential risks of duodenal or bile duct perforation. Additional potential drawbacks of this technique are the possibility of stenosis of the artificial choledochoduodenostomy or the creation of a sump syndrome since the distal sphincteric mechanism remains intact.? This report deals with a new method of precut papillotomy with a fine wire needle knife. Received April 9, 1986. Accepted May 14, 1986. From the Department of Gastro-Entero-Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and the Department of Medicine, Division of Gastroenterology, Oregon Health Science University, Portland, Oregon. Reprint requests: K. Huibregtse, MD, Division of Gastroenterology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. VOLUME 32, NO.6, 1986
METHODS
The needle knife consists of a O.2-mm diameter straight wire that can be extended 5 mm from the tip of the cannula (Fig. 1). The electrosurgical current setting is the same as that employed in routine papillotomy. Before one begins actually cutting with the knife, it is important to make several trial movements of the catheter tip by turning the control knobs or by using the elevator. The wire is then extended 5 mm from the tip of the catheter and inserted into the papillary orifice (Fig. 2). A 5- to 6-mm incision is made at the 11 o'clock orientation, which is the usual position of the bile duct. The proper orientation of the cut is achieved by creating pressure with the wire on the roof of the papilla, using either the cannula elevator or control knobs to deflect the wire. It is essential to move the knife while giving current to avoid excessive focal coagulation. After a small incision is made, the orifice to the biliary tract may be noted by outflow of bile. The precut incision should be gently probed with a smooth metal-tipped cannula. The actual opening may be anywhere along the site of the incision, but in the majority of cases it is not located in the superior aspect. If biliary tract access is still not achieved, the incision can be extended another 2 to 4 mm or a slightly deeper incision can be made. Once biliary opacification is achieved, the precut incision may be extended via a standard papillotome, which will allow stone extraction or endoprosthesis placement. RESULTS
The needle knife technique was employed only in therapeutic endoscopy situations. The technique was utilized in 19.2% of patients prior to endoprosthesis insertion and in 14.5% prior to biliary stone removal. Only the results in 987 patients with biliary endopros-
Figure 1. Fine-needle knife papillotome, 5 mm in length and 0.2 mm in diameter (Wilson Cook, Inc., Winston-Salem, N.C.).
403
Figure 2. Precut technique using the fine-needle knife papillotome. A, The fine-needle knife is inserted into papilla. B, A 5-mm incision has been made at the 11 o'clock position. C, A standard ERCP catheter has entered the biliary tract. D, The papillotomy incision has been extended with the standard papillotome. thesis will be presented here. This group was studied from August 1980 until January 1985. Cannulation or standardpapillotomy was unsuccessful in 190 (19.2%). Precut with the fine-needle technique was successful in 171 (91%). Of the 171 successful cases, 101 (53%) could be cannulated immediately after the precut technique and 58 (31 %) had successful cannulation during a second ERCP. Three or more ERCPs were needed for successful cannulation in the remaining 12 patients. The complication rate of perforation, bleeding, and pancreatitis in the group with standard papillotomy did not differ from the group who required precut prior to standard papillotomy (Table 1). DISCUSSION
We have demonstrated the efficacy and safety of a new needle knife precut technique in a large group of patients with obstructive jaundice who had failed biliary cannulation and/or sphincterotomy with standard techniques. Of 190 consecutive failed biliary can404
Table 1. Comparison of complications with standard endoscopic papillotomy (EPT) versus precut EPT Standard EPT Patients Perforation Bleeding Pancreatitis
797 3 (0.4%) 12 (1.5%) 2 (0.25%)
Precut EPT
190
o 3(1.5%) 2(1.0%)
nulations, the precut technique allowed biliary access in 171 (91%). Furthermore, the rate of complications following the precut technique was no higher than in the 797 patients who had standard papillotomy. Although the needle knife papillotome has been employed by other groups since 1977, it has had limited popularity. Our technique differs from that of prior authors who utilized the needle knife to create an artificial choledochoduodenal fistula by making an incision superior to the papilla in the visibly bulging intraduodenal common duct. The drawbacks of that technique include the possibility of perforation of the GASTROINTESTINAL ENDOSCOPY
biliary tract and duodenum and the fact that it can only be used in patients with obvious bulging intraduodenal common bile duct. The technique of precut papillotomy with the standard precut papillotome also is associated with several problems. It is often difficult to properly orient the cutting wire at the appropriate 11 or 12 o'clock position. In addition, the risk of pancreatitis following the use of this papillotome is increased, possibly because of edema resulting from excessive current applied to a focal area. However, our technique allows for easy orientation of the needle knife, and rapid movement of the cutting wire limits the risk of edema with resulting pancreatitis. The incision is generally a rather short one, limiting the risk of bleeding or perforation. This method should be used only by endoscopists who have had considerable experience with standard papillotomy techniques and in situations where therapeutic biliary endoscopy is likely to be indicated. With that caveat, the precut technique utilizing the fine-wire needle knife is a safe and controlled usually
Antegrade assistance for retrograde sphincterotomy using a new sphincterotome Hartley Cohen, MD Michael Quinn, MD
Endoscopic sphincterotomy occasionally requires the assistance of a percutaneous biliary catheter or guide wire. 1- 3 The sphincterotome is advanced into the common bile duct alongside the protruding catheter or guide wire, or the papilla may be dilated using a balloon catheter or held open by a partially opened Dormia basket to facilitate endoscopic retrograde cannulation. The radiologist also can snare the sphincterotome with the basket and pull it through the ampulla. We report an easier technique of assisted retrograde cannulation using a new 7 F diameter double lumen sphincterotome (Wilson-Cook PTG-30-7) that accommodates a guide wire in a separate insulated channel (Fig. 1).
