Endoscopy Master Videos: ERCP Precut with needle knife @ www.gastroliver.com.sg

When selective biliary cannulation fails due to anatomical reasons, precut sphincterotomy is a technique used to gain access to the bile duct. There are 3 techniques which I use: (1) needle knife method, (2) a short nose sphincterotome in the orifice, (3) trans-pancreatic septotomy with the sphincterotome tip in the pancreatic duct. The technique demonstrated is the needle knife (NK) method to "de-roof" the papilla. In this video, pre-cutting was performed exposing the sphincter muscle (grey-brown bulge). Next incision of the muscle sphincter is demonstrated. "Free hand" trial movements are made using the elevator bridge and in-out movements of the NK to orientate in the 11 o'clock direction. The depth of incision is judged by the tissue exposed: mucosa, submucosa, superficial part of ampullary sphincter muscle, salmon pink colored mucosa being the common channel, which is the landmark to stop cutting. Further incision beyond this plane reveals the deep part of the ampullary sphincter and beyond this, the duodenum wall. This is unnecessary and increases the risk of perforation. The incised papilla opens up like a book, exposing the common channel. The plane to achieve is the superficial ampullary sphincter. When this is incised further, the salmon pink colored common channel is exposed, sometimes with a gush of bile. The area is then gently probed with a soft tip catheter to locate the biliary orifice which is usually at the uppermost part of the incision.

Category:

Education

Tags:

• ERCP
• Singapore
• gastroenterologist
• sphincterotomy
• precut
• needle
• knife
• endoscopy
• ultrasound
• dave
• project
• international
• gastroenterology