title: Endoscopic suprapapillary blunt dissection of the distal common bile duct in cases of difficult cannulation: a pilot series.
abstract: OBJECTIVE
  There is no consensus about the optimal alternative procedure in cases of failed cannulation of the common bile duct (CBD). The alternatives are usually considered to be high-risk procedures. This study describes endoscopic dissection of the distal biliary tract (EDBT) as a new technique in cases of difficult cannulation of the CBD.
  
  
  METHODS
  Out of a total of 1057 patients in whom cannulation was attempted, deep cannulation failed in 49 patients, and 48 of those underwent EDBT. The procedure consists of cutting the mucosa, and the partial isolation of the distal part of the biliary tract using catheters, a needle-knife papillotome, and thin forceps. Access to the biliary tract was achieved with an endoscopic needle or forceps with or without electrocoagulation.
  
  
  RESULTS
  EDBT was successful in all cases. In 46 patients EDBT was followed by standard sphincterotomy. Four patients developed clinical pancreatitis and hyperamylasemia occurred in 11 cases. Perforation, uncontrolled bleeding, and other complications did not occur in this series.
  
  
  CONCLUSIONS
  EDBT is feasible, safe and constitutes a potential alternative for cannulation of the CBD. The endoscopic visualization of the wall structure and duodenal layers during the maneuvers at the papilla probably accounts for the absence of major complications.
authors.affiliation: Endoscopic Unit, Hospital Sírio Libanês, São Paulo, Brazil. hashiba@attglobal.net
authors.forename: K
authors.initials: K
authors.lastname: Hashiba
authors.forename: M A
authors.initials: MA
authors.lastname: D'Assunção
authors.forename: S
authors.initials: S
authors.lastname: Armellini
authors.forename: R T
authors.initials: RT
authors.lastname: Hassegawa
authors.forename: C A
authors.initials: CA
authors.lastname: Cappellanes
authors.forename: D
authors.initials: D
authors.lastname: Moribe
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater / Q000601:surgery*; D001660:Biliary Tract Diseases / Q000601:surgery*; D002404:Catheterization / Q000379:methods; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000379:methods*; D003135:Common Bile Duct / Q000601:surgery; D004210:Dissection / Q000379:methods; D004564:Electrocoagulation; D005260:Female; D006801:Humans; D008875:Middle Aged; D010865:Pilot Projects; D011183:Postoperative Complications; D012449:Safety; D016717:Sphincterotomy, Endoscopic / Q000379:methods*; D016896:Treatment Outcome