A prospective randomized trial of cannulation technique in ERCP: effects on technical success and post-ERCP pancreatitis

Dye-free wire-guided cannulation of the biliary tree during ERCP is associated with high success and low complication rates: outcomes in a single operator experience of 822 cases

BACKGROUND

Deep biliary cannulation (DBC) is a prerequisite to most endoscopic retrograde cholangiopancreatographies (ERCPs). Numerous techniques have been described to maximize success and minimize ERCP-related complications, most notably post-ERCP pancreatitis. Dye-free cannulation by using guidewires with hydrophilic tips has been proposed as a technique with a high rate of success and a low rate of complications. We report the outcomes 822 consecutive ERCP procedures by using dye-free guidewire cannulation techniques.

OBJECTIVE

To evaluate the success rate for DBC and rates of complications by using dye-free guidewire cannulation techniques.

DESIGN

Retrospective. Consecutive ERCP procedures with intent to achieve DBC exclusively by using dye-free guidewire technique were included. Complication data on post-ERCP pancreatitis, bleeding, perforation, and cholangitis were extracted.

SETTING

University.

PATIENTS

Patients undergoing biliary ERCP.

INTERVENTIONS

ERCP.

MAIN OUTCOME MEASUREMENTS

Success, complication rates.

RESULTS

Eight hundred and twenty-two ERCPs were performed on 744 patients. Five hundred and fifty-nine (68%) procedures were performed on inpatients, 263 (32%) on outpatients. DBC was successful in 801 of 822 (97%) ERCPs. In 795 of 801 (99%) ERCPs with successful DBC procedures, DBC was achieved in a dye-free fashion. Eleven patients (1.3%) developed post-ERCP pancreatitis-all cases were mild. Guidewire perforations occurred 11 times (1.3%), none required surgery. Ten of 11 patients with known or suspected (91%) guidewire perforation achieved successful DBC on repeat ERCP by the same endoscopist by using dye-free techniques.

LIMITATIONS

Retrospective.

CONCLUSIONS

In this large retrospective case series, a high success rate of DBC was achieved by using dye-free guidewire techniques. This technique has associated lower rates of complications in comparison to those reported earlier.

A prospective randomized controlled multicenter trial of duodenoscopes with 5 degrees and 15 degrees backward-oblique angle using wire-guided cannulation: effects on selective cannulation of the common bile duct in endoscopic retrograde cholangiopancreatography

BACKGROUND

In duodenoscopy, during endoscopic retrograde cholangiopancreatography (ERCP), a backward-oblique angle duodenoscope (BOAD) is generally used. In Japan, 15 degrees BOAD are mainly used, but in Western countries, 5 degrees BOAD are mostly used. In bile duct cannulation associated with ERCP, a catheter for contrast imaging is used in Japan, but wire-guided cannulation (WGC) using a papillotome is standard in Western countries. We conducted a randomized controlled multicenter trial to evaluate the contributions of different duodenoscopes using WGC to selective common bile duct cannulation.

METHODS

Subjects comprised 179 consecutive patients who underwent ERCP. Patients were randomized into the 15 degrees BOAD group (15 degrees group, n = 90) or the 5 degrees BOAD group (5 degrees group, n = 89).

RESULTS

The duodenal papilla could not be accessed endoscopically in two cases from each group. Success rates for bile duct cannulation by WGC without bow-up for the 15 degrees and 5 degrees groups were 85.6 and 56.2%, respectively (P < 0.01). Success rates for bile duct cannulation by WGC with bow-up for the 15 degrees and 5 degrees groups were 88.9 and 78.7%, respectively. Total rates of bile duct cannulation for the 15 degrees and 5 degrees groups were 94.4 and 92.1%, respectively. As for accidents, incidences of acute pancreatitis for the 15 degrees and 5 degrees groups were 5.6 and 9.0%, respectively, with no significant difference seen.

