• Biliary tract
• biopsy
• cytology
• diagnosis
• endoscopy
• pathology
• sensitivity
• specificity

• Access sphincterotomy
• Advanced techniques
• Cannulation
• Guidewire-assisted
• Pancreatic stent
• Post-ERCP pancreatitis
• Sphincterotomy

• Difficult biliary cannulation
• ERCP
• Malignant common bile duct strictures
• Rescue therapies

• Endoscopic retrograde cholangiopancreatography
• difficult biliary cannulation
• endoscopic ultrasound
• pancreatitis
• precut technique

Needle-knife fistulotomy (NKF) is used as a rescue technique for difficult cannulation. However, the data are limited regarding the use of NKF for primary biliary cannulation, especially when performed by beginners.

To assess the effectiveness and safety of primary NKF for biliary cannulation, and the role of the endoscopist’s expertise level (beginner vs expert).

We retrospectively evaluated the records of 542 patients with naïve prominent bulging papilla and no history of pancreatitis, who underwent bile duct cannulation at a tertiary referral center. The patients were categorized according to the endoscopist’s expertise level and the technique used for bile duct cannulation. We assessed the rates of successful cannulation and adverse events.

The baseline characteristics did not differ between the experienced and less-experienced endoscopists. The incidence rate of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) was significantly affected by the endoscopist’s expertise level in patients who received conventional cannulation with sphincterotomy (8.9% vs 3.4% for beginner vs expert, P = 0.039), but not in those who received NKF. In the multivariable analysis, a lower expertise level of the biliary endoscopist (P = 0.037) and longer total procedure time (P = 0.026) were significant risk factor of PEP in patients who received conventional cannulation with sphincterotomy but only total procedure time (P = 0.004) was significant risk factor of PEP in those who received NKF.

Primary NKF was effective and safe in patients with prominent and bulging ampulla, even when performed by less-experienced endoscopist. We need to confirm which level of endoscopist’s experience is needed for primary NKF through prospective randomized study.

• Needle-knife fistulotomy
• Primary biliary cannulation
• Endoscopic retrograde cholangiopancreatography
• Expertise levels
• Pancreatitis

Forty patients with one or more risk factors for PEP were prospectively enrolled between June 2018 and November 2019. The cannulation was conducted in all patients using NKS as the primary cannulation technique. Success rate of biliary cannulation, biliary cannulation time, and adverse event rate were assessed.

Of the 40 patients enrolled, 34 patients underwent primary NKS after the screening. Nine patients had 1 risk factor for PEP, 7 had 2, 8 had 3, 7 had 4, and 3 had 5. The success rate of biliary access by NKS was 94.1% (32/34). The median procedure time for NKS and the total procedure time for stone removal or biliary drainage were 4.1 minutes (range, 0.5-25.2) and 11.3 minutes (range, 3.8–40.4), respectively. Adverse events occurred in two patients (minor bleeding, n = 1; hyperamylasemia, n = 1). No patient experienced PEP or perforation.

NKS might be feasible as a primary cannulation procedure in patients at high risk of PEP. This trial is registered with KCT0004886 (03/06/2018).

• Bile duct cannulation
• Biliary access
• Biliary drainage
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Endoscopic ultrasound (EUS)

• Catheterization/methods
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Cholestasis/therapy
• Endosonography/methods
• Humans
• Randomized Controlled Trials as Topic
• Ultrasonography, Interventional/methods

• Bile duct stones
• Complication
• Endoscopic retrograde cholangiopancreatography
• Endoscopic sphincterotomy
• Post-endoscopic retrograde cholangiopancreatography pancreatitis

Perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare but feared adverse events with highly reported morbidity and mortality rates. The aim was to evaluate the incidence and outcome of ERCP-related perforations and to identify risk factors for death due to perforations in a population-based study.

Between May 2005 and December 2013, a total of 52,140 ERCPs were registered in GallRiks, a Swedish nationwide, population-based registry. A total of 376 (0.72%) were registered as perforations or extravasation of contrast during ERCP or as perforation in the 30-day follow-up. The patients with perforation were divided into fatal and non-fatal groups and analyzed for mortality risk factors. The case volume of centers and endoscopists were divided into the upper quartile (Q4) and the lower three quartile (Q1–3) groups. Furthermore, fatal group patients’ records were reviewed.

