AIM: To evaluate the technique of transpancreatic septotomy (TS) for cannulating inaccessible common bile ducts in endoscopic retrograde cholangiopancreatography (ERCP).

METHODS: Between May 2012 and April 2013, 1074 patients were referred to our department for ERCP. We excluded 15 patients with previous Billroth II gastrectomy, Roux-en-Y anastomosis, duodenal stenosis, or duodenal papilla tumor. Among 1059 patients who underwent ERCP, there were 163 patients with difficult bile duct cannulation. Pancreatic guidewire or pancreatic duct plastic stent assistance allowed for successful ERCP completion in 94 patients. We retrospectively analyzed clinical data from 69 failed patients (36 transpancreatic septotomies and 33 needle-knife sphincterotomies).

RESULTS: Of the 69 patients who underwent precut papillotomy, common bile duct cannulation was successfully achieved in 67. The success rates in the TS and needle knife sphincterotomy (NKS) groups were 97.2% (35/36) and 96.9% (32/33), respectively, which were not significantly different (P > 0.05). Complications occurred in 11 cases, including acute pancreatitis (n = 6), bleeding (n = 2), and cholangitis (n = 3). The total frequency of complications in the TS group was lower than that in the NKS group (8.3% vs 24.2%, P < 0.05).

CONCLUSION: Pancreatic guidewire or pancreatic duct plastic stent assistance improves the success rate of selective bile duct cannulation in ERCP. TS and NKS markedly improve the success rate of selective bile duct cannulation in ERCP. TS precut is safer as compared with NKS.

Endoscopic retrograde cholangiopancreatography (ERCP) is an important technique in the diagnosis and treatment of biliary and pancreatic diseases. Successful bile duct cannulation in ERCP is key to follow-up treatment. Biliary cannulation rates during ERCP exceed 90% in most large centers worldwide[1,2]. However, selective bile duct cannulation in ERCP is difficult to perform in patients with small duodenal papilla, papilla opening sclerosis, papilla looseness, peripapillary diverticulum or a history of Billroth II gastrectomy. Although a variety of catheters and guidewires are used to guide the knife, the failure rate of bile duct cannulation ranges from 5%-20%[3]. Prolonged or repeated attempts at cannulation in these patients increase the risk of ERCP related complications[2,4].

Pancreatic guidewire or stent placement can improve the success rate of bile duct cannulation during ERCP[5,6]. Endoscopic needle-knife precut papillotomy can also significantly increase ERCP cannulation success rate, but the complication rate is 6%-20%[7]. A thin septum between the pancreatic duct and the common bile duct has been reported (Figure 1)[8]; therefore, we hypothesized that difficult bile duct cannulation and repeated insertion into the pancreatic duct may be due to bile duct blockage by the septum in some cases. In the present study, a bow knife was used to cut the septum through the pancreatic duct toward the bile duct. Transpancreatic septotomy (TS) was compared with needle-knife sphincterotomy (NKS) during the same period to explore its clinical value.

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Figure 1 Septum between the pancreatic duct and common bile duct.

Endoscopy plays an increasingly important role in treating biliary and pancreatic diseases. Successful deep bile duct cannulation in ERCP is key to follow-up treatment of biliary diseases. However, the failure rate of bile duct cannulation is as high as 5%-20%[3]. At present, the most common methods to manage difficult bile duct cannulation include placement of a pancreatic guidewire or plastic stent, NKS, and TS. In this study, the success rate of bile duct cannulation increased to 93.4% by placement of a pancreatic guidewire or plastic stent, which is supposed to relieve the blockage of the pancreatic duct opening and facilitate the insertion of the second guidewire into the bile duct[10]. However, we believe that the guidewire or stent also changes the axis direction of the bile duct and straightens it.

Precut papillotomy is a complementary technique for conventional ERCP and endoscopic sphincterotomy (EST) that improves the success rate of ERCP and increases the success rate of papillotomy to 97%[11]. Needle-knife precut papillotomy is another commonly applied precut technique that has a high success rate of cannulation, as well as a high rate of complications (6%-20%), including perforation, bleeding, pancreatitis, and cholangitis[7]. Endoscopy researchers have been trying other precut techniques and hope to find a technique with a high success rate of cannulation and a low complication rate. Pancreatic duct cannulation has a relatively high success rate in clinical practice, but deep bile duct cannulation is relatively difficult, especially in patients with small papilla, peripapillary diverticulum, malposition of the papilla, or a history of Billroth II gastrectomy. We hypothesized that difficult bile duct cannulation may be related to duct blockage by the ampulla septum in cases where the guidewire repeatedly enters the pancreatic duct. The septum is located between the pancreatic duct and the common bile duct[8]. Therefore, we investigated TS in this study. Both NKS and TS resulted in high success rates, which were 96.9% and 97.2%, respectively, which were not significantly different between the two groups. However, the incidence of complications was significantly lower for TS than for NKS (8.3% vs 24.2%, P < 0.05).

TS was first reported by Goff[12]. In clinical practice, it is easy to insert the guidewire into the pancreatic duct but difficult to insert it into the bile duct. If the guidewire repeatedly enters the pancreatic duct but is unable to access the bile duct, a bow knife is used to make a 5-mm incision along the guidewire from the pancreatic duct at the 11-12 o’clock direction. After removing the bow knife, and the catheter is re-inserted into the bile duct along the upper left of the guidewire. This method has the advantages of a small incision; manageable direction; and a low incidence of bleeding, perforation, and infection. Goff reported an overall success rate up to 97.5% in his long-term study of 51 patients[13]. Weber et al[14] performed transpancreatic precut sphincterotomy for cannulating inaccessible common bile ducts in 108 patients. The success rate of selective bile duct cannulation was 95.4%, and the incidence of complications reached 11.1%. They suggested that the technique could be applied to the unsuccessful cases of conventional EST or needle-knife precutting. Catalano et al[8] compared TS with standard precut papillotomy in a randomized study and found that the former resulted in a higher success rate of bile duct cannulation and a lower incidence of complications; pancreatitis occurred in 3.4% and 11.8% of cases, respectively. Kahaleh et al[15] reported an overall success rate of 85% and a complication rate of 12% for 116 TS cases. In the present study, both TS and NKS had high success rates, which is similar to those reported in the literature. The results indicate that both techniques can improve bile duct surgery success rate, but TS is safer because of its lower complication rate. Of course, both techniques must be performed by skilled ERCP surgeons.

In summary, pancreatic guidewire or plastic stent assistance improves the success rate of selective bile duct cannulation in ERCP. TS and NKS further improve the success rate; however, TS is safer than NKS.