Submucosal injection to facilitate needle-knife sphincterotomy: a novel technique

Area of Science:

• Gastroenterology
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Interventional Endoscopy

Background:

• Needle-knife sphincterotomy (NKS) is a critical rescue technique for biliary access.
• Flat (type 1) ampullae present challenges for NKS, increasing risks of bleeding and perforation due to poor tissue plane visualization.
• Adverse events during NKS are often linked to difficulties in differentiating anatomical planes.

Purpose of the Study:

• To describe a novel technique using submucosal dye injection to improve visualization during NKS.
• To demonstrate the utility of submucosal dye injection for enhanced anatomical plane differentiation in NKS procedures.
• To present a case study of successful NKS with submucosal dye injection for difficult biliary access.

Main Methods:

• A 59-year-old female patient with pancreatic cancer and obstructive jaundice underwent ERCP.
• Standard sphincterotomy failed due to a flat ampulla; NKS with submucosal lift was employed.
• Three mL of hetastarch with methylene blue was injected submucosally, creating a lift, followed by controlled dissection.

Main Results:

• Submucosal injection of hetastarch with methylene blue successfully created an adequate submucosal lift.
• Layer-by-layer dissection was performed, achieving deep cannulation of the bile duct.
• The procedure was completed without any adverse events, such as bleeding or perforation.

Conclusions:

• Submucosal dye injection significantly enhances visualization of anatomical planes during NKS.
• This technique allows for controlled, anatomically guided dissection, improving safety and efficacy.
• Submucosal dye injection represents a valuable adjunct for challenging NKS procedures, particularly in cases with flat ampullae.