Clinical Endoscopy

Safety and feasibility of opening window fistulotomy as a new precutting technique for primary biliary access in endoscopic retrograde cholangiopancreatography: Yasuhiro Kuraishi, Kazuo Hara, Shin Haba, Takamichi Kuwahara, Nozomi Okuno, Takafumi Yanaidani, Sho Ishikawa, Tsukasa Yasuda, Masanori Yamada, Nobumasa Mizuno; Clin Endosc 2023;56(4):490-498. Published online April 27, 2023; DOI: https://doi.org/10.5946/ce.2022.130

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Background
/Aims: Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common and serious complication of endoscopic retrograde cholangiopancreatography. To prevent this event, a unique precutting method, termed opening window fistulotomy, was performed in patients with a large infundibulum as the primary procedure for biliary cannulation, whereby a suprapapillary laid-down H-shaped incision was made without touching the orifice. This study aimed to assess the safety and feasibility of this novel technique.
Methods
One hundred and ten patients were prospectively enrolled in this study. Patients with a papillary roof size ≥10 mm underwent opening window fistulotomy for primary biliary access. In addition, the incidence of complications and success rate of biliary cannulation were evaluated.
Results
The median size of the papillary roof was 6 mm (range, 3–20 mm). Opening window fistulotomy was performed in 30 patients (27.3%), none of whom displayed PEP. Duodenal perforation was recorded in one patient (3.3%), which was resolved by conservative treatment. The cannulation rate was high (96.7%, 29/30 patients). The median duration of biliary access was 8 minutes (range, 3–15 minutes).
Conclusions
Opening window fistulotomy demonstrated its feasibility for primary biliary access by achieving great safety with no PEP complications and a high success rate for biliary cannulation.

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Comments on ‘Safety and feasibility of opening window fistulotomy as a new precutting technique for primary biliary access in endoscopic retrograde cholangiopancreatography’
Masood Muhammad Karim, Adeel Ur Rehman, Faisal Wasim Ismail, Om Parkash
Clinical Endoscopy.2024; 57(2): 280. CrossRef

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Rotatable sphincterotome as a rescue device for endoscopic retrograde cholangiopancreatography cannulation: a single-center experience: Takeshi Okamoto, Takashi Sasaki, Tsuyoshi Takeda, Takafumi Mie, Chinatsu Mori, Takaaki Furukawa, Yuto Yamada, Akiyoshi Kasuga, Masato Matsuyama, Masato Ozaka, Naoki Sasahira; Clin Endosc 2024;57(1):96-104. Published online April 25, 2023; DOI: https://doi.org/10.5946/ce.2022.248

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Background
/Aims: Selective bile duct or pancreatic duct cannulation remains a significant initial hurdle in endoscopic retrograde cholangiopancreatography (ERCP) despite advances in endoscopy and accessories. This study evaluated our experience with a rotatable sphincterotome in cases of difficult cannulation.
Methods
We retrospectively reviewed ERCP cases using TRUEtome, a rotatable sphincterotome, as a rescue device for cannulation at a cancer institute in Japan from October 2014 to December 2021.
Results
TRUEtome was used in 88 patients. Duodenoscopes were used for 51 patients, while single-balloon enteroscopes (SBE) were used for 37 patients. TRUEtome was used for biliary and pancreatic duct cannulation (84.1%), intrahepatic bile duct selection (12.5%), and strictures of the afferent limb (3.4%). Cannulation success rates were similar in the duodenoscope and SBE groups (86.3% vs. 75.7%, p=0.213). TRUEtome was more commonly used in cases with steep cannulation angles in the duodenoscope group and in cases requiring cannulation in different directions in the SBE group. There were no significant differences in adverse events between the two groups.
Conclusions
The cannulation sphincterotome was useful for difficult cannulations in both unaltered and surgically altered anatomies. It may be an option to consider before high-risk procedures such as precut and endoscopic ultrasound-guided rendezvous techniques.

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All‐in‐one sphincterotome with high rotation performance and freely bendable blade for endoscopic sphincterotomy in patients with surgically altered anatomy (a case series with video)
Yasuhito Kunogi, Atsushi Irisawa, Akira Yamamiya, Manabu Ishikawa, Tomoya Sakamoto, Yasunori Inaba, Ken Kashima, Fumi Sakuma, Koh Fukushi, Takumi Maki, Kazunori Nagashima, Yoko Abe, Shuichi Kitada, Akane Yamabe, Keiichi Tominaga
DEN Open.2025;[Epub] CrossRef
Non-tip and rotatable sphincterotome for biliary cannulation in patients with Roux-en-Y gastrectomy
Haruo Miwa, Kazuya Sugimori, Kazuki Endo, Ritsuko Oishi, Hiromi Tsuchiya, Takashi Kaneko, Shin Maeda
Endoscopy.2024; 56(S 01): E103. CrossRef
Progress in minimally invasive treatment of biliary pancreatic duct obstruction after digestive tract reconstruction by endoscopic retrograde cholangiopancreatography
Ru-Yi Wang, Zhen Fan
World Chinese Journal of Digestology.2024; 32(7): 490. CrossRef