CONCLUSIONS

With 15 degrees BOAD, bile duct cannulation was favorable without papillotome bow-up. With 5 degrees BOAD, the success rate of WGC may be improved by adjusting the angle based on papillotome bow-up.

Needle-knife sphincterotomy: factors predicting its use and the relationship with post-ERCP pancreatitis (with video)

BACKGROUND

In the absence of precut needle-knife sphincterotomy (NKS), failure of biliary cannulation may occur in up to 10% of cases. There are few prospective evaluations of the safety and efficacy of NKS, and studies of its early use in difficult cannulation have been inconclusive. Whether precut NKS after failure of primary biliary cannulation is independently associated with post-ERCP pancreatitis (PEP) remains controversial.

OBJECTIVE

To examine the relationship between NKS and PEP.

DESIGN

Analysis of prospectively collected data from two randomized trials of ERCP techniques, with PEP as the primary endpoint measure.

SETTING

Tertiary-care academic medical center.

PATIENTS

This study involved 732 patients from two successive, prospective, randomized trials of naïve papilla cannulation between November 2001 and April 2006. Patients with pancreatic or ampullary cancer were excluded.

INTERVENTION

Naïve papilla cannulation, NKS, primary guidewire versus contrast-assisted cannulation, and glyceryl trinitrate patch versus placebo.

MAIN OUTCOME MEASUREMENTS

PEP and procedure-related complications.

RESULTS

NKS was performed in 94 of 732 patients (12.8%) and was successful in achieving bile duct access in 80 of 94 patients (85%). Cannulation success in the entire group was 717 of 732 patients (97.7%). The overall frequency of PEP following NKS was 14.9% (14 of 94 patients) compared with 6.1% (39 of 638 patients) without NKS (P < .001). The incidence of PEP increased with an increasing number of attempts at cannulating the papilla. Pancreatic stents were inserted in 22 patients, 5 of whom developed pancreatitis. In multivariate analysis, independent predictors of PEP were as follow: female sex (odds ratio [OR] = 3.5, P = .028), suspected sphincter of Oddi dysfunction (SOD) (OR = 9.7, P < .001), partial pancreatic drainage (OR = 4.8, P = .011), 10 to 14 attempts at papilla cannulation (OR = 4.4, P = .031), and >/=15 attempts at papilla cannulation (OR = 9.4, P = .013). NKS was not an independent predictor of PEP. There were no perforations, no major bleeding, and no cases of severe pancreatitis in the NKS group.

LIMITATIONS

Nonrandomized for NKS intervention.

CONCLUSIONS

The number of attempts at cannulating the papilla is independently associated with PEP, and the risk increases with an increasing number of attempts. NKS is not an independent predictor of PEP.

Prospective randomized blinded comparison of a short-wire endoscopic retrograde cholangiopancreatography system with traditional long-wire devices

BACKGROUND

Short-wire endoscopic retrograde cholangiopancreatography (ERCP) systems are perceived to carry advantage over traditional long-wire devices. To date, this potential advantage has not been well documented, and gastroenterologists are confronted in everyday practice with the dilemma of choosing a particular system without the benefit of having objective comparative data.

AIMS

The aim of this study was to compare the performance characteristics of the Fusion ERCP short-wire system with traditional long-wire devices.

METHODS

This is a prospective, blinded, randomized, controlled trial. Patients with a clinical indication for ERCP were randomized to undergo the procedure with the Fusion short-wire system or long-wire devices. All procedures were done by one experienced endoscopist who was blinded to the outcomes of the study. The person recording the outcomes was an independent observer not involved in the procedure and was blinded to the study hypothesis. The main outcome was device exchange time. Secondary outcomes included stent insertion time, total procedure time, fluoroscopy time, cannulation time, successful cannulation of the desired duct, and complications.

