Biliary - Difficult Cannulation Treated with Needle Knife Pre-Cut Over a Pancreatic Stent
Comments: This elderly woman has recurrent cholangitis, an unknown biliary diversion operation 30 years ago. MRCP is inderminate for biliary stricture versus complete surgical diversion. Outside attempt at ERCP resulted in failed cannulation and mild post-ERCP pancreatitis.
A a pancreatogram is obtained with Autotome 39 and 025 Jagwire; then a 5-4-3 catheter (Boston Scientific) is attempted but also enters PD, so a 018 Roadrunner wire (Wilson Cook) is advanced to tail of pancreas to see if it helps with biliary cannulation, and guarantee access for placement of a pancreatic stent to reduce risk. Note the safety loop of wire in the tail
A 5-4-3 cannula is used to attempt bile duct cannulation but reenters PD as can be seen on flouroscopy
A 4 French 9cm unflanged pancreatic stent (Hobbs Medical, Stafford Springs CT) is placed to protect the pancreas. The external pigtail is flipped down to stay out of the way. This stent will fall out in a few weeks
A needle knife (Microknife, Boston Scientific) is used to unroof the papilla. As long as the incision does not go below the pancreatic stent, it is not to deep. The goal is to unroof the common channel.
A 5-4-3 is used to probe and cannulate the bile duct.
This turns out to be complete cutoff of the distal CBD due to prior surgery. It is tiny and no bile has flowed out of this for 30 years.
| Contributed by: |
Martin L. Freeman, M.D. Professor of Medicine Hennepin County Medical Center University of Minnesota |
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Citation: Freeman, ML (Feb 16 2006). Biliary - Difficult Cannulation Treated with Needle Knife Pre-Cut Over a Pancreatic Stent. The DAVE Project. Retrieved Sep, 9, 2010, from http://daveproject.org/viewfilms.cfm?film_id=316 Times viewed since Feb 2006: 8170 |
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