Precut papillotomy: a risky technique not only for experts but also for average endoscopists skilled in ERCP

Safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients aged 85 years and older: A single center experience

Objective: To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients (≥85 years old).

Material and Methods: Patients who underwent ERCP for any reason within 12 months were evaluated. Patients undergoing ERCP were classified as the elderly group aged 85 years and older or the controls under the age of 85 years.

Results: A total of 1225 patients, 504 males and 721 females, were included in the study. Length of hospital stay, the number of patients in whom pre- cut sphincterotomy was performed in ERCP, and mortality rate showed similar characteristics compared to the control group in patients with advanced age (≥85 years old). Except for pancreatitis, there was no significant difference between the groups in terms of complications related to the procedure. Post ERCP pancreatitis was observed significantly less in the elderly group (p= 0.042). Pre-cut sphincterotomy was required in a total of 191 (15.5%) patients. In patients who underwent pre-cut sphincterotomy and patients with cholangitis, post ERCP complication rates were not significant between the groups.

Conclusion: ERCP is a safe procedure for older patients (≥85 years old) as well as young patients.

Primary Needle-Knife Sphincterotomy for Biliary Access in Patients at High Risk of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Methods

Forty patients with one or more risk factors for PEP were prospectively enrolled between June 2018 and November 2019. The cannulation was conducted in all patients using NKS as the primary cannulation technique. Success rate of biliary cannulation, biliary cannulation time, and adverse event rate were assessed.

Results

Of the 40 patients enrolled, 34 patients underwent primary NKS after the screening. Nine patients had 1 risk factor for PEP, 7 had 2, 8 had 3, 7 had 4, and 3 had 5. The success rate of biliary access by NKS was 94.1% (32/34). The median procedure time for NKS and the total procedure time for stone removal or biliary drainage were 4.1 minutes (range, 0.5-25.2) and 11.3 minutes (range, 3.8–40.4), respectively. Adverse events occurred in two patients (minor bleeding, n = 1; hyperamylasemia, n = 1). No patient experienced PEP or perforation.

Conclusion

NKS might be feasible as a primary cannulation procedure in patients at high risk of PEP. This trial is registered with KCT0004886 (03/06/2018).

Trainee involvement increases precut rates and delays access to the common bile duct without an increase in procedure-related adverse events: a brave new world of ERCP training?

BACKGROUND AND AIMS

Selective cannulation of the desired duct is a key element in ERCP procedures and an important step in the training of fellows. However, there is limited data about technical success and patient safety for ERCPs conducted in a training setting.We aimed to evaluate the impact of trainee involvement on the cannulation technique and procedure related outcomes at ERCP.

MATERIALS AND METHODS

We conducted an observational study of all ERCP conducted in an endoscopy unit with an on-going training program. Patient related data and procedure-related data (method of cannulation, time to cannulation, degree of trainee involvement, technical success and procedure-related adverse events) were collected using a standard form. The method of cannulation, time to cannulation and procedure-related adverse events were compared between ERCPs with trainee involvement and those without.

RESULTS

641 consecutive ERCPs were evaluated and 474 native papilla cases performed by 4 trainers and 3 trainees were included in the final analysis. Trainees were involved in 171 procedures (36.1%), achieving cannulation of the desired duct in 50.8% of the cases. Cannulation rates were similar in the trainee group compared to the control group (91.7% vs. 88.7%) and there was no increase in the rate of adverse events. However, cannulation time was significantly longer in the trainee group with a significant increase in the rate of precut use (32.1% vs. 23.4%, p < 0.001).

CONCLUSIONS

Trainee involvement resulted in longer cannulation times and increased use of precut sphincterotomy, but, was not associated with an increased risk of procedure related adverse events.

Can Early 'Shallow' Needle-knife Papillotomy be the First Choice in ERCP?

PURPOSE

Needle-knife sphincterotomy, known as 'precut' is recommended as the second option in the case of difficult cannulation due to its potential higher complication (bleeding and perforation) rates. The aim of this study was to present our experience on early shallow needle-knife papillotomy (eSNKP) as the first-line choice independently of standard technique with or without difficult cannulation.