RESULTS

A total of 71 patients were enrolled. The short-wire system provided for significantly faster mean device exchange time (125 versus 177 s; P = 0.05) and stent insertion time (135 versus 254 s; P < 0.001) as compared with the long-wire system. A trend towards shorter total procedure time, fluoroscopy time, and cannulation time was noted with the short-wire system but did not reach statistical significance. Successful cannulation of the desired duct was achieved in all patients. Post-ERCP pancreatitis occurred in one patient in the short-wire and in two patients in the long-wire group.

CONCLUSIONS

This short-wire system provides for significantly shorter device exchange and stent insertion times compared with traditional long-wire devices.

Post-ERCP pancreatitis

Pancreatitis remains the most common severe complication of endoscopic retrograde cholangiopancreatography (ERCP). Detailed information about the findings of previous studies concerning post-ERCP pancreatitis has not been utilized sufficiently. The purpose of the present article was to present guidelines for the diagnostic criteria of post-ERCP pancreatitis, and its incidence, risk factors, and prophylactic procedures that are supported by evidence. To achieve this purpose, a critical examination was made of the articles on post-ERCP pancreatitis, based on the data obtained by research studies published up to 2009. At present, there are no standardized diagnostic criteria for post-ERCP pancreatitis. It is appropriate that post-ERCP pancreatitis is defined as acute pancreatitis that has developed following ERCP, and its diagnosis and severity assessment should be made according to the diagnostic criteria and severity assessment of the Japanese Ministry of Health, Labour and Welfare. The incidence of acute pancreatitis associated with diagnostic and therapeutic ERCP is 0.4-1.5 and 1.6-5.4%, respectively. Endoscopic papillary balloon dilation is associated with a high risk of acute pancreatitis compared with endoscopic sphincterotomy. It was made clear that important risk factors include dysfunction of the Oddi sphincter, being of the female sex, past history of post-ERCP pancreatitis, and performance of pancreaticography. Temporary prophylactic placement of pancreatic stents in the high-risk group is useful for the prevention of post-ERCP pancreatitis [odds ratio (OR) 3.2, 95% confidence interval (CI) 1.6-6.4, number needed to treat (NNT) 10]. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with a reduction in the development of post-ERCP pancreatitis (OR 0.46, 95% CI 0.32-0.65). Single rectal administration of NSAIDs is useful for the prevention of post-ERCP pancreatitis [relative risk (RR) 0.36, 95% CI 0.22-0.60, NNT 15] and decreases the development of pancreatitis in both the low-risk group (RR 0.29, 95% CI 0.12-0.71) and the high-risk group (RR 0.40, 95% CI 0.23-0.72) of post-ERCP pancreatitis. As for somatostatin, a bolus injection may be most useful compared with short- or long-term infusion (OR 0.271, 95% CI 0.138-0.536, risk difference 8.2%, 95% CI 4.4-12.0%). The usefulness of gabexate mesilate was not apparent in any of the following conditions: acute pancreatitis (control 5.7 vs. 4.8% for gabexate mesilate), hyperamylasemia (40.6 vs. 36.9%), and abdominal pain (1.7 vs. 8.9%). Formulation of diagnostic criteria for post-ERCP pancreatitis is needed. Temporary prophylactic placement of pancreatic stents in the high-risk group offers the most promise as a means of preventing post-ERCP pancreatitis. As for pharmacological attempts, there are high expectations concerning NSAIDs because they are excellent in terms of cost-effectiveness, ease of use, and safety. There was no evidence of effective prophylaxis with the use of protease inhibitors, especially gabexate mesilate.

Guidewire versus conventional contrast cannulation of the common bile duct for the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis

BACKGROUND

The use of a guidewire (GW) for cannulation of the bile duct during ERCP may prevent post-ERCP pancreatitis (PEP).

OBJECTIVES

A systematic review and meta-analysis of GW-guided versus conventional contrast (CC)-guided bile duct cannulation for the prevention PEP.

