Document resource
Introduction Needle-knife fistulotomy (NKF) is an advanced cannulation strategy for difficult biliary access, yet formal training is inconsistent and many ERCPists report low confidence in performing and teaching it. We aimed to describe UK consultant ERCPists’ baseline NKF experience and to evaluate the impact of a national series of advanced biliary cannulation masterclasses on NKF knowledge and intended use within a structured escalation algorithm.Methods Ten one-day advanced biliary cannulation masterclasses were delivered across the UK for consultant ERCPists. Delegates completed pre-course questionnaires assessing prior NKF use, formal training, experience teaching trainees, and self-rated NKF knowledge and teaching confidence (1–10 scale). Courses combined didactic teaching, video-based discussion of varied ampullary morphology and group discussion of escalation pathways when standard cannulation fails. Core sessions covered NKF, double guidewire technique, transpancreatic septotomy and cannulation of papilla in diverticulum. Using a stepwise escalation framework aligned with European guidance, the technical steps of NKF were deconstructed and reinforced with hands-on model training, emphasising when to escalate and how to teach NKF within an algorithmic approach. Post-course questionnaires captured retrospective pre- and post-course NKF knowledge scores, intention to use NKF more frequently, and willingness to consider primary fistulotomy in selected cases. Descriptive statistics are reported.Results Of 152 participants, 126 completed pre-course and 122 post-course questionnaires. At baseline, 82.5% had previously used NKF, but only 33.3% reported prior formal NKF training and 27.0% had trained trainees in the technique. Mean baseline NKF knowledge was 5.4/10, with low confidence in teaching trainees (mean 3.7/10). Post-course, mean NKF knowledge increased to 8.6/10, a mean improvement of 3.2 points; 84% improved by at least two points. Overall, 94.3% stated they would use NKF more frequently and 79.5% would consider primary fistulotomy in selected cases. Knowledge of other advanced access strategies also improved.Conclusions Among UK consultant ERCPists, NKF is used but formal training and teaching confidence remain limited. A national series of focused masterclasses incorporating video-based discussion, hands-on training and an explicit escalation algorithm was associated with substantial improvements in NKF knowledge and a clear shift towards earlier and more confident use, including primary fistulotomy in selected cases. Structured, morphology-based training that also reinforces other advanced cannulation strategies may help close the gap between everyday practice and teaching confidence, supporting safer dissemination of advanced biliary access techniques.