Management of biliary diseases after the failure of initial needle knife precut sphincterotomy for biliary cannulation

Abstract

Endoscopic retrograde cholangiopancreatography is not always successful even with needle knife precut sphincterotomy (NKPS). How to manage these patients with initial NKPS failure has not been well studied. We report the outcomes of patients who received endoscopic and non-endoscopic rescue treatment after the initial NKPS failure. During the 15 years from 2004 to 2018, 87 patients with initial NKPS failure received interval endoscopic treatment (IET group, n = 43), percutaneous transhepatic biliary drainage (PTBD group, n = 25), or bile duct surgery (BDS group, n = 19) were retrospectively studied. Compared with the PTBD group, the prevalence of choledocholithiasis was higher (69.8% vs. 16.0%, p < 0.001), and malignant bile duct stricture were lower (20.9% vs. 76.0%, p < 0.001) in the IET group. Furthermore, the IET group had a significantly longer time interval between the first and second treatment procedures (4 days vs. 2 days, p = 0.001), a lower technique success rate (79.1% vs. 100%, p = 0.021), and a shorter length of hospital stay (7 days vs. 18 days, p < 0.001). Compared to the BDS group, the only significant finding was that the patients in the IET group were older. Although not statistically significant, the complication rate was lowest in the IET group (7.0%) while highest in the BDS group (15.8%). Complications in the IET group were also mild, as compared with the other two groups. In conclusion, IET should be considered after initial failed NKPS for deep biliary cannulation before contemplating more invasive treatment such as BDS. PTBD may be the alternative therapy for patients with malignant biliary obstruction.

Predictive factors of needle-knife pre-cut papillotomy failure in patients with difficult biliary cannulation

“…NKP was performed immediately after the failure of the conventional cannulation methods during the same endoscopic session. The NKP method was the same as that described in our previous study 24 , as shown in Fig. 1 .…”

Endoscopic salvage therapy after failed biliary cannulation using advanced techniques: A concise review

“…In a literature search in early 2022, we were only able to find 7 studies (371 patients in total) reporting interval ERCP[ 9 , 12 - 17 ]. All of these studies were retrospective.…”

“…There were no review/meta-analysis articles on this topic. However, when SBC cannot be achieved by advanced cannulation techniques, such as NKP or NKF, these studies have shown that interval ERCP is a viable treatment option (Table 1 )[ 9 , 12 - 17 ]. The overall success rate of interval ERCP was 76.3% (68%-79% between studies).…”

“…Today, most qualified ERCP endoscopists can master at least some of these advanced cannulation techniques, so these procedures can often be performed by the same endoscopist during the same endoscopic session[ 8 ]. Despite these rescue techniques, failed biliary cannulation can occur[ 9 ]. Therefore, in this review, difficult biliary cannulation was defined as failure to achieve SBC using the advanced techniques described above[ 10 , 11 ].…”

“…Therefore, in this review, difficult biliary cannulation was defined as failure to achieve SBC using the advanced techniques described above[ 10 , 11 ]. In the setting of difficult bile duct cannulation, there is currently no consensus on the next steps in treatment[ 9 ]. Because endoscopic therapy has the advantage of a broader range of treatment options and no need for external drainage, this review aims to propose and discuss potential endoscopic options, alone or in combination with the percutaneous procedure, for patients who have failed initial ERCP due to difficult bile duct cannulation.…”