DESIGN

A November 2008 search of gray literature, databases, reference lists, and meeting abstracts was conducted for randomized, controlled trials comparing GW and CC. Two independent reviewers extracted the data. The outcomes included PEP, primary cannulation success, and other adverse events.

RESULTS

From 2132 citations, 7 randomized, controlled trials (5 noncrossover trials and 2 crossover trials) were included. Among noncrossover trials only, there was significant reduction in PEP when using a GW (3.2%) compared with CC (8.7%) (relative risk [RR] 0.38; 95% CI, 0.19-0.76). Subgroup analysis showed a significantly lower occurrence of PEP after GW entry versus CC injection of the pancreatic duct (1.1% vs 9.5%; RR 0.19; 95% CI, 0.06-0.58). Among patients with a precut sphincterotomy from a failed primary cannulation, there was less PEP with GW cannulation compared with CC (2.4% vs 21.7%; RR 0.21; 95% CI, 0.04-1.04). The other adverse event rates were comparable between GW and CC groups (2% vs 2%; RR 1.05; 95% CI, 0.39-2.83). Primary cannulation success was significantly greater with GW use compared with CC (89% vs 78%; RR 1.19; 95% CI, 1.05-1.35).

CONCLUSION

ERCP GW cannulation reduces the risk of PEP compared with the use of CC. GW cannulation is associated with a higher cannulation success rate and less PEP after pancreatic duct entry.

Can wire-guided cannulation reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis? A meta-analysis of randomized controlled trials

BACKGROUND AND AIM

The use of wire-guided cannulation (WGC) for prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is controversial. The aim of the present study was to assess the overall effect of WGC for PEP compared with conventional contrast-assisted cannulation by carrying out a meta-analysis of all available randomized controlled trials (RCT).

METHODS

Electronic databases, including PubMed, EMBASE, the Cochrane library and the Science Citation Index, were searched to retrieve relevant trials. In addition, meeting abstracts and the reference lists of retrieved articles were reviewed for further relevant studies. Outcome measures were the incidence of PEP.

RESULTS

Four RCT, enrolling a total of 1413 patients, were included. The meta-analysis failed to indicate a significant association between the use of WGC and the reduction of PEP (RR 0.34; 95% CI: 0.10-1.17; P = 0.09). Subgroup analysis including trials without cross-over design showed a significant benefit with the use of WGC in reducing PEP (RR 0.20; 95% CI: 0.09-0.40; P < 0.00001) and trials without precut used failed to indicate a significant differences between the two group (RR 0.38; 95% CI: 0.01-11.73; P = 0.58).

CONCLUSIONS

This meta-analysis showed only a non-significant reduction in the rate of PEP with the use of WGC. Further well-designed RCT are required to confirm the effect of WGC, especially in patients who were easier to cannulate.

Double-guidewire technique for difficult bile duct cannulation: a multicenter randomized, controlled trial

BACKGROUND

ERCP can be associated with serious complications. Difficulty in common bile duct (CBD) cannulation is one of the main risk factors for post-ERCP pancreatitis. The double-guidewire technique (DGT) has been considered a promising alternative approach in difficult cannulation situations.

OBJECTIVE

To compare the performance of DGT with the standard cannulation technique (SCT) in patients in whom CBD cannulation is difficult to perform.

DESIGN

Multicenter randomized, controlled trial.

SETTING

Six tertiary referral centers.

PATIENTS

A total of 188 patients with difficult CBD cannulation defined by completion of 5 unsuccessful cannulation attempts were enrolled.

INTERVENTIONS

Ninety-seven patients were assigned to the DGT group and 91 to the SCT group. Both techniques were compared for an extra 10 cannulation attempts.

MAIN OUTCOME MEASUREMENTS

CBD cannulation rate, number of attempts required to cannulate, and ERCP-related complications.

