Biliary endoscopic sphincterotomy: Techniques and complications

Figure 1 Needle knife sphincterotome was used for endoscopic sphincterotomy over a plastic stent inserted into the common bile duct in a patient with an altered anatomy. A: A juxtapapillary diverticula is seen in a patient with Billroth II gastrectomy; B: A 7Fr-plastic stent is inserted to the common bile duct after cannulation; C-E: Sphincterotomy is performed step wise with a needle knife sphincterotome over the plastic stent; F: Common bile duct stone is extracted with a basket catheter.

Figure 2 Precautions for decreasing the sphincterotomy related complications. A: Sphincterotomy is started with a standard sphincterotome after biliary cannulation; B: Extended towards 11 o’clock; C: Biliary drainage is noticed; D: Sphincterotomy is finished near the roof of the papilla.

Figure 3 Rotating the scope to the left with simultaneous advancement to a long or semi-long position must be done for correct positioning. A: Sphincterotome is oriented towards the wrong direction (black arrow) in the short endoscope position; B: Endoscope is pushed to the long position; C: Sphincterotome is oriented towards the right direction (white arrow).

Figure 4 It may be safer to terminate endoscopic sphincterotomy early and switch to balloon dilation of the papilla in patients with periampullary diverticula. A: Papilla is located on the edge of the diverticulum at 7 o’clock; B: A small sphincterotomy could be made because of difficulty in maintaining appropriate position; C: Papilla is dilated with a 12-mm balloon, D: A notch on the balloon is seen.

Figure 5 Transpancreatic biliary sphincterotomy. A: Pancreatic duct is unintentionally cannulated during biliary cannulation attempts; B: Guidewire is inserted to the pancreatic duct; C: Cutting wire of the sphincterotome is oriented towards 11 o’clock to cut the septum between the pancreatic duct and bile duct; D: Bile duct is cannulated after a 5-Fr plastic stent is inserted to the pancreatic duct for post-endoscopic retrograde cholangiopancreatography pancreatitis prophylaxis.