Cystotome Use for Impassable Biliopancreatic Strictures: Efficacy and Safety-Systematic Review and Single Center Case Series.

INTRODUCTION

Certain biliary or pancreatic duct strictures can be crossed with a guidewire but remain impassable by standard dilation devices. Alternative strategies are sometimes required, such as drilling into the stricture with a cystotome, a 6Fr wire-guided electrocautery catheter. Data on the efficacy and safety of this rescue technique are scarce. We conducted a systematic literature review complemented by our single-center experience using a cystotome for unpassable biliopancreatic strictures.

METHODS

A systematic review of PubMed, Embase, Google Scholar, and Cochrane library was performed, including studies using a cystotome for biliary or pancreatic strictures that could not be dilated with standard accessories. Alternative devices (e.g., Soehendra) were excluded. Primary outcomes were the combination of technical success (ability to traverse the stricture and deploy a stent) and safety (absence of procedure-related adverse event). Clinical success (short- and long-term) were collected if available. Our review was supplemented with consecutive cases performed at Beaujon Hospital (Clichy, France) from 2020 to 2025.

RESULTS

A total of 102 patients were included (93 patients from 9 studies and 9 from our center). The primary composite outcome, combining technical success and safety, was achieved in 90.2% of patients. Technical success was 100% (102/102), with clinical success reported in 94% (84/89). Cystotome-related mild adverse events occurred in 9.8% of patients.

DISCUSSION: Cystotome-assisted electrosurgical drilling seems to be technically reliable and effective for complex biliopancreatic strictures that are resistant to standard dilation. This comprehensive study could encourage to integrate the cystotome in the endoscopists' endoscopic retrograde cholangiopancreatography toolbox.