Cutting the difficult papilla : Ancillary techniques in the perf ortnance of endoscopic sphincterototny

Of 1040 endoscopic sphincterotomies performed over a five year 
period, standard papillotomy was possible in 874 (84%). In 166 cases (16%) a 
difficult papilla was encountered requiring nonstandard techniques of precutting, 
transpapillary guided endoscopic sphincterotomy, transhepatic guided endoscopic 
sphincterotomy and percutaneous transhepatic sphincterotomy. The 
technique first attempted in these 166 cases was successfully completed in 154 
(93%). Among the 135 cases with intradiverticular papillas, successful papillotomy 
was achieved in 125 (92.7%). Early complications of standard endoscopic 
sphin-.lerotomy included bleeding, perforation, pancreatitis and cholangitis, 
comprising 4.3% of the 1040 sphincterocomies. There were five deaths (mortality 
rate 0.5%) and laparotomy was required in six patients (0.6%). Conditions 
contributing to complications included an intradiverticular papilla and precutting. 
Evaluation of endoscopic sphincterotomy by transpapillary or transhepatic 
routes guided by guidewire or drain placement revealed complication rates of 6.6 
and 10.6%, respectively. Of the patients with histories of gastric resection and 
Billroth II anastomoses, standard sphincterotomy was possible in 15 (55.5%); in 
two cases the papilla was unapproachable endoscopically, requiring use of percutaneous 
transhepatic sphincterotomy. The percutaneous transhepatic sphincterotomy 
without endoscopic control is felt to be a higher risk procedure and 
should be reserved for rare indications. Appropriate use of these techniques 
should allow performance of endoscopic sphincterotomy in almost all clinical 
settings.

T l IE SUCCESS RA TE OF ENDOSCOPIC sphincterotomy 1s dependent on a va ri ety of factors.Most important among these arc the experience of the endoscop ist, the use of appropriate material (fihrcscopc and ancillary equipment) and the existence of anatomical problems.
Papillary va riants such as a polypoid form, location at an unusual place in the duodenum and presence of a duo<lenal diverriculum are common problems.The papilla which 1s clearly locatcJ on the margin of or in a d1verticulum may be difficult to access, but the sunple presence of a d iverriculum may change the orientation of the lower part of rhe common bile duct and thus make Jeep cannula lion more difficult.Additional, ly, previous gastric surgery and reconstruction may make t he papilla difficult or impossible to approach endoscopi, cally.The present study focuses on these techn ically challenging papillas and identifies common features in series of patients p resen ting with each of t hese problems in an effort to facilitate mastery of the <lifficult sphinctcrotomy.
From January 1985 through May 1989, 1040 endoscopic sphinctcrotomies w~re performed at the Clinique de !'Alma.There were 49 patients (4.7%) who had been referred after an unsuccessful attempt at endoscopic sphincterotomy at another centre.The papilla was located at the inner edge or inaduodenaldiverticulum in l 35cases.ln 27 patients there was a history of previous gastric resection with Billroth II anastomosis.A review of the l 040 consecutive cases revealed that the difficult papilla was encountered in 166 (16%).Four different techniques were used to successfully cut the difficult papilla, depending on the anatomy, as follows.Precutting: The precutting technique allows selective bile duct cannulation after a small incision upward on the papillary orifice or on the bulging i nfundibulum is made.A diathermy blade is used through a standard catheter to perform this technique.Transpapillary guided endoscopic sphincterotomy: Int roduction of a guidewire into the bile duct via the endoscopic route allows subsequent introduction of a special papillotome over rhe guidewire.The sphincterotomy is then performed after removal of the guidewire.Transhepatic guided endoscopic sphincterotomy: 1f a gui<lewirc cannot be introduced mto the bile duct via the endoscopic approach, a percutaneous transhepatic approach can be use<l for insertion of an internal-external drain across the papilla, followed hy a guided sph incterotomy under endoscopic control.The drain creates an artificially wide open papilla in this case.The tip of the papillotome is inserted in the open end of the drain and pushed into the papilla as the drain is carefully withdrawn.The sphincterotome is then in position for sphincterotomy.Variations of this technique include passage of the sphincterotome a longside the <lram into the papilla, L)r use of the diathermy blade to cut the papilla, over the drain in the direction of the infundibulum.The sphincterowme can then be introduced into the bile duct to complete the sphincterotomy.Alternatively, a guidewire alone may be placed via the transhepatic route with endoscopic insertion of the sphincterotome over the guidewire into the papilla.This latter technique obviates the need for dilation of the trnnshepatic tract for drain insertion.Percutaneous transhepatic sphincterotomy: This technique is reserved for the rare case of the endoscopically unapproachahle papilla.A guidewire is first placed rranshepatically across the CAN J 0ASTR0ENTEROL VOL 4 No 9 DECEMBER 1990 papilla.A special papillotome 1s then inserted over the gu idewire to perform the sp hinc.tcrotomytranshcpatically under fluoroscopic control.The procedure is performe<l with visua lization of the common bile duct throughout by injection of contrast media through the papillotome.One must place the cutting wire al the choledochoduodenal junction under fluoroscopic control.