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Factors Predicting Difficult Biliary Cannulation during Endoscopic Retrograde Cholangiopancreatography for Common Bile Duct Stones: Hirokazu Saito, Yoshihiro Kadono, Takashi Shono, Kentaro Kamikawa, Atsushi Urata, Jiro Nasu, Haruo Imamura, Ikuo Matsushita, Tatsuyuki Kakuma, Shuji Tada; Clin Endosc 2022;55(2):263-269. Published online November 12, 2021; DOI: https://doi.org/10.5946/ce.2021.153

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Background
/Aims: Difficult biliary cannulation is an important risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Therefore, this study aimed to identify the factors that predict difficult cannulation for common bile duct stones (CBDS) to reduce the risk for PEP.
Methods
This multicenter retrospective study included 1,406 consecutive patients with native papillae who underwent ERCP for CBDS. Factors predicting difficult cannulation for CBDS were identified using univariate and multivariate analyses.
Results
Univariate analysis showed that six factors significantly predicted difficult cannulation: ERCP performed by non-expert endoscopists, low-volume center, absence of acute cholangitis, normal serum bilirubin, intradiverticular papilla, and type of major duodenal papilla. Multivariate analysis identified ERCP performed by non-expert endoscopists (odds ratio [OR], 2.5; p<0.001), low-volume center (OR, 1.6; p<0.001), intradiverticular papilla (OR, 1.3; p=0.007), normal serum bilirubin (OR, 1.3; p=0.038), and absence of acute cholangitis (OR, 1.3; p=0.049) as factors significantly predicting difficult cannulation for CBDS.
Conclusions
Initial cannulation by an experienced endoscopist, early rescue cannulation, or early takeover by an experienced endoscopist should be considered when performing ERCP for CBDS in the presence of factors predicting difficult cannulation.

