Difficult cannulation during endoscopic retrograde cholangiopancreatography – needle knife fistulotomy versus transpancreatic sphincterotomy on the basis of successful cannulation and adverse events

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Aims When cannulation is difficult in endoscopic retrograde cholangiopancreatography (ERCP) and standard guidewire technique with sphincterotomy is unsuccessful, alternative cannulation techniques must be employed to access the biliary tree. The objective of this study was to compare the frequency of adverse events and the success rates of cannulation between transpancreatic sphincterotomy (TPS) and needle knife sphincterotomy (NKS). Methods Data from GallRiks, the Swedish Registry for Gallstone Surgery and ERCP collected from 2011 to 2022 were analyzed. 105,303 ERCP procedures were recorded in GallRiks throughout the study period. Exclusion criteria consisted of non-juvenile papilla, cannulation assistance, altering surgery, pancreatic duct intention and other sphincter manipulation. After exclusion, 45,543 ERCP procedures formed the study population. Out of these, 4,696 received NKS and 3,411 received TPS. 35,436 ERCP procedures with conventional sphincterotomy were used as a control group. Primary outcomes were successful cannulation and 30-day adverse events. Results Successful cannulation was more frequent with the TPS technique than with the NKS technique (86.5% vs 69.4%, P<.001). The TPS group had a longer procedure time compared to the NKS group (50.3 minutes vs. 47.9 minutes, P<.001). Both the NKS and TPS procedures had a higher rate of intraprocedural complications in comparison to the control group (5.2% vs. 4.3% vs 2.3%, P<.001). The TPS group had a higher occurrence of adverse events compared to the NKS group (24.1% vs. 18.8%, P<.001) and both groups had a higher incidence of adverse events compared to the control group (15.5%, P<.001). The subgroup analysis revealed significant differences in the frequency of pancreatitis (10.2% vs. 6.3%, P<.001) and perforation (1.6% vs. 0.8%, P<.001) between the NKS and TPS groups. However, there were no differences in the rates of cholangitis or bleeding. [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] Conclusions Although not performed in the same difficult cannulation ERCP scenarios, TPS appears to be more successful at cannulation. However, this comes at a higher cost of overall adverse events, particularly increased risks of both pancreatitis and perforation. Therefore, the procedure should be reserved only for particularly difficult situations and executed exclusively by skilled endoscopists who take all necessary prophylactic measures. Publication History Article published online: 15 April 2024 © 2024. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

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