A New Approach to the Bile Duct via Needle Puncture of the Papillary Roof

 

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Precut is an alternative technique for bile duct access when the conventional cannulation method has failed, although it is considered to be associated with a high risk of complication by acute pancreatitis [1] [2].

We describe an approach to the bile duct via puncture of the papillary roof without endoscopic ultrasound control, using a new design of catheter (CMS-Medical, São Paulo, Brazil). This catheter is made of polyethylene, with an 18-gauge needle covered by a flexible metallic sheath at the distal end (Figure [1]). The puncture is made in the midline of the proximal roof of the papilla, along the axis of the bile duct. After puncturing, a 0.025/0.018-inch guide wire is gently pushed through the catheter and into the bile duct under fluoroscopic control. A double-lumen catheter for cholangiography is then slid over the wire into the bile duct and the contrast medium is injected (Figure [2]). If there is resistance to progression of the guide wire, a fresh attempt at puncture of the papilla should be made in order to access the bile duct.

Figure 1 The CMS-Medical catheter with an 18-gauge needle, covered by a flexible metallic sheath at the distal end.

Figure 2 Schematic view (a) and endoscopic view (b) of the puncture site in the roof of the papilla. c Placement of the guide wire through the catheter into the common bile duct. d Radiological view showing the needle (black arrow) and the guide wire (white arrow).

This new technique represents a safe, low-cost approach to gaining access to the bile duct for investigative and therapeutic procedures. It is not complicated by thermal injury or by the acute pancreatitis associated with sphincterotomy [3].

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Reference

• 1 Masci E, Mariani A, Curioni S . et al . Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a meta-analysis.  Endoscopy. 2003;  35 830-834
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• 2 Schapira L, Khawaja F I. Endoscopic fistulo-sphincterotomy: an alternative method of sphincterotomy using a new sphincterotome.  Endoscopy. 1982;  14 58-60
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• 3 Mavrogiannis C, Liatsos C, Romanos A . et al . Needle-knife fistulotomy versus needle-knife precut papillotomy for the treatment of common bile duct stones.  Gastrointest Endosc. 1999;  50 334-339
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E. L. A. Artifon, M. D.

Gastrointestinal Endoscopy Unit, São Paulo University Medical School, São Paulo, Brazil

R. Panamericana, 64
São Judas 04303-170
São Paulo SP
Brazil

Fax: +55-11-3083-5216

Email: eartifon@yahoo.com