DIFFICULT BILIARY CANNULATION: SECOND ERCP, NEEDLE KNIFE PRECUT, FISTULOTOMY AND DASE

by Monzur Ahmed

A 76 year old man was admitted with a 3 week history of painless jaundice, dark urine and one stone weight loss. Initial investigations were as follows:
- Bilirubin 181 umol/L, ALT 105, Alk Phosp 270 (NR<130)
- WBC 8.4 increasing to 16, Hb 14.2 g/dL, Platelets 370
- CT scan:
  - large calcified stone in low CBD
  - dilated CHD/ IHD
It was thought that he had cholangitis secondary to a CBD stone. An ERCP, performed 2 days ago by colleagues, showed a bulky papilla and despite a needle knife precut, it was not possible to enter the bile duct. He was therefore referred for a second ERCP 2 days later (see video)...
Cannulation again proved difficult and the needle knife was again used to perform a further precut and fistulotomy. The CBD was eventually accessed but the stone proved stubborn. A sphincterotomy and sphincteroplasty were necessary before we were able to extract the stone with a balloon (dilatation assisted stone extraction, DASE). Finally, a pigtail stent was inserted because there was an additional short stricture (??) in the mid bile duct. Despite the messy procedure, the patient did not have any complications and went home a couple of days later with a view to having another ERCP 6 weeks later to remove the stent and reassess the CBD.

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