Needle Knife Transduodenal Access of Common Bile Duct, a Novel Technique. The primary author is Navkirin Randhawa and the senior author is Dr. Cameron Ayub. There are no funding or relationships with industry disclosures to reveal. Endoscopic Retrograde Cholangiopancreography, or ERCP, has a high success rate for the treatment of biliary obstructive diseases. In complicated cases, cannulation of the biliary and pancreatic ducts can sometimes be unsuccessful even for expert endoscopists. We report a novel technique of bile duct access via needle knife transduodenal approach in patients where cannulation through the ampulla is unattainable. We report a multi-center perspective case series in which enrolled patients had failed attempts at cannulation of the bile duct through the ampulla due to the location of the ampulla being inside a diverticulum. Our technique entailed locating the duodenal bulge of the bile duct during endoscopy. A needle knife approach was used to dissect the duodenal wall layers and access the common bile duct. For our first case, we had a 92-year-old male with a past medical history of hypertension and hyperlipidemia who presented with obstructive jaundice. He had previously underwent two ERCPs with two different experienced endoscopists. However, both endoscopists were not able to cannulate the ampulla. The ampulla was deeply embedded within a diverticulum. For our second case, we had a 72-year-old female with a past medical history of coronary artery disease, gastroesophageal reflux disease, and hypertension who presented with significant right upper quadrant pain. She was also noted to have obstructive jaundice. She underwent four ERCPs with experienced endoscopists. However, the endoscopists were not able to cannulate the ampulla. The ampulla was also deeply embedded within the diverticulum. For the first part of the endoscopic technique, the duodenal bulge of the bile duct was located during the endoscopy. A needle knife approach was used to dissect the duodenal wall layers to access the common bile duct. The duodenal layers were dissected up until the bile duct or bile fluid was seen. A guide wire was passed through the bile duct and the position was confirmed by fluoroscopy and contrast injection. A fully covered metal stent was placed to create a fistula from the bile duct directly into the duodenum. The stent was removed in approximately four weeks. A total of three patients with filled biliary access due to ambulatory diverticulum were included in this series. All three patients had obstructive jaundice with multiple stones visible on imaging in the bile duct. CRCP was attended by experienced endoscopists, however, was unsuccessful as the ambulance was located completely inside a diverticulum and was unable to be cannulated. All patients underwent needle-knife access of the bile duct through the duodenal wall. A covered metal stent was placed into the common bile duct. A follow-up endoscopy was performed at four to six weeks for stent removal and balloon sweep. At six-month follow-up, all three patients had resolution of symptoms with no major adverse stents. In this pilot study, needle-knife access of the common bile duct through the duodenum proved to be an effective and safe option in patients with filled ERCPs due to inability to cannulate the ampulla.

Needle Knife Transduodenal Access

common bile duct

ampulla

endoscopy

metal stent