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Development of a Scoring System for Predicting the Difficulty of Bile Duct Cannulation and Selecting the Appropriate Cannulation Method
Taira Kuroda, Hideki Miyata, Kozue Kanemitsu-Okada, Emi Yanagihara, Hironobu Saneto, Taisei Murakami, Hirofumi Izumoto, Kei Onishi, Shogo Kitahata, Tomoe Kawamura, Ryuichiro Iwasaki, Fujimasa Tada, Eiji Tsubouchi, Atsushi Hiraoka, Tomoyuki Ninomiya
Digestive Diseases and Sciences.2025; 70(2): 843. CrossRef
Unsedated emergent ERCP is feasible and efficient for acute cholangitis in old patients over 80 years
Jia-Qi Xu, Yi-Fan Qu, Zhao-Chao Zhang, Shi-Yao Chen, Yun-Shi Zhong, Yi-Qun Zhang, Wei-Feng Chen, Jian-Wei Hu, Ming-Yan Cai, Li-Qing Yao, Quan-Lin Li, Ping-Hong Zhou
Surgical Endoscopy.2025; 39(5): 2847. CrossRef
Difficult biliary cannulation during endoscopic retrograde cholangiopancreatography for distal malignant biliary obstruction caused by pancreatic cancer: An observational study
Jun Noda, Yuichi Takano, Naoki Tamai, Masataka Yamawaki, Tetsushi Azami, Fumitaka Niiya, Naotaka Maruoka, Masatsugu Nagahama
DEN Open.2025;[Epub] CrossRef
Advancements in Research on Challenges in Selective Biliary Cannulation during Endoscopic Retrograde Cholangiopancreatography (ERCP)
天雨张
Journal of Clinical Personalized Medicine.2024; 03(01): 100. CrossRef
The impact of transpancreatic precut sphincterotomy on the quality of ERCP in a low-volume setting
Wei-Chih Su, Chia-Chi Wang, Tsung-Hsien Hsiao, Hung-Da Chen, Jiann-Hwa Chen
Gastrointestinal Endoscopy.2024; 99(5): 747. CrossRef
Morphology of the papilla can predict procedural safety and efficacy of ERCP—a systematic review and meta-analysis
Edina Tari, Endre Botond Gagyi, Anett Rancz, Dániel Sándor Veres, Szilárd Váncsa, Péter Jenő Hegyi, Krisztina Hagymási, Péter Hegyi, Bálint Erőss
Scientific Reports.2024;[Epub] CrossRef
Quality Indicators of Endoscopic Retrograde Cholangiopancreatography in Korea
Hyung Ku Chon, Ki-Hyun Kim, Tae Jun Song, Dong-Won Ahn, Eaum Seok Lee, Yun Nah Lee, Yoon Suk Lee, Tae Joo Jeon, Chang Hwan Park, Kwang Bum Cho, Dong Wook Lee, Jin-Seok Park, Seung Bae Yoon, Kwang Hyun Chung, Jin Lee, Miyoung Choi
Gut and Liver.2024; 18(4): 564. CrossRef
Quality Indicators of Endoscopic Retrograde Cholangiopancreatography in Korea
Ki-Hyun Kim, Hyung Ku Chon, Tae Jun Song, Dong Won Ahn, Eaum Seok Lee, Yun Nah Lee, Yoon Suk Lee, Tae Joo Jeon, Chang Hwan Park, Kwang Bum Cho, Dong Wook Lee, Jin-Seok Park, Seung Bae Yoon, Kwang Hyung Chung, Jin Lee, Miyoung Choi
The Korean Journal of Gastroenterology.2024; 84(3): 111. CrossRef
Quality Indicators of Endoscopic Retrograde Cholangiopancreatography in Korea
Ki-Hyun Kim, Hyung Ku Chon, Tae Jun Song, Dong Won Ahn, Eaum Seok Lee, Yun Nah Lee, Yoon Suk Lee, Tae Joo Jeon, Chang Hwan Park, Kwang Bum Cho, Dong Wook Lee, Jin-Seok Park, Seung Bae Yoon, Kwang Hyung Chung, Jin Lee, Miyoung Choi
The Korean Journal of Pancreas and Biliary Tract.2024; 29(4): 144. CrossRef
En face position of the major duodenal papilla using a reopenable clip during endoscopic retrograde cholangiopancreatography
Hirokazu Saito, Akiko Ikebata, Shunpei Hashigo
Digestive Endoscopy.2023;[Epub] CrossRef
Criterios 5-5-2 de canulación biliar y complicaciones post colangiopancreatografía retrógrada endoscópica: Experiencia en un hospital de referencia, Perú
Wilmer Gustavo Quiroga Purizaca, Diego Ricardo Páucar Aguilar, Jackeline Amparo Barrientos Pérez, Isamar Benyi Gutiérrez Córdova, Renato Garrido Acedo, Daniel Andrei Vargas Blácido
Revista de Gastroenterología del Perú.2023; 43(2): e1461. CrossRef
Predictive factors of difficult biliary cannulation: An experience of a tunisian tertiary center
K. Ben Abdallah, L. Hamzaoui, M. Mahmoudi, I. Cherif, A. Ben Mohamed, M. Yakoubi, A. Khsiba, M. Medhioub, M.M. Azouz
Heliyon.2022; 8(12): e12526. CrossRef

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Prevention of Postendoscopic Retrograde Cholangiopancreatography Pancreatitis: The Endoscopic Technique: Byeong Jun Song, Dae Hwan Kang; Clin Endosc 2014;47(3):217-221. Published online May 31, 2014; DOI: https://doi.org/10.5946/ce.2014.47.3.217

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Pancreatitis is the most frequent and distressing complication of endoscopic retrograde cholangiopancreatography (ERCP). Many recent studies have reported the use of pharmacological agents to reduce post-ERCP pancreatitis (PEP); however, the most effective agents have not been established. Reduction in the incidence of PEP in high-risk patients has been reported through specific cannulation techniques such as guide wire-assisted cannulation and the use of pancreatic stents. The present review focuses on ERCP techniques for the prevention of PEP.

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Risk of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis After Double-Guidewire Biliary Cannulation in an Average-Risk Population
Joseph T. Krill, Tomas DaVee, Jade S. Edwards, J. Chris Slaughter, Patrick S. Yachimski
Pancreas.2018; 47(6): 748. CrossRef
Optimal Use of Wire-Assisted Techniques and Precut Sphincterotomy
Tae Hoon Lee, Sang-Heum Park
Clinical Endoscopy.2016; 49(5): 467. CrossRef

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Successful Bile Duct Cannulation Guided by Indigocarmine Injection via PTGBD: Bum Suk Son, M.D., Sang-Heum Park, M.D., Tae Hoon Lee, M.D., Seung Kyu Chung, M.D., Jae Man Park, M.D., Il-Kwun Chung, M.D., Hong Soo Kim, M.D. and Sun-Joo Kim, M.D.; Korean J Gastrointest Endosc 2011;42(1):62-65. Published online January 30, 2011