MATERIALS AND METHODS

A total of 70 patients underwent therapeutic endoscopic retrograde cholangiopancreatography. A standard eSNKP and guidewire cannulation technique was routinely preferred as a first-line intervention. Deep biliary cannulation rate and timing were recorded, as well as intraoperative and postoperative complication rates.

RESULTS

Successful deep biliary cannulation was performed in 66 (94.3%) patients during the first procedure. In 4 patients (5.7%), the procedure was terminated due to failed cannulation and repeated successfully after 72 hours. Minor complications were observed in 3 (4.3%) patients. No mortality was seen.

CONCLUSION

eSNKP is a safe, time-saving, and effective technique as the first-line of endoscopic retrograde cholangiopancreatography for common bile duct cannulation.

Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist

Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.

What is the most cost-effective method for a difficult biliary cannulation in ERCP?

Editorial dealing with difficult biliary cannulation in ERCP. Pancreatic techniques that take advantage of a guidewire inserted in the Main Pancreatic Duct are preferred to needle-knife precut.

Needle-knife papillotomy and fistulotomy improved the treatment outcome of patients with difficult biliary cannulation

BACKGROUND AND AIMS

Needle-knife papillotomy and fistulotomy (NKPF) is a new, modified technique designed for difficult biliary cannulation. The safety and efficacy of performing NKPF based on characteristics of main duodenal papilla (MDP) was evaluated.

METHODS

We performed a retrospective review of consecutive patients with intact papilla who were established as candidates for therapeutic ERCP at tertiary referral center. A total of 532 patients were included in conventional endoscopic retrograde cholangiopancreatography (ERCP) group in which repeated cannulation was tried in patients with difficult bile duct cannulation; and 598 patients enrolled in early NKPF group according to predefined parameters. Based on the characteristics of MDP, different types of NKPF were performed. The endoscopic data (mean procedure time, anatomy of the main papilla), rate of cannulation success, and post-ERCP complications were collected.

RESULTS

A total of 82 patients underwent NKPF. The mean procedure time of the small papilla group was longer than bulging papilla group (P < 0.05). The success rate of biliary cannulation in the small papilla group (69.3 %) was lower than in the bulging papilla group (100 %, P < 0.01). The overall successful biliary cannulation of patients in the NKPF group was significantly higher than in the conventional group (98.8 vs 90.8 %, P > 0.05). The total complication rate was 6.6 % among conventional group patients and 5.7 % among NKPF group, respectively. The overall complication rate and rates of specific complications (pancreatitis, bleeding, cholangitis, and perforation) in the two groups were similar (P > 0.05).

CONCLUSION

Early NKPF based on characteristics of MDP raised the success rate of biliary cannulation when conventional cannulation failed and did not increase the complication rate post-ERCP. Clinic Trials. gov number, Hongwei-1102-12.

Transpapillary selective bile duct cannulation technique: Review of Japanese randomized controlled trials since 2010 and an overview of clinical results in precut sphincterotomy since 2004

In 1970, a Japanese group reported the first use of endoscopic retrograde cholangiopancreatography (ERCP), which is now carried out worldwide. Selective bile duct cannulation is a mandatory technique for diagnostic and therapeutic ERCP. Development of the endoscope and other devices has contributed to the extended use of ERCP, which has become a basic procedure to diagnose and treat pancreaticobiliary diseases. Various techniques related to selective bile duct cannulation have been widely applied. Although the classical contrast medium injection cannulation technique remains valuable, use of wire-guided cannulation has expanded since the early 2000s, and the technique is now widely carried out in the USA and Europe. Endoscopists must pay particular attention to a patient's condition and make an attendant choice about the most effective technique for selective bile duct cannulation. Some techniques have the potential to shorten procedure time and reduce the incidence of adverse events, particularly post-ERCP pancreatitis. However, a great deal of experience is required and endoscopists must be skilled in a variety of techniques. Although the development of the transpapillary biliary cannulation approach is remarkable, it is important to note that, to date, there have been no reports of transpapillary cannulation preventing post-ERCP pancreatitis. In the present article, selective bile duct cannulation techniques in the context of recent Japanese randomized controlled trials and cases of precut sphincterotomy are reviewed and discussed.

