Ercp Cannulation Using Precut Techniques

With the emergence of endoscopic ultrasound and magnetic resonance retrograde cholangiopancreatography for the non-invasive diagnosis of hepatobiliary and pancreatic (HBP) disease, ERCP has evolved into a predominantly therapeutic technique. Failed bile duct or pancreatic duct cannulation may result in persistent patient morbidity and the need for more invasive procedures (e.g. biliary surgery and/or percutaneous biliary drainage). So-called needle knife pre-cut (NKP) biliary and pancreatic sphincterotomy has emerged as a useful technique when standard cannulation proves difficult. Multiple small retrospective studies - and handful of prospective reports - suggest that in expert hands, NKP is a safe and effective means of achieving therapeutic cannulation. NKP should only be performed by skilled endoscopists with supervised training in the procedure, a detailed knowledge of HBP anatomy, a thorough understanding of the physics of electrosurgery and the ability to place protective (prophylactic) pancreatic duct stents. Various techniques of 'free-hand' NKP are described, as well as trans-sphincteric papillotomy (the Goff technique). Pre-NKP preparation requires careful attention to coagulation issues, and post-NKP patients need to be monitored for complications including pancreatitis, bleeding, perforation and sepsis. After failed NKP in the setting of biliary obstruction, the patient must remain on broad-spectrum antibiotic coverage and a decision made regarding the urgency of biliary drainage. If this cannot wait at least 2-3 days for the NKP site to mature, the patient should be referred for urgent percutaneous biliary drainage or surgery. Copyright (C) 2010 S. Karger AG, Basel