Received May 27, 1986. Accepted August 20, 1986. From the Departments of Medicine and Radiology, Los Angeles County-USC Medical Center, University of Southern California School of Medicine, Los Angeles, California. Reprint requests: Hartley Cohen, MD, Department of Medicine, USC School of Medicine, 2025 Zonal Avenue, Los Angeles, California 90033. VOLUME 32, NO.6, 1986
successful method for entering the biliary tract when standard methods fail. REFERENCES 1. Demling L. Endoscopic papillotomy (EPT)-indications and technique. Endoscopy 1983;15:162-4. 2. Cotton PB, Vallon AG. British experience with duodenoscopic sphincterotomy for removal of bile duct stones. Br J Surg 1981;68:373-5. 3. Geenen JE, Vennes JA, Silvis SE. Resume of a seminar on endoscopic retrograde sphincterotomy (ERS). Gastrointest Endose 1981;27:31-7. 4. Siegel JH. Precut papillotomy: a method to improve success of ERCP and papillotomy. Endoscopy 1981;12:130-3. 5. Cotton PB. Duodenoscopic sphincterotomy and bile-duct stone retrieval. In: Bennett JR, ed. Therapeutic endoscopy and radiology of the gut. London: Chapman and Hall, 1981:169-83. 6. Coletti GC, Verucchi G, Bolondi L, Labo G. Diathermy ERCPan alternative method for endoscopic retrograde cholangiopancreatography (ERCP) in jaundiced patients. Gastrointest Endose 1980;26:13-5. 7. Kozarek RA, Sanowski RA. Endoscopic choledochoduodenostomy. Gastrointest Endosc 1983;29:119-21. 8. Osnes M, Kahr T. Endoscopic choledochoduodenostomy for choledocholithiasis through choledochoduodenal fistula. Endoscopy 1977;9:162-5.
MATERIALS AND METHODS
A 90-year-old man admitted with jaundice was found on ultrasonographic examination to have stones in the gallbladder and a bile duct with a caliber of 7 mm. Endoscopic retrograde cholangiography was unsuccessful because the papilla lay in a duodenal diverticulum precluding cannulation. A percutaneous transhepatic cholangiogram using a skinny needle revealed a filling defect (interpreted as a gallstone) in the common bile duct and the presence of the duodenal diverticulum (Fig. 2). The bile ducts were entered percutaneously with a 5 F polyethylene sheath-needle combination (Ring biliary needle, Cook Inc.) The polyethylene sheath was advanced into the duodenum over a torque control guide wire, and the latter then was exchanged for a 400-cm long, O.035-inch diameter guide wire. Duodenoscopy was performed and the end of the guide wire was lassoed in the duodenum with a polypectomy snare and pulled through the biopsy channel and valve of the duodenoscope. A 7 F sphincterotome with an insulated channel (Wilson-Cook PTG-30-7) (Fig. 1) was advanced over the
Figure 1. Distal end of sphincterotome with a guide wire in the insulated channel. 405
New Methods-New Materials Precut papillotomy via fine-needle knife papillotome: a safe and effective technique K. Huibregtse, MD R. M. Katon, MD G. N. J. Tytgat, MD
Endoscopic sphincterotomy is now an established method for removal of common bile duct calculi and treatment of ampullary stenosis, the sump syndrome, and certain cases of ampullary carcinoma. It is also generally performed prior to biliary endoprosthesis placement. I -:l Despite refinements in fiberscopes and techniques, selective bile duct cannulation is unsuccessful in 10% to 15% of cases, even in the hands of experienced endoscopists. 4 When biliary cannulation fails, a precut papillotome is employed by some endoscopists. 5 This papillotome consists of a I-em wire which can be bowed and extends to the tip of the catheter. A short incision is made in the 11 or 12 o'clock position in an attempt to cut the roof off the common channel to facilitate access to the common bile duct. This device may be associated with pancreatitis or perforation and is generally thought to be rather risky.4 Cotton5 states that "precutting should not be used by beginners; it is an uncontrolled process and may leave the patients worse off than before." Other authors have utilized a straight 5-mm wire papillotome (needle knife) to gain access to the biliary tract when direct cannulation fails. 6 - s This technique involves the creation of an artificial choledochoduodenal fistula proximal to the papilla itself by making a 1- to 1.5-cm long incision in the bulging intraduodenal common duct. This technique has not had widespread popularity due to its difficulty and potential risks of duodenal or bile duct perforation. Additional potential drawbacks of this technique are the possibility of stenosis of the artificial choledochoduodenostomy or the creation of a sump syndrome since the distal sphincteric mechanism remains intact.? This report deals with a new method of precut papillotomy with a fine wire needle knife. Received April 9, 1986. Accepted May 14, 1986. From the Department of Gastro-Entero-Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and the Department of Medicine, Division of Gastroenterology, Oregon Health Science University, Portland, Oregon. Reprint requests: K. Huibregtse, MD, Division of Gastroenterology, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. VOLUME 32, NO.6, 1986