Death within 90 days after ERCP-related perforations or at the index hospitalization occurred in 20% (75 out of 376) for all perforations and 0.1% (75 out of 52,140) for all ERCPs. The independent risk factors for death after perforation were malignancy (OR 11.2, 95% CI 5.8–21.6), age over 80 years (OR 3.8, 95% CI 2.0–7.4), and sphincterotomy in the pancreatic duct (OR 2.8, 95% CI 1.1–7.5). In Q4 centers, the mortality was similar with or without pancreatic duct sphincterotomy (14% vs. 13%, p = 1.0), but in Q1–3 centers mortality was higher (45% vs. 21%, p = 0.024).

ERCP-related perforations are severe adverse events with low incidence (0.7%) and high mortality rate up to 20%. Malignancy, age over 80 years, and sphincterotomy in the pancreatic duct increase the risk to die after a perforation. The risk of a fatal outcome in perforations after pancreatic duct sphincterotomy was reduced when occurred at a Q4-center. In the case of a complicated perforation a transfer to a Q4-center may be considered.

• Adverse event
• ERCP
• Perforation

• ERCP
• adverse events
• sphincterotomy
• training

• Cholangiocarcinoma
• Cytology
• ERCP
• EUS
• FISH
• Indeterminate biliary stricture
• PSC

Needle-knife precut fistulotomy (NK-F) is a well-known freehand technique for difficult biliary cannulation (DBC). Another approach involves the use of Iso-Tome^®, a modified precutting device with an insulated needle tip to prevent direct thermal injury. This comparative study aimed to evaluate the efficacy of the Iso-Tome^® precut (IT-P) compared to that of NK-F for DBC.

Patients with a naive papilla who underwent early IT-P or NK-F for DBC were enrolled. DBC was defined as failure to achieve selective biliary access by wire-guided cannulation despite 5 minutes of attempted cannulation, ≥5 papillary contacts, or a hook-nose-shaped papilla. The primary endpoint was the primary technical success rate, which was based on a noninferiority model.

A total of 239 DBC cases were enrolled. The primary technical success rates were 74.7% (89/119) in the IT-P group and 91.6% (110/120) in the NK-F group (lower limit of 90% confidence interval, −0.23; p=0.927 for a noninferiority margin of 10%). The total technical success rates were 87.4% and 95.0%, respectively (p=0.038). The mean precutting times for successful biliary access were 11.2 minutes for IT-P and 7.3 minutes for NK-F (p<0.01). The procedure-related adverse event rates were 9.2% for IT-P and 5.8% for NK-F (p=0.318). The rates of post-endoscopic retrograde cholangiopancreatography pancreatitis were 4.2% and 2.5%, respectively (p=0.499).

IT-P failed to exhibit noninferiority compared with NK-F regarding the primary technical success rate of DBC, but there was no difference in the frequency of adverse events.

• Biliary
• Cannulation
• Iso-Tome
• Needle-knife
• Precut

• Difficult biliary cannulation
• Endoscopic retrograde cholangiopancreatography
• Needle-knife fistulotomy
• Precut techniques
• Transpancreatic septotomy

• Endoscopic ultrasound
• Periampullary diverticulum
• Post-endoscopic retrograde cholangiopancreatography pancreatitis
• Precut technique
• Rendezvous endoscopic retrograde cholangiopancreatography
• Selective biliary cannulation

Biliary endoscopic sphincterotomy (EST) refers to the cutting of the biliary sphincter and intraduodenal segment of the common bile duct following selective cannulation, using a high frequency current applied with a special knife, sphincterotome, inserted into the papilla. EST is either used solely for the treatment of diseases of the papilla of Vater, such as sphincter of Oddi dysfunction or to facilitate subsequent therapeutic biliary interventions, such as stone extraction, stenting, etc. It is a prerequisite for biliary interventions, thus every practitioner who performs endoscopic retrograde cholangiopancreatography needs to know different techniques and the clinical and anatomic parameters related to the efficacy and safety of the procedure. In this manuscript, we will review the indications, contraindications and techniques of biliary EST and the management of its complications.

