Early institution of pre-cutting for difficult biliary cannulation: a prospective study comparing conventional vs. a modified technique

Safety and feasibility of opening window fistulotomy as a new precutting technique for primary biliary access in endoscopic retrograde cholangiopancreatography

BACKGROUND/AIMS

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common and serious complication of endoscopic retrograde cholangiopancreatography. To prevent this event, a unique precutting method, termed opening window fistulotomy, was performed in patients with a large infundibulum as the primary procedure for biliary cannulation, whereby a suprapapillary laid-down H-shaped incision was made without touching the orifice. This study aimed to assess the safety and feasibility of this novel technique.

METHODS

One hundred and ten patients were prospectively enrolled in this study. Patients with a papillary roof size ≥10 mm underwent opening window fistulotomy for primary biliary access. In addition, the incidence of complications and success rate of biliary cannulation were evaluated.

RESULTS

The median size of the papillary roof was 6 mm (range, 3-20 mm). Opening window fistulotomy was performed in 30 patients (27.3%), none of whom displayed PEP. Duodenal perforation was recorded in one patient (3.3%), which was resolved by conservative treatment. The cannulation rate was high (96.7%, 29/30 patients). The median duration of biliary access was 8 minutes (range, 3-15 minutes).

CONCLUSION

Opening window fistulotomy demonstrated its feasibility for primary biliary access by achieving great safety with no PEP complications and a high success rate for biliary cannulation.

Predictive factors of needle-knife pre-cut papillotomy failure in patients with difficult biliary cannulation

Predictors of needle-knife pre-cut papillotomy (NKP) failure for patients with difficult biliary cannulation has not been reported. Between 2004 and 2016, 390 patients with difficult biliary cannulation undergoing NKP were included in this single-center study. Following NKP, deep biliary cannulation failed in 95 patients (24.4%, NKP-failure group) and succeeded in 295 patients (75.6%, NKP-success group). Patient and technique factors were used to identify the predictors of initial NKP failure. Compared with the NKP-success group, periampullary diverticulum (28.4% vs. 18%, p = 0.028), surgically altered anatomy (13.7% vs. 7.1%, p = 0.049), number of cases performed by less experienced endoscopists, and bleeding during NKP (38.9% vs. 3.4%, p < 0.001), were significantly more frequent in the NKP-failure group. On multivariate analysis, surgically altered anatomy (OR 2.374, p = 0.045), endoscopists’ experience (OR 3.593, p = 0.001), and bleeding during NKP (OR 21.18, p < 0.001) were significantly associated with initial failure of NKP. In conclusion, NKP is a highly technique-sensitive procedure, as endoscopists’ experience, bleeding during NKP, and surgically altered anatomy were predictors of initial NKP failure.

Second endoscopic retrograde cholangiopancreatography after failure of initial biliary cannulation: A single institution retrospective experience

Endoscopic retrograde cholangiopancreatography (ERCP) is not always successful when difficult biliary cannulation occurs. A second ERCP seems to be a worthwhile option following initial failure cannulation; however, relevant data are limited. Thus, the aim of the present study was to determine the outcomes of repeating ERCP in patients in whom the first biliary cannulation with or without precut sphincterotomy failed. It retrospectively analyzed 4,136 patients who underwent an initial biliary access between June 2016 and September 2020. Data from our databases were analyzed. Efficacy was based on the cannulation rate of the second ERCP and safety was assessed in terms of adverse events. Of 94 patients, 56 (59.6%) underwent a second ERCP and the success rate in biliary cannulation was 83.9% (47 of 56). The median operative time in the second ERCP was shorter than that in the initial procedure (47 vs. 65 min, P<0.001). A total of 5 patients (8.9%) suffered from mild ERCP-associated complications following the second ERCP. Compared with patients that did not undergo a second ERCP, patients that underwent a second ERCP had a lower 30-day mortality rate (13.2 vs. 1.8%, P=0.038). In addition, by univariate and multivariate analysis, it was observed that normal preoperative serum bilirubin levels and an interval time of <3 days were correlated with the cannulation failure of a second ERCP (OR=9.211, P=0.019, OR=6.765, P=0.041, respectively). A second ERCP following failure of an initial biliary cannulation appears to be safe and effective. For most clinically stable patients with an unsuccessful initial ERCP, a second ERCP after 2-4 days may be an optimal strategy. Preoperative normal serum bilirubin levels may be a risk factor that can be used for predicting cannulation failure of a second ERCP procedure.