METHODS
The needle knife consists of a O.2-mm diameter straight wire that can be extended 5 mm from the tip of the cannula (Fig. 1). The electrosurgical current setting is the same as that employed in routine papillotomy. Before one begins actually cutting with the knife, it is important to make several trial movements of the catheter tip by turning the control knobs or by using the elevator. The wire is then extended 5 mm from the tip of the catheter and inserted into the papillary orifice (Fig. 2). A 5- to 6-mm incision is made at the 11 o'clock orientation, which is the usual position of the bile duct. The proper orientation of the cut is achieved by creating pressure with the wire on the roof of the papilla, using either the cannula elevator or control knobs to deflect the wire. It is essential to move the knife while giving current to avoid excessive focal coagulation. After a small incision is made, the orifice to the biliary tract may be noted by outflow of bile. The precut incision should be gently probed with a smooth metal-tipped cannula. The actual opening may be anywhere along the site of the incision, but in the majority of cases it is not located in the superior aspect. If biliary tract access is still not achieved, the incision can be extended another 2 to 4 mm or a slightly deeper incision can be made. Once biliary opacification is achieved, the precut incision may be extended via a standard papillotome, which will allow stone extraction or endoprosthesis placement. RESULTS
The needle knife technique was employed only in therapeutic endoscopy situations. The technique was utilized in 19.2% of patients prior to endoprosthesis insertion and in 14.5% prior to biliary stone removal. Only the results in 987 patients with biliary endopros-
Figure 1. Fine-needle knife papillotome, 5 mm in length and 0.2 mm in diameter (Wilson Cook, Inc., Winston-Salem, N.C.).
403
Figure 2. Precut technique using the fine-needle knife papillotome. A, The fine-needle knife is inserted into papilla. B, A 5-mm incision has been made at the 11 o'clock position. C, A standard ERCP catheter has entered the biliary tract. D, The papillotomy incision has been extended with the standard papillotome. thesis will be presented here. This group was studied from August 1980 until January 1985. Cannulation or standardpapillotomy was unsuccessful in 190 (19.2%). Precut with the fine-needle technique was successful in 171 (91%). Of the 171 successful cases, 101 (53%) could be cannulated immediately after the precut technique and 58 (31 %) had successful cannulation during a second ERCP. Three or more ERCPs were needed for successful cannulation in the remaining 12 patients. The complication rate of perforation, bleeding, and pancreatitis in the group with standard papillotomy did not differ from the group who required precut prior to standard papillotomy (Table 1). DISCUSSION
We have demonstrated the efficacy and safety of a new needle knife precut technique in a large group of patients with obstructive jaundice who had failed biliary cannulation and/or sphincterotomy with standard techniques. Of 190 consecutive failed biliary can404
Table 1. Comparison of complications with standard endoscopic papillotomy (EPT) versus precut EPT Standard EPT Patients Perforation Bleeding Pancreatitis
797 3 (0.4%) 12 (1.5%) 2 (0.25%)
Precut EPT
190
o 3(1.5%) 2(1.0%)
nulations, the precut technique allowed biliary access in 171 (91%). Furthermore, the rate of complications following the precut technique was no higher than in the 797 patients who had standard papillotomy. Although the needle knife papillotome has been employed by other groups since 1977, it has had limited popularity. Our technique differs from that of prior authors who utilized the needle knife to create an artificial choledochoduodenal fistula by making an incision superior to the papilla in the visibly bulging intraduodenal common duct. The drawbacks of that technique include the possibility of perforation of the GASTROINTESTINAL ENDOSCOPY