RESULTS
Standard papillntomy was possible and successfully completed in 874 patients {84%).Of the l66 cases (16%) with a difficult papilla, the techntque of first attempt was precutting in I 18 cases, transpapillary gu ided endoscopic sp h,ncterotomy 1n 30, transhepatic guided endoscopic sphincteroromy in 16 and percutaneous transhepatic sphincterotomy in two.Both patients in this last group had undergone gastric resection with Billroth II anastommes.Ad<litionally, there were 12 cases of prccutting failures; transhepatic guided en<loscopic sp hinctcrotomy was the secondary procedure of c hoice in these cases bringing the tota l to 42 fo r th is technique.
The technique first attempted could not be completed in 12 of the 166 difficu lt papilla cases (7%).In these 12 failures, all precutting, a transhepatic gu ided endoscopic sphincterotomy was use<l ro success( ully complete the procedure.Table 1 delineates distribution of techniques and success rate.Among the 135 cases with intradiverucular papillas, a successfu l papillotomy was achieved in 125 (92.7%).
Early complications of standard endoscopic sphincterotomy included bleeding, perforation, pancreatitis and c holangitis.Therewere45 {4.3%) complications in the 1040sphincterotomies (Table 2).There were five deaths giving a mortality rate of 0.5% .Laparocomy was required in six cases {0.6%).Bleeding ( 1.7%) and perforation ( 1.1 %) were the most common complications, comprising all patients requiring laparotomy and all but on e of the <leaths.There was one death at-tributeJ to cholangitts.
Special conditions contributing to comp I ications included an intradiver-  ticular papilla and prccutting.Of the 18 cases with hemorrhage, four were in patients having an mcradiverticular papilla and three in patients having undergone precutting.Of the 12 cases with perforation, there were two and four patients with intradiverticular papillas and precutting, respectively.This yields 3% hemorrhage and 1.5% perforation rates for sphincterocomy in the presence of an intradiverticular papilla and 2.5% hemorrhage and 3.4% perforation rates in patients undergoing precutting.
Techniques used in the approach to patients with previous gastric resection and Billroth II anastomoses are noted in Table 3.The papilla could not be visualized with standard duodenoscopy in two patients; these two went on to undergo percutaneous transhepatic sph incterotomy.Standard sp hincterotomy was possible in l 5 of 2 7 patients (55.5%) .In the two cases of unapproachable papillas the papillotomy was performed without endoscopic control, and there was one case of massive bleeding which was managed conservatively using lavage through the percutaneous drain and blood transfusions.
Evaluation of endoscopic sphincterotomy guided by transpapillary or transhepatic routes revealed complication races of 6.6 and 10.6%, respectively.As expected, the transhepatic route carried a higher risk than the 4% complication rate found fo llowing standard sphincterotomy.The higher rate of complications with the percutaneous approach is related to transhepatic drain placement.The complication rate of endoscopic sphincterotomy after precutting was 11.8%, and evaluation of these cases revealed that complication was related to local anatomy, being lower in cases with a bulging, well defined infundibulum.S ince then thousands of sph incterotomies have been practised throughout the world, and this endoscop ic su rgical technique certainly represents a major therapeutic advance in the treatment of obstructive disease of the biliary tract.
Endoscopic papillotomy is now possible m nearly all cases using a variety  The papillary projection has a variable form, usually hemispheric with con, centric grooves, but it is occas1onall1 mult1lobular and rnrely flat.Theie variations can make cannulation d1f, ficult and may limit the application of ancillary technique:.used in cutting the difficult paptlla.At the tip, the papilla11 orifice also has a variable appearance, being villous in 52%, granular in 15%, irregular in 13%, vertically opening in 11 % 1 and circular and fixed in 3% (5).