Abstract PDF: Even though percutaneous transhepatic gallbladder drainage (PTGBD) is performed prior to ERCP or following ERCP because of the patients' medical condition or failed bile duct cannulation, there are no definite endoscopic landmarks that are useful for successful bile duct cannulation in some cases. We report here on 4 patients in whom selective bile duct cannulation, as guided by the endoscopic landmarks, was successful following indigocarmine injection via PTGBD. (Korean J Gastrointest Endosc 2011;42:62-66)

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The Balloon Occluded Method for Selective Cannulation of the Intrahepatic Duct: A Case Report: Yong Wuk Kim, M.D., Dae Han Kang, M.D., Dong Uk Kim, M.D., Cheol Woong Choi, M.D., Pyo Jun Kim, M.D., Kyung Sik Jung, M.D. and Woo Jin Jung, M.D.; Korean J Gastrointest Endosc 2009;38(1):57-59. Published online January 30, 2009

Abstract PDF: Selective cannulation into the intrahepatic duct during ERCP can occasionally be difficult and time-consuming depending on the GI tract anatomy and the presence of biliary tree anomalies or pathology. A variety of techniques or devices have been used to enhance the success rate of selective cannulation in these situations. The balloon occluded method for selective cannulation of the LHD (left hepatic duct) with using an inflated balloon catheter to occlude the RHD (right hepatic duct) has also been reported. We report here a case of successful selective cannulation of the RHD with using an inflated balloon catheter to occlude the LHD in a patient who had a GB cancer with liver metastasis. After this maneuver, a guidewire is advanced; it deflects off the inflated balloon and then proceeds to the RHD. (Korean J Gastrointest Endosc 2009;38:57-60)

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Bile Duct Cannulation Guided by a Percutaneous Transhepatic Biliary Drainage (PTBD) Tube: Modified Rendezvous Procedure: Hong Joo Kim, M.D., Seon Hyeong Choi, M.D.*, Jung Ho Park, M.D., Dong Il Park, M.D., Yong Kyun Cho, M.D., Chong Il Sohn, M.D., Woo Kyu Jeon, M.D. and Byung Ik Kim, M.D.; Korean J Gastrointest Endosc 2007;34(3):138-142. Published online March 30, 2007

Abstract PDF: Background
/Aims: To describe a simple and useful modification of the rendezvous technique using a PTBD tube as guidance. Methods: From January 2005 to August 2006, a total of 436 ERCPs were performed. A diagnosis of choledocholithiasis was made in 235 cases. Deep cannulation of the bile duct using standard techniques was unsuccessful in 27 patients (11.5%). A precut papillotomy led to successful cannulation in 16 out of these 27 patients (59.3%). The remaining 11 patients (40.7%) underwent PTBD with the tube tip placed in the second portion of the duodenum. Bile duct cannulation was attempted with the guidance of a PTBD tube in 9 cases. In the other 2 cases, the transduodenal approach was impossible due to a previous Billroth II operation. Results: Bile duct cannulation guided by a PTBD tube, which is also known as a modified rendezvous procedure, was successful in 9 out of 11 patients (81.8%). Deep cannulation of the bile duct was achieved in 100% of patients, who could be treated by endoscopy. There were 7 cases of transient hyperamylasemia (77.8%) but no procedure-related major complications or mortality. Conclusions: Bile duct cannulation guided by a PTBD tube in patients with choledocholithiasis can be recommended when ERCP is unsuccessful using the standard technique. (Korean J Gastrointest Endosc 2007;34:138⁣142)

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게실 내 유두에서 두 개의 카테타를 이용한 췌담관 삽관술 ( A Novel Approach for Cannulation of the Ampulla within a Diverticulum : A Two - Catheter Method ): Korean J Gastrointest Endosc 2001;23(1):53-55. Published online November 30, 2000

Abstract PDF: cAn ampulla within a diverticulum is not rare especially in elderly patients with duct stones, but may pose a problem in identifying the papilla and properly orienting this structure for cannulation during endoscopic retrograde cholangiopancreatography. We therefore have used a new technique using the application of an additional catheter to keep the ampulla outside the diverticulum. When we pushed the duodenal fold downward and laterally with the first catheter, the ampulla was everted from the diverticulum and the hidden papilla was brought into view. Once the papilla was visible, the second catheter which was identical to the first, was advanced alongside it and inserted into the papillary orifice without difficulty. Bventually a successful Cholangiogram was obtained. With the insertion of a guidewire through the second catheter, sphincterotomy and insertion of endoscopic nasobiliary drainage tube were also performed successfully. (Korean J Gastrointest Endosc 2001;23;53-55)

