A novel method for estimating the safe margin and the adequate direction of endoscopic biliary sphincterotomy in choledocholithiasis with complications (with videos)

Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy

“…83 Recommended methods to avoid this adverse event include the over-the-stent EST method with biliary stent placement and the use of a wire-guided sphincterotome, 90 or the method in which a balloon for stone removal is inflated at the papilla to verify oral protrusion and incision direction. 58 Furthermore, in reports from high-volume institutions, 91 there was no significant difference found in the incidence of post-EST hemorrhage between the group with diverticulum and the group without (1/46 vs 1/100). Statement 3-2: EST for impacted stones at the papilla effectively removes the stone, and improves the elevated pressure in the bile and pancreatic ducts Strength of recommendation: 1, evidence level: C Delphi scores: median = 9, lowest = 9, highest = 9…”

“…However, anatomical examinations may not necessarily be consistent with actual living bodies and, depending on the cutting direction, perforation can occur even if the superior margin of the papillary bulge is not reached, and thus due care should be exercised. A reported technique to confirm the superior margin of the incision involves dilating a balloon in the distal end of the bile duct, then pulling the balloon creating a bulge at the papilla, which is used as a landmark to verify the incision range and upper margin …”

“…In patients with periampullary diverticulum, if the papilla is tilted and the oral protrusion is unclear, it can be difficult to determine the incisional length and direction, and it has been reported that there is significantly more post‐EST hemorrhage in actual patients with diverticula compared to those without (8.8% vs 4.8%; P = 0.039) . Recommended methods to avoid this adverse event include the over‐the‐stent EST method with biliary stent placement and the use of a wire‐guided sphincterotome, or the method in which a balloon for stone removal is inflated at the papilla to verify oral protrusion and incision direction . Furthermore, in reports from high‐volume institutions, there was no significant difference found in the incidence of post‐EST hemorrhage between the group with diverticulum and the group without (1/46 vs 1/100).…”

“…A reported technique to confirm the superior margin of the incision involves dilating a balloon in the distal end of the bile duct, then pulling the balloon creating a bulge at the papilla, which is used as a landmark to verify the incision range and upper margin. 57,58 Statement 2-4: In cases of difficult biliary cannulation, precutting using a needle-knife or a sphincterotome is associated with a high success rate Strength of recommendation: N/A, evidence level: B Delphi scores: median = 9, lowest = 9, highest = 9…”

Feasibility of the Mucosa-Tracking Technique in Precut Papillotomy with the Iso-Tome as an Alternative to the Needle-Knife Technique

“…1,2,[16][17][18][19] The endoscopically visible papillary roof or an artificial bulge created by inflated-balloon-pulling technique are endoscopic landmarks which guarantee safe and effective endoscopic biliary sphincterotomy. 15,20 PP can also be made safer and more effective if endoscopic landmark is suggested. Several reports have noted that bile, or the PIPM which is exposed by PP, can be used as a guide for successful bile duct cannulation.…”