In rare cases (0.56%) there exist two separate papillas for the biliary and pancreatic ducts (6).The superior orifice gives access to the bile duct and the inferior gives access to the pan, creatic duct.From a practical point oi view, papillary anatomy is quite van, able and there are really no two papilla1 exactly alike.
The appearance of the infundibulum is also quite variable and may vary depending on clinical presencanon.For example, the infundibulum is quite pro, minent and firm when a common hile duct stone is trapped within the papilla.
Additionally, it can be the location fix c holedochoduodenal fistulas and have the appearance of either a true orifice or a simple mucosa!erosion (7); the infun.dibulum may be absent.The dllitance between the papillary orifice and the junction of the common bile duct aoo duodenum varies between LS an<l 21 mm and can be longer in cases of lithias1sci the common bile duct (7,8).
For the standard sphincterotomy, the authors prefer the proximal sphincterotome with rhe cutting wire place<l 3 to 4 cm from the distal tip.Th~ has two advantages: the introduction of 5 to 6 cm of sphincterotome into the papilla serves to stab ii ize the instrument and allows graded movements to obcam the best possible position prior to sectioning of the papilla; anJ the risk of expulsion of the sphincterotome during sphincterotomy is avoided (9,10).In case of fai lure, the distal sphincterotome is used with the cutting wire positioned at the end (l l, 12).
The present authors inittally attempt guidewire placement across the papilla endoscopically in the event of failure of selective cannulat1on of the bile duct with standard methods.If successful, a guided sphincterocomy can be performed with a minimally higher complication rate (6.6 versus 4(Yo for standard techniques).In the event of failure to pass a guidewin . .' inro the sphincter orifice, precutllng is attempted if there is a well Jefined and 8. Barraya L, Pujol-Soler R, Yvcrgncaux bulging infunJibulurn.
This technique can be performeJ with a standard sphincterotome or with a special one with a very short ( I cm) cutting wire exiting theJistal end of the catheter ( 13,14).The authors prefer to use the diathermic wire with a diameter o( 0.2 mm exteriorizcd 3 to 5 mm from the end of the catheter (9).The precutting method is not used 1f the papilla is planar or excessively hidden in duodenal folds.AdJiuonally, precutting is only rarely useJ in cases of papillary association with duoJenal diverticula, as this anatomic assnciation significantly increases complications, notably perforation.T ranshepatic guided enJoscopic sphinctemtomy is reserved for very select cases with good mJicatinns for the procedure and failure of standard methods -precutting (if anatomically appropriate) and tramp:ipillary guideJ techniques (15)(16)(17)(18).It is also useJ as the proceJure ol ,econd choice i( rhc infun• dibulum 1s not dearly defined or nut visible . .Pcrcuranenus rranshepattc sphmcterntomy 1s consiJerc<l Jangerous and should he pursueJ only in very select cases in which sphmcterotnmy 1~ mandatory and the papilla is tru ly unapproachable by all ~randard techniques ( 19,20).Usually, the papilla is not cndoscopically visible due to previous surgical intervention sud1 as gasrrecromy with Billroth II or Roux-en-Y reconstruction (21-23).
In summary, a careful approach tn the difficult papilla baseJ on snlid anatomic underscanJing with appropriate ancillary equipment and mterventtonal radiological help shoulJ unprove the interven tional hi liary enJnscoptst's ability to perform successfully and safolv an endoscopic sphmcterotomy in al-mo~t all clinical settings.

DISCUSSION
Anazawa et al ( 1) first extracted a stone across the papilla using a biopsy • forceps in 1972.The first work on endoscopic sphincterotomy for calculi of the common bile duct was performed simultaneously in Germany (2) and Japan (3) m 1973 and in France (4) in 1974.
and tram, hepatic approaches.The choice of technique depends on papillary anacomi.

TABLE 1
Technique of first attempt of endoscopic sphincterotomies