An early attempt at needle-knife fistulotomy (NKF) is the rescue technique for selective
biliary cannulation (SBC) [1]
[2]
[3]. To complete NKF, it is crucial to identify critical landmarks, including the glistening
pink adventitia of the bile duct, the onion skin-like biliary orifice within the incision,
and the pearly-white biliary mucosa [4]. However, owing to the diversity of papillary morphology, it is challenging to identify
these landmarks and determine appropriate incision depth in every individual attempt
[5].
An 88-year-old female patient with a nonspecific medical history was referred to our
department because of obstructive jaundice. Magnetic resonance cholangiopancreatography
revealed Bismuth type IV perihilar cholangiocarcinoma ([Fig. 1]). Transpapillary biliary drainage was attempted; however, primary wire-guided cannulation
met the criteria for difficult SBC [1]. We performed NKF using a needle knife (KD-V451M; Olympus Medical Systems, Tokyo,
Japan) with a generator (VIO 200D; ERBE, Tubingen, Germany) in accordance with the
manufacturer’s recommendations [1]. Layer-by-layer incision was extended to the narrow distal segment ([Fig. 2 a]). However, SBC could not be achieved after several attempts and we were therefore
considering whether a further cut might be needed. We then inserted a guidewire into
the narrow distal segment from the papillary orifice, and the emergence of the guidewire
from the incision site ([Fig. 2 b]) indicated that the incision depth was appropriate. Hence, further NKF was unnecessary,
and we resumed guidewire insertion from the fistula until SBC was achieved ([Fig. 2 c, d]; [Video 1]). Finally, we completed transpapillary biliary drainage using multiple inside (that
is, placed above the duodenal papilla) plastic stents.
Fig. 1 Magnetic resonance cholangiopancreatography (MRCP) reveals Bismuth type IV perihilar
stenosis (yellow circle).
Fig. 2 Needle-knife fistulotomy (NKF) and confirmation of incision depth by guidewire insertion
from the papillary orifice. a Layer-by-layer NKF incision reached the narrow distal segment; however, biliary access
was not obtained. b The emergence of the guidewire, which was inserted from the papillary orifice, indicated
that the NKF incision depth was appropriate. c, d Achievement of biliary access from the incision.
Video 1 Confirmation of appropriate incision depth using a guidewire during needle-knife
fistulotomy (NKF). SBC, selective biliary cannulation; NDS, narrow distal segment;
BDC, bile duct cannulation.
Guidewire insertion from the papillary orifice can help confirm the appropriate depth
of NKF and avoid thermal injury of the main pancreatic duct and retroperitoneal perforation
caused by an unnecessarily deep incision. When the guidewire sticks at the narrow
distal segment, further NKF incision is needed. If the guidewire advances into the
main pancreatic duct, transpancreatic sphincterotomy could be a useful alternative
precut technique.
Endoscopy_UCTN_Code_TTT_1AR_2AC
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