How to confirm the appropriate incision depth using a guidewire during needle-knife fistulotomy

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

• References

• 1 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
• 2 Facciorusso A, Ramai D, Gkolfakis P. et al. Comparative efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis. Gastrointest Endosc 2022; 95: 60-71.e12
• 3 Jang SI, Kim DU, Cho JH. et al. Primary needle-knife fistulotomy versus conventional cannulation method in a high-risk cohort of post-endoscopic retrograde cholangiopancreatography pancreatitis. Am J Gastroenterol 2020; 115: 616-624
• 4 Magulick JP, Campbell 3rd EV, Muniraj T. et al. Access fistulotomy: technical tips for success. VideoGIE 2020; 6: 49-53
• 5 Zhang QS, Xu JH, Dong ZQ. et al. Success and safety of needle knife papillotomy and fistulotomy based on papillary anatomy: A prospective controlled trial. Dig Dis Sci 2021;