Troubleshooting Difficult Bile Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or EUS-Guided Rendezvous Technique?

Despite experienced hands and availability of various well-designed catheters and wires, selective bile duct cannulation may still fail in 10–20% of cases during endoscopic retrograde cholangiopancreatography (ERCP). In case standard ERCP cannulation technique fails, salvage options include advanced ERCP cannulation techniques such as double-guidewire technique (DGW) with or without pancreatic stenting and precut papillotomy, percutaneous biliary drainage (PBD), and endoscopic ultrasound-guided Rendezvous (EUS-RV) ERCP. If the pancreatic duct is inadvertently entered during cannulation attempts, DGW technique is a reasonable next step, which can be followed by pancreatic stenting to reduce risks of post-ERCP pancreatitis (PEP). Studies suggest that early precut papillotomy is not associated with a higher risk of PEP, while needle-knife fistulotomy is the preferred method. For patients with critical clinical condition who may not be fit for endoscopy, surgically altered anatomy in which endoscopic biliary drainage is not feasible, and non-communicating multisegmental biliary obstruction, PBD has a unique role to provide successful biliary drainage efficiently in this particular population. As endoscopic ultrasound (EUS)-guided biliary drainage techniques advance, EUS-RV ERCP has been increasingly employed to guide bile duct access and cannulation with satisfactory clinical outcomes and is especially valuable for benign pathology at centres where expertise is available. Endoscopists should become familiar with each technique’s advantages and limitations before deciding the most appropriate treatment that is tailored to patient’s anatomy and clinical needs.

Primary needle-knife fistulotomy for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: Importance of the endoscopist’s expertise level

BACKGROUND

Needle-knife fistulotomy (NKF) is used as a rescue technique for difficult cannulation. However, the data are limited regarding the use of NKF for primary biliary cannulation, especially when performed by beginners.

AIM

To assess the effectiveness and safety of primary NKF for biliary cannulation, and the role of the endoscopist’s expertise level (beginner vs expert).

METHODS

We retrospectively evaluated the records of 542 patients with naïve prominent bulging papilla and no history of pancreatitis, who underwent bile duct cannulation at a tertiary referral center. The patients were categorized according to the endoscopist’s expertise level and the technique used for bile duct cannulation. We assessed the rates of successful cannulation and adverse events.

RESULTS

The baseline characteristics did not differ between the experienced and less-experienced endoscopists. The incidence rate of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) was significantly affected by the endoscopist’s expertise level in patients who received conventional cannulation with sphincterotomy (8.9% vs 3.4% for beginner vs expert, P = 0.039), but not in those who received NKF. In the multivariable analysis, a lower expertise level of the biliary endoscopist (P = 0.037) and longer total procedure time (P = 0.026) were significant risk factor of PEP in patients who received conventional cannulation with sphincterotomy but only total procedure time (P = 0.004) was significant risk factor of PEP in those who received NKF.

CONCLUSION

Primary NKF was effective and safe in patients with prominent and bulging ampulla, even when performed by less-experienced endoscopist. We need to confirm which level of endoscopist’s experience is needed for primary NKF through prospective randomized study.

Early precut versus primary precut sphincterotomy to reduce post-ERCP pancreatitis: randomized controlled trial (with videos)

BACKGROUND AND AIMS

Precut sphincterotomy, usually performed after prolonged and failed cannulation, is considered a risk factor for post-ERCP pancreatitis (PEP). There are limited studies on primary needle-knife precut for the prevention of PEP. The aim of this study was to assess the safety and efficacy of primary precut.

METHODS

A randomized controlled trial was conducted in a tertiary care setting on patients who underwent ERCP. Patients were randomized to very early precut (group A, precut after 2 failed attempts of wire-guided sphincterotome cannulation) and primary precut (group B, direct needle-knife precut). All procedures were done by an experienced endoscopist. The primary outcome of the study was to compare the incidence of PEP between the 2 groups.

RESULTS

Three hundred three patients were randomized to group A (n = 152, age 48.2 ± 15.4 years, 61 men) and group B (n = 151, age 46.7 ± 13.8 years, 65 men). There was no significant difference in baseline characteristics and indications for ERCP between the 2 groups. Development of PEP (5.2% vs .67%; P = .04) and asymptomatic hyperamylasemia (12.5% vs 2.6%; P = .01) were lower in group B compared with group A. The bile duct cannulation time (13.8 ± 2.2 vs 7.2 ± 1.7 minutes; P = .001) was lower in group B, whereas the overall cannulation success rate (98% vs 98.6%; P = 1.0) was similar in both the groups.

