title: Wire assisted transpancreatic septotomy, needle knife precut or both for difficult biliary access.
abstract: OBJECTIVE
  Pre-cut techniques, the most commonly described being needle knife papillotomy (NK), have been used to facilitate biliary access in failed standard biliary cannulation (BC). Transpancreatic septotomy (TS) is a pre-cut technique with limited outcome data. We aim to assess the outcomes of wire assisted transpancreatic septotomy (WTS) as the primary pre-cut technique after initial failed attempted BC and to compare these with outcomes of primary NK.
  
  
  METHODS
  We retrospectively reviewed all endoscopic retrograde cholangiopancreatographies (ERCPs) performed by endoscopists who performed WTS over a 3-year period. We selected cases where WTS and/or NK were performed, and these cases were reviewed to assess for procedure related complications and BC success.
  
  
  RESULTS
  During the study period 1336 ERCPs were performed. WTS was performed in 53 cases. In seven cases WTS and NK were performed sequentially (resulting in immediate cannulation in all these cases). Immediate BC was achieved on first attempt in 36 (68%) WTS cases and in a further 14 cases on a repeat attempt (cumulative BC rate 94%). During the same period 66 (5%) patients underwent primary NK. In these cases initial cannulation was achieved in 50 (76%) cases and cannulation on repeat attempt in six cases (cumulative success rate 85%). Complications occurred in three WTS patients (5.6%) and seven NK patients (10.6%). The differences were not statistically significant.
  
  
  CONCLUSIONS
  Wire assisted transpancreatic septotomy is a safe and effective alternative technique to traditional NK in patients who have failed standard BC techniques. It also allows other pre-cut techniques such as NK to be used should initial WTS be unsuccessful.
authors.affiliation: Department of Gastroenterology, Sir Charles Gairdner Hospital, Perth, Australia. calvinhychan@gmail.com
authors.forename: Calvin H Y
authors.initials: CH
authors.lastname: Chan
authors.forename: Frank N
authors.initials: FN
authors.lastname: Brennan
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Zimmerman
authors.forename: Donald G
authors.initials: DG
authors.lastname: Ormonde
authors.forename: Spiro Costa
authors.initials: SC
authors.lastname: Raftopoulos
authors.forename: Ian F
authors.initials: IF
authors.lastname: Yusoff
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001652:Bile Ducts / Q000601:surgery*; D001660:Biliary Tract Diseases / Q000601:surgery*; D002404:Catheterization; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D016717:Sphincterotomy, Endoscopic / Q000295:instrumentation / Q000379:methods*; D013525:Surgical Instruments; D013997:Time Factors; D016896:Treatment Outcome; D014904:Western Australia