biliary tract and duodenum and the fact that it can only be used in patients with obvious bulging intraduodenal common bile duct. The technique of precut papillotomy with the standard precut papillotome also is associated with several problems. It is often difficult to properly orient the cutting wire at the appropriate 11 or 12 o'clock position. In addition, the risk of pancreatitis following the use of this papillotome is increased, possibly because of edema resulting from excessive current applied to a focal area. However, our technique allows for easy orientation of the needle knife, and rapid movement of the cutting wire limits the risk of edema with resulting pancreatitis. The incision is generally a rather short one, limiting the risk of bleeding or perforation. This method should be used only by endoscopists who have had considerable experience with standard papillotomy techniques and in situations where therapeutic biliary endoscopy is likely to be indicated. With that caveat, the precut technique utilizing the fine-wire needle knife is a safe and controlled usually
Antegrade assistance for retrograde sphincterotomy using a new sphincterotome Hartley Cohen, MD Michael Quinn, MD
Endoscopic sphincterotomy occasionally requires the assistance of a percutaneous biliary catheter or guide wire. 1- 3 The sphincterotome is advanced into the common bile duct alongside the protruding catheter or guide wire, or the papilla may be dilated using a balloon catheter or held open by a partially opened Dormia basket to facilitate endoscopic retrograde cannulation. The radiologist also can snare the sphincterotome with the basket and pull it through the ampulla. We report an easier technique of assisted retrograde cannulation using a new 7 F diameter double lumen sphincterotome (Wilson-Cook PTG-30-7) that accommodates a guide wire in a separate insulated channel (Fig. 1).
Received May 27, 1986. Accepted August 20, 1986. From the Departments of Medicine and Radiology, Los Angeles County-USC Medical Center, University of Southern California School of Medicine, Los Angeles, California. Reprint requests: Hartley Cohen, MD, Department of Medicine, USC School of Medicine, 2025 Zonal Avenue, Los Angeles, California 90033. VOLUME 32, NO.6, 1986
successful method for entering the biliary tract when standard methods fail. REFERENCES 1. Demling L. Endoscopic papillotomy (EPT)-indications and technique. Endoscopy 1983;15:162-4. 2. Cotton PB, Vallon AG. British experience with duodenoscopic sphincterotomy for removal of bile duct stones. Br J Surg 1981;68:373-5. 3. Geenen JE, Vennes JA, Silvis SE. Resume of a seminar on endoscopic retrograde sphincterotomy (ERS). Gastrointest Endose 1981;27:31-7. 4. Siegel JH. Precut papillotomy: a method to improve success of ERCP and papillotomy. Endoscopy 1981;12:130-3. 5. Cotton PB. Duodenoscopic sphincterotomy and bile-duct stone retrieval. In: Bennett JR, ed. Therapeutic endoscopy and radiology of the gut. London: Chapman and Hall, 1981:169-83. 6. Coletti GC, Verucchi G, Bolondi L, Labo G. Diathermy ERCPan alternative method for endoscopic retrograde cholangiopancreatography (ERCP) in jaundiced patients. Gastrointest Endose 1980;26:13-5. 7. Kozarek RA, Sanowski RA. Endoscopic choledochoduodenostomy. Gastrointest Endosc 1983;29:119-21. 8. Osnes M, Kahr T. Endoscopic choledochoduodenostomy for choledocholithiasis through choledochoduodenal fistula. Endoscopy 1977;9:162-5.
MATERIALS AND METHODS
A 90-year-old man admitted with jaundice was found on ultrasonographic examination to have stones in the gallbladder and a bile duct with a caliber of 7 mm. Endoscopic retrograde cholangiography was unsuccessful because the papilla lay in a duodenal diverticulum precluding cannulation. A percutaneous transhepatic cholangiogram using a skinny needle revealed a filling defect (interpreted as a gallstone) in the common bile duct and the presence of the duodenal diverticulum (Fig. 2). The bile ducts were entered percutaneously with a 5 F polyethylene sheath-needle combination (Ring biliary needle, Cook Inc.) The polyethylene sheath was advanced into the duodenum over a torque control guide wire, and the latter then was exchanged for a 400-cm long, O.035-inch diameter guide wire. Duodenoscopy was performed and the end of the guide wire was lassoed in the duodenum with a polypectomy snare and pulled through the biopsy channel and valve of the duodenoscope. A 7 F sphincterotome with an insulated channel (Wilson-Cook PTG-30-7) (Fig. 1) was advanced over the
Figure 1. Distal end of sphincterotome with a guide wire in the insulated channel. 405