• Complication
• Indication
• Biliary endoscopic sphincterotomy
• Endoscopic retrograde cholangiopancreatography

• difficult biliary access
• early precut sphincterotomy
• ercp
• post-ercp pancreatitis
• systematic review

• Biliary Tract Surgical Procedures
• Cholangiopancreatography, Endoscopic Retrograde
• Humans
• Pancreatitis/diagnostic imaging
• Pancreatitis/epidemiology
• Postoperative Complications/epidemiology
• Randomized Controlled Trials as Topic
• Risk
• Sphincterotomy/methods

• ERCP
• EST
• endoscopic retrograde cholangiopancreatography
• endoscopic sphincterotomy
• guideline

• Precut sphincterotomy
• biliary
• endoscopic retrograde cholangiopancreatography
• learning curve
• pancreatitis

• Complications
• Endoscopic retrograde cholangiopancreatography
• Fistulotomy
• Papillotomy

• Adult
• Aged
• Aged, 80 and over
• Catheterization/adverse effects
• Catheterization/instrumentation
• Catheterization/methods
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Female
• Humans
• Male
• Middle Aged
• Outcome Assessment, Health Care
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Postoperative Complications/prevention & control
• Retrospective Studies
• Sphincterotomy, Endoscopic/adverse effects
• Sphincterotomy, Endoscopic/instrumentation
• Sphincterotomy, Endoscopic/methods

Various endoscopic techniques have been developed to overcome the difficulties in biliary or pancreatic access during endoscopic retrograde cholangiopancreatography, according to the preference of the endoscopist or the aim of the procedures. In terms of endoscopic methods, guidewire-assisted cannulation is a commonly used and well-known initial cannulation technique, or an alternative in cases of difficult cannulation. In addition, precut sphincterotomy encompasses a range of available rescue techniques, including conventional precut, precut fistulotomy, transpancreatic septotomy, and precut after insertion of pancreatic stent or pancreatic duct guidewire-guided septal precut. We present a literature review of guidewire-assisted cannulation as a primary endoscopic method and the precut technique for the facilitation of selective biliary access.

• Catheterization
• Cholangiopancreatography, endoscopic retrograde
• Guidewire
• Precut

The management strategy for endoscopic retrograde cholangiopancreatography-related duodenal perforation can be determined based on the site and extent of injury, the patient’s condition, and time to diagnosis. Most cases of perivaterian or bile duct perforation can be managed with a biliary stent or nasobiliary drainage. Duodenal wall perforations had been treated with immediate surgical repair. However, with the development of endoscopic devices and techniques, endoscopic closure has been reported to be a safe and effective treatment that uses through-the-scope clips, ligation band, fibrin glue, endoclips and endoloops, an over-the-scope clipping device, suturing devices, covering luminal stents, and open-pore film drainage. Endoscopic therapy could be instituted in selected patients in whom perforation was identified early or during the procedure. Early diagnosis, proper conservative management, and effective endoscopic closure are required for favorable outcomes of non-surgical management. If endoscopic treatment fails, or in the cases of clinical deterioration, prompt surgical management should be considered.

• Cholangiopancreatography, endoscopic retrograde
• Endoscopic closure
• Perforation

• bile duct cannulation
• precut fistulotomy
• precut papillotomy
• precut sphincterotomy
• transpancreatic sphincterotomy

• Advanced cannulation technique
• Biliary cannulation
• ERCP
• Guidewire-assisted cannulation
• Needle knife sphincterotomy
• Precut sphincterotomy
• Transpancreatic septotomy

AIM: To compare diagnostic sensitivity, specificity and accuracy of magnetic resonance cholangiopancreatography (MRCP) without contrast medium and endoscopic ultrasound (EUS)/endoscopic retrograde cholangiopancreatography (ERCP) for biliary calculi.