CONCLUSIONS

Primary precut by an experienced endoscopist results in low risk of PEP. (Clinical trial registration number: CTRI/2017/08/009510.).

Extrahepatic cholangiocarcinoma: Current status of endoscopic approach and additional therapies

The prognosis of patients with advanced or unresectable extrahepatic cholangiocarcinoma is poor. More than 50% of patients with jaundice are inoperable at the time of first diagnosis. Endoscopic treatment in patients with obstructive jaundice ensures bile duct drainage in preoperative or palliative settings. Relief of symptoms (pain, pruritus, jaundice) and improvement in quality of life are the aims of palliative therapy. Stent implantation by endoscopic retrograde cholangiopancreatography is generally preferred for long-term palliation. There is a vast variety of plastic and metal stents, covered or uncovered. The stent choice depends on the expected length of survival, quality of life, costs and physician expertise. This review will provide the framework for the endoscopic minimally invasive therapy in extrahepatic cholangiocarcinoma. Moreover, additional therapies, such as brachytherapy, photodynamic therapy, radiofrequency ablation, chemotherapy, molecular-targeted therapy and/or immunotherapy by the endoscopic approach, are the nonsurgical methods associated with survival improvement rate and/or local symptom palliation.

Endosonographic finding of the simultaneous depiction of bile and pancreatic ducts can predict difficult biliary cannulation on endoscopic retrograde cholangiopancreatography

Thus far, no curved linear array endoscopic ultrasound (CLAEUS) findings were established as predictors of difficult selective bile duct cannulation (SBDC). This study aimed to identify CLAEUS findings to predict endoscopic retrograde cholangiopancreatography (ERCP) cases with difficult SBDC. This single-center, retrospective cohort study was conducted between July 2014 and June 2017. This study included all consecutive patients who underwent CLAEUS prior to naïve ERCP. A CLAEUS finding of the simultaneous depiction of bile and pancreatic ducts at the second portion of the duodenum (D2) (simultaneous depiction) was selected as a possible predictor of difficult SBDC, and the κ values in the evaluation of inter- and intra-observer variabilities for “simultaneous depiction” were 0.65 and 0.77, respectively, with substantial correlation. Among the 986 patients who underwent ERCP, 80 patients were relevant for evaluation. Logistic regression analysis revealed strong association between “simultaneous depiction” and difficult SBDC (odds ratio 15.4, 95% confidence interval 4.2–56.0; p<0.001). Among patients who underwent CLAEUS prior to naïve ERCP, a strong correlation was observed between “simultaneous depiction” and the risk of difficult SBDC. An endoscopist can prepare for difficult SBDC by “simultaneous depiction.” The finding enables pertinent planning when performing ERCP, such as setting time limits and selecting alternative devices, techniques, and skilled endoscopists, for difficult SBDC with minimal complications including post-ERCP pancreatitis. However, a future prospective study is necessary to establish the procedure algorithm for suspected difficult SBDC cases based on CLAEUS.

Management of difficult or failed biliary access in initial ERCP: A review of current literature

Selective bile duct cannulation is the prerequisite for all endoscopic biliary therapeutic interventions, but this cannot always be achieved easily. Despite advances and new developments in endoscopic accessories, selective biliary access fails in 5%-15% of cases, even in expert high volume centers. Various techniques - such as double-guidewire induced cannulation, pre-cut papillotomy or transpancreatic sphincterotomy with or without placement of a pancreatic stent - have been used to improve cannulation success rates. Repeated and prolonged attempts at cannulation increase the risk of pancreatitis. Repeating the ERCP within a few days after initial failed pre-cut is a successful strategy and should be tried before contemplating more invasive, alternative interventions such as percutaneous-endoscopic or endoscopic ultrasound guided rendezvous procedure, percutaneous transhepatic or surgical intervention. However, standard guidelines or sequential protocol has not been existed up to now. In certain circumstances, there are unique clinical indications for which invasive, alternative interventions should be preferred. We present and discuss the methods that can be used in difficult or failed initial ERCP, therefore to provide practical advice for endoscopists, especially those who are inexperienced.

Is the Isolated-Tip Needle-Knife Precut as Effective as Conventional Precut Fistulotomy in Difficult Biliary Cannulation?