RESULTS

Successful CBD cannulation was achieved in 46 of 97 (47%) patients in the DGT group compared with 51 of 91 (56%) in the SCT group (OR 0.85; 95% CI, 0.64-1.12). The median number of attempts required for each group was 9 and 7, respectively (P = .128). The incidence of post-ERCP pancreatitis was 17% in the DGT group and 8% in the SCT group (OR 2.13; 95% CI, 0.89-5.05).

LIMITATIONS

Reduced number of enrolled subjects and a lack of detailed information regarding the number and extent of pancreatic duct contrast injections.

CONCLUSIONS

In patients with difficult CBD cannulation, DGT was not superior to SCT in achieving CBD cannulation. DGT might be associated with a higher risk of post-ERCP pancreatitis.

Can a wire-guided cannulation technique increase bile duct cannulation rate and prevent post-ERCP pancreatitis?: A meta-analysis of randomized controlled trials

OBJECTIVES

The most common technique used to achieve primary deep biliary cannulation is the standard contrast-assisted method. To increase the success rate and reduce the risk of complications, a wire-guided cannulation strategy has been proposed. Prospective studies provided conflicting results as to whether the wire-guided cannulation technique increases the cannulation rate and reduces post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis risk compared with the standard method. The objective of this study was to carry out a meta-analysis of randomized controlled trials (RCTs) that compares primary biliary cannulation and post-ERCP pancreatitis rates with the wire-guided method and the standard cannulation technique.

METHODS

Literature searches of electronic databases and online clinical trial registers up to March 2009 were conducted to identify RCTs comparing primary cannulation and post-ERCP pancreatitis rates with the wire-guided method and the standard cannulation technique. A meta-analysis of these clinical trials was performed.

RESULTS

Five RCTs were included. Overall, the primary cannulation rates reported with the wire-guided cannulation technique and the standard method were 85.3 and 74.9%, respectively. The pooled analysis of all the selected studies comparing the wire-guided cannulation technique with the standard method yielded an odds ratio (OR) of 2.05 (95% confidence interval (CI): 1.27-3.31). The pooled analysis comparing the post-ERCP pancreatitis rates for the wire-guided-cannulation groups with those for the standard-method groups yielded an OR of 0.23 (95% CI: 0.13-0.41).

CONCLUSIONS

This meta-analysis shows that the wire-guided technique increases the primary cannulation rate and reduces the risk of post-ERCP pancreatitis compared with the standard contrast-injection method. Further large, well-performed, randomized controlled studies are needed to confirm these findings.

Palliation of malignant obstructive jaundice

Peri-ampullary and hepatic malignancies will frequently present with obstructive jaundice. For unresectable tumors, effective and lasting decompression of the biliary tree is essential to improve quality of life and survival. An overview of present treatment modalities for palliation of obstructive jaundice is provided, including a systematic review of the English literature regarding the optimum choice of palliation.

ERCP wire systems: The long and the short of it

Guidewires are routinely used at the time of endoscopic retrograde cholangiopancreatography (ERCP) to gain and maintain access to the desired duct and aid in the advancement of various devices. Limitations of the traditional long-wire systems have led to the introduction of three proprietary short-wire systems. These systems differ in many respects but share two main principles: They lock a shorter wire in position to allow advancement or removal of various devices without displacement of the wire and they all allow for physician control of the wire. In this comprehensive review, we describe the key features of the three currently available short-wire systems: RX, Fusion and V systems. We also focus on the potential benefits and drawbacks that accompany the short-wire concept as a whole and each specific system in particular. Although the available data are limited, it appears that the use of the short-wire systems lead to reduced procedure, fluoroscopy and device exchange times, decreased sedation requirements, improved wire stability and increased endoscopist control of the wire. Furthermore, the physician-controlled wire-guided cannulation has the potential to decrease ampullary trauma and the rate of post-ERCP pancreatitis. The short guidewire systems appear to be an improvement over the traditional long-wire systems but further studies directly comparing the two approaches are needed.