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내시경적 담도삽관을 위한 침형절개도를 이용한 누두절개술 ( Infundibulotomy ) 의 유용성 ( Efficacy of Needle-knife Infundibulotomy in Failed Cannulation on Endoscopic Retrograde Cholangiopancreatography ): Korean J Gastrointest Endosc 2000;20(4):267-273. Published online November 30, 1999

Abstract PDF: Background
/Aims : Cannulation failure to biliary tract has been reported in 10% of patients who are performed diagnostic and therapeutic ERCP. Infundibulotomy by use of needle knife is cutting a bulbar part of protruding papilla, which has merit to avoid complete destruction of sphincter of Oddi and serious side effects than general precutting method. We want to know effectiveness and safety of infundibulotomy. Methods : From January 1997 to December 1998, 36 patients who failed cannulation over three times trial by conventional method are included to this study. We compared the success rate of cannulation and procedure related complication according to bile duct dilatation, periampullary diverticulum and shape of ampulla of Vater. Results : 1) Success rate of cannulation to bile duct is 81% (29/36). 2) All patients in group of bile duct dilatation (14) are succeed to cannulation, which is significantly high compare to other group (p=0.0288). 3) There was no statistical difference in success rate according to presence of periampullary diverticulum. 4) In groups of bulging prominent papilla are succeed in 23 among 26 patients, which is tendency of high in patients than other group (p=0.0760). 5) Total occurrence of procedure related complication was 33% (12/36). 6) The complication rate was not different in two groups according to cannulation success 7) The complication rate was tendency of high in patients without bile duct dilatation (p=0.0756). Conclusions : Infundibulotomy by use of needle knife is effeetive and safe cannulation method to patient who failed cannulation to bile duct. Success of cannulation is low and occurrence of complication is tendency of high in patient without bile duct dilation, which propose endoscopists attention in selection of indications. (Korean J Gastrointest Endosc 2000;20:267-273)

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유두부 주위 게실 환자에서의 파악겸자를 이용한 췌담도의 선택적 삽관술 (Application of Grasp Forceps on Selective Cannulation of Pancreatobiliary Duct in a Patient with Peripapillary Diverticulum ): Korean J Gastrointest Endosc 1999;19(2):313-317. Published online November 30, 1998

Abstract PDF: During endoscopic retrograde cholangiopancreatography (ERCP), cannulation is more difficult in patients with anatomical variations, ampullary stenosis, impacted stone in the papilla, papillary cancer, peripapillary diverticulum, postoperative states such as those after Billroth II or Braun operations. In patients with peripapillary diverticulum, the position of the papilla can be modified by the presence of the diverticulum, rendering the cannu-lation more difficult. In this situation, the success rate of ERCP is lower than that in nor-mal situation. We have, therefore, used a new technique with the application of grasp forceps to expose the duodenal papilla properly during ERCP in a patient whose papilla was located on the edge of a large duodenal diverticulum and the papillary orifice was hidden behind the edge of the diverticulum. (Korean J Gastrointest Endosc 19: 313 ∼317, 1999)

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증례 : 담도 췌장 ; 담낭 이중조영술이 진단에 유용했던 만성 담낭염 1예 ( Case Reports : Biliary Tract & Pancreas ; A Case af Chronic Cholecystitis Diagnosed with Double Contrast Study of the Gallbladder ): Korean J Gastrointest Endosc 1998;18(1):117-121. Published online November 30, 1997

Abstract PDF: The combined diagnostic modalities using abdominal ultrasound, endoscopic ultrasound and endascopic retrograde cholangiopancreatogram are useful for the diagnosis of gall bladder disease. But, these diagnostic methods have limitations for the detection of early flat-type gallbladder cancer. To cope with these problems, double contrast study of gallbladder disease is being recently used to diagnose the flat-type cancer of gallbladder in Japan. Herein we report a case of chronic cholecystitis confirmed histologically and assisted by double contrast method of gallbladder, which was diagnosed as a gallbladder polyp by abdominal sonogram at first. The method requires the cystic duct cannulation and placement of the catheter to the gallbladder. And then Barium sulfate and CO2 are injected through the catheter. The patient didnt experience any complication during and after this procedure except for hyperamylasemia. After the simple cholecystectomy, he improved completely. In conclusion, double contrast study of gallbladder can be useful in the diagnosis of the gallbladder disease and compensate for the other dignostic tools. (Korean J Gastrointest Endosc 18: 117-121, 1998)

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