Most biliary or pancreatic duct strictures can be passed with a guidewire but a subset of especially tight ones remain impassable by standard dilation devices. Alternative techniques, such as drilling into the stricture, may be needed in such instances. 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 6Fr electrocautery device for “impassable” biliopancreatic strictures.

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 stent retriever) were excluded. Primary outcomes was 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 cases performed at Beaujon Hospital (Clichy, France) from 2020 to 2025.

A total of 99 patients were included (90 patients from 9 studies and 9 from our center). The primary composite outcome, combining technical success and safety, was achieved in 90% of patients. Technical success, allowing stent insertion in the desired position, was 100% (99/99). Clinical success was achieved in 94% (81/86).

Adverse events occurred in 10% of patients (11/99). All complications were considered mild or moderate, with no case of perforation or severe (Clavien-Dindo grade ≥3) adverse event observed. Four Patients (4%) had papillary bleeding following ERCP (including one during sphincterotomy, before the use of the cystotome in our cohort and without information for the others), three patients (3%) had mild pancreatitis developed after a pancreatic ERCP.  One patient (1%) had a cholangitis. One study included transient abdominal pain as an adverse event and reported 3 cases without documented pancreatitis.

Cystotome-assisted electrosurgical drilling appears 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’ ERCP toolbox.