Suprapapillary puncture of the common bile duct for selective biliary access: a novel technique (with videos)

BackgroundSelective cannulation of the bile duct while avoiding the potential mechanisms that initiate the cascade of pancreatic injury may prevent or minimize post-ERCP pancreatitis. This could be accomplished by suprapapillary needle puncture of the bile duct with a specially designed needle.ObjectivesThe aim of this study is to describe a new technique to perform selective biliary cannulation by using a novel needle-puncture device and its outcome in 28 patients with suspected biliary pathology.DesignThis is a single-center, prospective pilot study of suprapapillary puncture of bile duct for both diagnosis and therapy of biliary pathology.SubjectsThirty patients were enrolled: 28 patients underwent suprapapillary puncture to gain biliary access, and 2 patients with a large periampullary diverticulum were excluded.InterventionsAfter successful biliary cannulation by using a suprapapillary puncture technique and balloon dilation of the tract if necessary, stone removal, plastic stent insertion, and metal stent insertion were attempted.Main Outcome MeasurementsSuccessful biliary cannulation, time for cannulation, outcome of therapy (clearing the stones or providing stent drainage with stent insertion), and complications were recorded. At 60 days, the suprapapillary puncture was evaluated to check the status of drainage.ResultsSuprapapillary puncture was successful in 25 of the 28 patients, and, in 1 patient, it was successful after a week. It was useful in demonstrating a normal bile duct in 9 of 11 patients with suspected biliary pathology. Subsequent therapy was successful in the management of 11 patients with stones, benign biliary pathology in 2 patients, and malignant biliary pathology in 3 of 4 patients. None of the patients developed post-ERCP pancreatitis. Complications included small perforations that resolved with conservative management (n = 2), minor bleeding (n = 2), and submucosal injection (n = 1). At 60 days, all the puncture sites healed in patients who did not undergo dilation, while those with dilation of the tract had a patent orifice, with excellent flow of bile.ConclusionsSuprapapillary puncture for biliary cannulation is a useful technique for selective cannulation of the bile duct and avoids injury to the pancreas but with higher complication rates. Further studies will be needed to define its safety and its relative benefits compared with conventional access methods.