Equipment<unk> s: a<unk>  (also called a papillotome) is a catheter with a cutting wire at its far end. They have various configurations based on cutting wire length, outer diameter, number of lumens, and presence of other features such as the ability to rotate. The<unk>  is connected to an electrosurgical generator, allowing the cutting wire to function as a knife when an electrical current is applied. Additional lumens allow the addition of a guidewire and injection of radio-opaque contrast. They can be broadly categorized as pull-type, push-type, or needle-knife. Pull-type: pull-type<unk> s consist of a steel cutting wire within a Teflon catheter. The wire exits the catheter approximately 3 cm before its distal end and re-enters the catheter approximately 3 mm from its tip. When tension is applied to the wire, the distal portion of the catheter becomes curved so that the exposed wire is brought upwards into contact with the<unk>  sphincter and papilla, away from the catheter. Push-type: push-type<unk> s have a similar design to pull-type, but instead tightening the wire pushes it out to form a bow oriented downwards. This is useful for patients with Billroth II anatomy. Needle-knife: a needle-knife<unk>  has a retractable cutting wire of 3 to 5 mm with a Teflon sheath. They are most often used for a pre-cut<unk>  when standard methods of cannulation fail. Technique Standard<unk> : the<unk>  is inserted into the bile duct. A cholangiogram is then used to evaluate any<unk>  abnormalities requiring further intervention. The papilla is then incised with the cutting wire by applying electrocautery. Pre-cut<unk> : pre-cut<unk>  refers to the techniques used to cut the papillary mucosa and<unk>  sphincter in order to expose the underlying bile duct and gain access to it when standard cannulation fails. Transpancreatic<unk><unk>  (septotomy): when the guidewire is unintentionally inserted into the main pancreatic duct the<unk>  is then placed in the pancreatic duct and used to cut the septum between the pancreatic duct and bile duct. It is then withdrawn and re-directed through the incision site into the bile duct with the guidewire. Needle knife papillotomy: a needle knife<unk>  is placed en face to the<unk>  papilla. An incision is then made stepwise, starting at the upper margin of the papillary orifice and extending towards the<unk>  sphincter, creating an incision to allow the bile duct to be cannulated. Needle knife fistulotomy: a needle knife fistulotomy has two different technique which are used. For the first technique an incision is made a few millimeters above the opening to the duct and then extended upwards. The other option is to make an incision in the roof of the papilla and then extend it either up or down without cutting the papillary orifice itself. The rate of pancreatitis after ERCP was significantly lower after fistulotomy, compared to other precut techniques. Modifications for anatomic variations Periampullary diverticulum: periampullary diverticulum makes the procedure more difficult because it becomes harder to assess the incision. Needle-knife fistulotomy or pancreatic stent placement followed by precut<unk>  are two of several techniques that have been used to account for the increased difficulty. Surgically altered anatomy (Billroth II): if a patient has undergone a partial gastrectomy with Billroth II anastomosis, the papilla may appear to be upside down from the perspective of the endoscope compared to normal. Cannulation may need to be performed in a reverse position with the bile duct oriented downwards.
Biliary endoscopic sphincterotomy
Endoscopic retrograde cholangiopancreatography
Cholecystectomy
Hepatic artery embolization
Percutaneous ethanol injection
Percutaneous hepatic perfusion
Hepatoportoenterostomy
Cholecystenterostomy