Needle-knife precut papillotomy with a small incision over a pancreatic stent improves the success rate and reduces the complication rate in difficult biliary cannulations

BACKGROUND

Successful precut sphincterotomy (PS) in difficult biliary cannulation (DBC) requires a large incision for deroofing the papilla. However, the high complication rate poses a substantial problem, in addition to the need for expert skills. Pancreatic stent placement could facilitate this procedure. Needle-knife precut papillotomy with a small incision using a layer-by-layer method over a pancreatic stent (NKPP-SIPS) could potentially improve the success rate and reduce the complication rate of PS.

AIMS

To validate the efficacy, feasibility and safety of NKPP-SIPS in DBC.

METHODS

Therapeutic endoscopic retrograde cholangiopancreatography with a naïve papilla was performed in 1619 cases between May 2004 and July 2011. We prospectively divided the patients chronologically, in terms of the period during which the procedure was performed, into two groups: group A; needle-knife precut papillotomy (NKPP) performed between April 2004 and October 2006; group B; NKPP-SIPS performed between November 2006 and July 2011. The success rates and complication rates were evaluated. NKPP was performed without pancreatic stent placement and the cut was made starting at the papillary orifice, extended upward over a length of more than 5-10 mm for deroofing the papilla. On the other hand, in NKPP-SIPS, a pancreatic stent was placed initially as a guide, and to prevent post-ERCP pancreatitis, the incision was begun at the papillary orifice in a layer-by-layer fashion and extended upward in 1-2 mm increments, not going beyond the oral protrusion, finally measuring less than 5 mm in length.

RESULTS

PS was performed in 8.3 % of the patients (134/1619). The cannulation success rate of PS in the entire group was 94.0 % (126/134). NKPP and NKPP-SIPS were performed in 36 and 98 of the patients, respectively. There was one case of major bleeding in group A, and no severe complications in group B. The success rates of bile duct cannulation increased from 86.1 % (31/36) in group A to 96.9 % (95/98) in group B (p = 0.0189). The overall complication rate of PS was YC 33 % (12/36) in group A (major bleeding 8.3 %; mild to moderate pancreatitis 19.4 %; perforation requiring surgery 2.8 %), and 7.1 % (7/98) in group B (mild to moderate pancreatitis 6.1 %; minor perforation 1 %) (p < 0.001).

CONCLUSIONS

NKPP-SIPS has significantly improved the success rate and reduced the complication rate of DBC, proving that a small incision starting at the orifice of the PS is sufficient, feasible and safe in DBC, when a pancreatic stent is inserted at the outset.

Precut fistulotomy for difficult biliary cannulation: is it a risky preference in relation to the experience of an endoscopist?

BACKGROUND

Several studies have reported on the correlation between the experience level of an endoscopist and the outcomes of precut procedures. However, there are limited data on the early use of the precut fistulotomy in relation to the experience of an endoscopist.

AIM

To evaluate the efficacy and safety of precut fistulotomy in difficult biliary cannulation after ERCP training.

METHODS

Two endoscopists, one at each tertiary referral center, performed the precut fistulotomy for difficult biliary cannulation between September 2008 and February 2010. The technical success, complications, and clinical outcomes in three groups were recorded prospectively over time.

RESULTS

A total of 159 (23.1%) patients underwent precut fistulotomy. The mean procedure time was decreased as the number of procedures increased (p < 0.01). The success rates of selective biliary cannulation in the three groups were 86.8, 86.8, and 88.7% respectively, for the first attempt (p = 0.77) and 93.7% for the second attempt. Post-ERCP pancreatitis developed in nine (5.7%) patients, which was not statistically significant between the three groups. As the frequency of papillary contacts increased, post-ERCP pancreatitis tended to increase (p = 0.017). In the multivariate analysis, more than 15 attempts at cannulating the major papilla prior to fistulotomy was a risk factor for pancreatitis (odds ratio 4.8, 95% CI 1.178-19.580, p = 0.029).

CONCLUSIONS

After therapeutic ERCP training involving at least 100 ERCPs, including at least half that were therapeutic cases and more than ten that were precut papillotomies, a precut fistulotomy can be performed safely and effectively in low-risk patients.