Rescue Needle Knife Papillotomy Endoscopic Retrograde Cholangiopancreatography (ERCP) Cannulation: Success and Complications in a Retrospective Comparative Study With Procedure Time-Matched Controls.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a crucial endoscopic procedure for pancreato-biliary diseases for diagnostic and therapeutic purposes. Although commonly performed, difficult biliary cannulation (DBC) cases remain challenging when using conventional technology alone.

Objective: This study aimed to assess the efficacy and safety of rescue needle knife papillotomy (RNKP) compared to sphincterotomy only (SPTO) in DBC.  Methods: A retrospective observational study with sequential intervention analysis to evaluate outcomes between the SPTO and RNKP groups among endoscopic sphincterotomy (EST)-naïve cases that underwent ERCP in Sheikh Khalifa Specialty Hospital in the UAE. RNKP was performed after an unsuccessful conventional cannulation attempt with SPTO, utilizing the delicate technique of a needle knife catheter. Comparative analysis of procedural outcomes and adverse events was conducted using the procedure time-matched case pairs of both groups.

Results: Among 333 EST-naïve cases, SPTO was attempted initially in all patients, achieving successful cannulation in 277 (83.2%). In 56 cases where SPTO failed, the RNKP technique was applied, resulting in 55 successful cannulations with only one overall failure, leading to a total cannulation success rate of 332 (99.1%). After 1:1 time-matched case-control selection, 43 case-control pairs of SPTO vs. RNKP groups were analyzed. There were no statistically significant differences in post-ERCP complications between the two groups: cholangitis occurred in 2 cases (5.6%) in the SPTO group vs. 3 (7.3%) in the RNKP group (p=0.855); pancreatitis occurred in 1 (2.3%) vs. 3 (7.0%) (p=0.609); bleeding occurred in 0 (0%) vs. 1 (2.3%); and perforation did not occur in either group (0%).

Conclusion: RNKP is a highly effective rescue technique for difficult biliary cannulation, significantly increasing success rates following failed conventional SPTO cannulation, without elevating complication risks. This approach offers valuable clinical utility, especially for early-career endoscopists managing complex ERCP cases.