METHODS: From January 2012 to December 2013, two-hundred-sixty-three patients underwent MRCP at our institution, all MRCP procedure were performed with the same machinery. In two-hundred MRCP was done for pure hepatobiliary symptoms and these patients are the subjects of this study. Among these two-hundred patients, one-hundred-eleven (55.5%) underwent ERCP after MRCP. The retrospective study design consisted in the systematic revision of all images from MRCP and EUS/ERCP performed by two radiologist with a long experience in biliary imaging, an experienced endoscopist and a senior consultant in Hepatobiliopancreatic surgery. A false positive was defined an MRCP showing calculi with no findings at EUS/ERCP; a true positive was defined as a concordance between MRCP and EUS/ERCP findings; a false negative was defined as the absence of images suggesting calculi at MRCP with calculi localization/extraction at EUS/ERCP and a true negative was defined as a patient with no calculi at MRCP ad at least 6 mo of asymptomatic follow-up. Biliary tree dilatation was defined as a common bile duct diameter larger than 6 mm in a patient who had an in situ gallbladder. A third blinded radiologist who examined the MRCP and ERCP data reviewed misdiagnosed cases. Once obtained overall data on sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) we divided patients in two groups composed of those having concordant MRCP and EUS/ERCP (Group A, 72 patients) and those having discordant MRCP and EUS/ERCP (Group B, 20 patients). Dataset comparisons had been made by the Student’s t-test and χ² when appropriate.

RESULTS: Two-hundred patients (91 men, 109 women, mean age 67.6 years, and range 25-98 years) underwent MRCP. All patients attended regular follow-up for at least 6 mo. Morbidity and mortality related to MRCP were null. MRCP was the only exam performed in 89 patients because it did show only calculi into the gallbladder with no signs of the presence of calculi into the bile duct and symptoms resolved within a few days or after colecistectomy. The patients remained asymptomatic for at least 6 mo, and we assumed they were true negatives. One hundred eleven (53 men, 58 women, mean age 69 years, range 25-98 years) underwent ERCP following MRCP. We did not find any difference between the two groups in terms of race, age, and sex. The overall median interval between MRCP and ERCP was 9 d. In detecting biliary stones MRCP Sensitivity was 77.4%, Specificity 100% and Accuracy 80.5% with a PPV of 100% and NPV of 85%; EUS showed 95% sensitivity, 100% specificity, 95.5% accuracy with 100% PPV and 57.1% NPV. The association of EUS with ERCP performed at 100% in all the evaluated parameters. When comparing the two groups, we did not find any statistically significant difference regarding age, sex, and race. Similarly, we did not find any differences regarding the number of extracted stones: 116 stones in Group A (median 2, range 1 to 9) and 27 in Group B (median 2, range 1 to 4). When we compared the size of the extracted stones we found that the patients in Group B had significantly smaller stones: 14.16 ± 8.11 mm in Group A and 5.15 ± 2.09 mm in Group B; 95% confidence interval = 5.89-12.13, standard error = 1.577; P < 0.05. We also found that in Group B there was a significantly higher incidence of stones smaller than 5 mm: 36 in Group A and 18 in Group B, P < 0.05.

CONCLUSION: Major finding of the present study is that choledocholithiasis is still under-diagnosed in MRCP. Smaller stones (< 5 mm diameter) are hardly visualized on MRCP.

• Biliary strictures
• Magnetic resonance cholangiopancreatography
• Biliary stones
• Endoscopic retrograde cholangiopancreatography
• Endoscopic ultrasound

• Aged
• Aged, 80 and over
• Catheterization/adverse effects
• Catheterization/methods
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Common Bile Duct
• Common Bile Duct Diseases/etiology
• Female
• Hemorrhage/etiology
• Humans
• Male
• Middle Aged
• Pancreatitis/etiology
• Retrospective Studies
• Risk Factors
• Sex Factors
• Sphincter of Oddi Dysfunction/complications
• Sphincterotomy, Endoscopic/adverse effects
• Sphincterotomy, Endoscopic/methods

• Endoscopic retrograde cholangiopancreatography
• Post-endoscopic retrograde cholangiopancreatography pancreatitis
• Sphincterotomy

• Anti-Inflammatory Agents/therapeutic use
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/instrumentation
• Humans
• Pancreatitis/diagnosis
• Pancreatitis/etiology
• Pancreatitis/prevention & control
• Risk Assessment
• Risk Factors
• Stents
• Treatment Outcome

• Cannulation
• Indomethacin
• Manometry
• Pancreatic stents
• Pancreatitis
• Precut
• Sphincter of Oddi dysfunction
• Sphincterotomy