Facilitating transpancreatic biliary sphincterotomy with a rotatable sphincterotome: a case of improved biliary cannulation

To perform endoscopic retrograde cholangiopancreatography (ERCP), cannulation of the common bile duct through the major papilla is necessary. However, even experts fail to achieve selective biliary cannulation in 5% to 20% of cases [1]. When standard cannulation techniques fail, precut incision methods such as needle-knife sphincterotomy and transpancreatic biliary sphincterotomy (TPBS) can be employed. However, these precut techniques also have failure rates of 10% to 40% [2]. Needle-knife sphincterotomy allows for flexible incision lines but is technically challenging, while TPBS is easier but limited by a fixed incision line and difficulty aligning with the bile duct axis. The new rotatable sphincterotome may overcome these limitations, making TPBS easier and more efficient. We herein report a case of successful selective biliary cannulation via TPBS using a novel sphincterotome (ENGETSU; Kaneka Medical, Osaka, Japan).

A 67-year-old woman was admitted to our hospital with obstructive jaundice caused by cholangiocarcinoma ([Fig. 1]). ERCP was performed using a lateral-viewing endoscope (TJF 290V; Olympus Marketing, Tokyo, Japan), with uneventful insertion and visualization of the papilla. Biliary cannulation attempts using wire-guided and double-guidewire techniques were unsuccessful. We then performed TPBS using the new rotatable sphincterotome for the first time ([Video 1]). By rotating the sphincterotome, the blade could be directed in any desired orientation ([Fig. 2] a–c). TPBS was carried out with careful alignment to the expected direction of the bile duct axis ([Fig. 2] d). After TPBS, bile duct cannulation was successfully achieved, and the planned procedures (biopsy and stent placement) were completed without complications.

Fig. 1 Computed tomography at the time of diagnosis. A mass was identified in the common bile duct, with dilation of the bile duct upstream from the mass.

Fig. 2 Transpancreatic biliary sphincterotomy (TPBS) using the new rotatable sphincterotome. a Neutral position during initial insertion. b Position of the sphincterotome after clockwise rotation. c Position of the sphincterotome after counterclockwise rotation. d Appearance of the papilla after TPBS.

Transpancreatic biliary sphincterotomy using a new rotatable sphincterotome in a case of difficult biliary cannulation.Video 1

This novel sphincterotome enabled effective and safe TPBS in cases where biliary cannulation was difficult.

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Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

We thank Angela Morben, DVM, ELS, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.

• References

• 1 Testoni PA, Mariani A, Aabakken L. et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2016; 48: 657-684
• 2 de-la-Morena-Madrigal EJ. Impact of combined precut techniques on selective biliary cannulation. Rev Esp Enferm Dig 2013; 105: 338-344

Publikationsverlauf

Artikel online veröffentlicht:
03. Februar 2025