Background/Aims

Needle-knife precut fistulotomy (NK-F) is a well-known freehand technique for difficult biliary cannulation (DBC). Another approach involves the use of Iso-Tome^®, a modified precutting device with an insulated needle tip to prevent direct thermal injury. This comparative study aimed to evaluate the efficacy of the Iso-Tome^® precut (IT-P) compared to that of NK-F for DBC.

Methods

Patients with a naive papilla who underwent early IT-P or NK-F for DBC were enrolled. DBC was defined as failure to achieve selective biliary access by wire-guided cannulation despite 5 minutes of attempted cannulation, ≥5 papillary contacts, or a hook-nose-shaped papilla. The primary endpoint was the primary technical success rate, which was based on a noninferiority model.

Results

A total of 239 DBC cases were enrolled. The primary technical success rates were 74.7% (89/119) in the IT-P group and 91.6% (110/120) in the NK-F group (lower limit of 90% confidence interval, −0.23; p=0.927 for a noninferiority margin of 10%). The total technical success rates were 87.4% and 95.0%, respectively (p=0.038). The mean precutting times for successful biliary access were 11.2 minutes for IT-P and 7.3 minutes for NK-F (p<0.01). The procedure-related adverse event rates were 9.2% for IT-P and 5.8% for NK-F (p=0.318). The rates of post-endoscopic retrograde cholangiopancreatography pancreatitis were 4.2% and 2.5%, respectively (p=0.499).

Conclusions

IT-P failed to exhibit noninferiority compared with NK-F regarding the primary technical success rate of DBC, but there was no difference in the frequency of adverse events.

Comparison of efficacy and safety of transpancreatic septotomy, needle-knife fistulotomy or both based on biliary cannulation unintentional pancreatic access and papillary morphology

BACKGROUND

Precut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography (ERCP). However, scarce data are available on different precut techniques for difficult biliary cannulation. This study aimed to evaluate the efficacy and safety of transpancreatic septotomy (TPS), needle-knife fistulotomy (NKF) or both based on the presence of unintentional pancreatic access and papillary morphology.

METHODS

Between March 2008 and December 2016, 157 consecutive patients undergoing precutting for an inaccessible bile duct during ERCP were identified. Precut techniques were chosen depending on repetitive inadvertent pancreatic cannulation and the papillary morphology. We retrospectively assessed the rates of cannulation success and procedure-related complications among three groups, namely TPS, NKF, and TPS followed by NKF.

RESULTS

The baseline characteristics of the three groups were comparable. The overall success rate of biliary cannulation reached 98.1%, including 111 of 113 (98.2%) with TPS, 35 of 36 (97.2%) with NKF and 8 of 8 (100%) with NKF following TPS, without significant difference among groups. The incidences of total complications and post-ERCP pancreatitis were 9.6% and 7.6%, respectively. There was a trend towards less frequent post-ERCP pancreatitis after NKF (0%) compared with 11 cases (9.7%) after TPS and one case (12.5%) after NKF following TPS, but not significantly different (P = 0.07). No severe adverse event occurred during this study period.

CONCLUSIONS

The choice of precut techniques by the presence of unintended pancreatic access and the papillary morphology brought about a high success rate without increasing risk in difficult biliary cannulation.

Emergency endoscopic needle-knife precut papillotomy in acute severe cholangitis resulting from impacted common bile duct stones at duodenal papilla

AIM

To evaluate the efficacy and safety of emergency endoscopic needle-knife precut papillotomy in acute severe cholangitis resulting from impacted common bile duct stones at duodenal papilla.

METHODS

Between January 2010 and January 2015, 118 cases of acute severe cholangitis with impacted common bile duct stones at the native papilla underwent emergency endoscopic retrograde cholangiopancreatography (ERCP) and early needle-knife precut papillotomy in a tertiary referral center. Precut techniques were performed according to the different locations of stones in the duodenal papilla. Clinical data about therapy and recovery of the 118 patients were recorded and analyzed.

RESULTS

One hundred and eighteen patients underwent emergency ERCP within 24 h after hospitalization, with a total success rate of 100%. The mean operating time was 6.4 ± 4.1 min. Postoperative acute physiology and chronic health evaluation (APACHE) II scores, white blood cell count and liver function improved significantly. The complication rate was 4.2% (5/118); two with hemorrhage and three with acute pancreatitis. There was no procedure-related mortality.

CONCLUSION

Emergency endoscopic needle-knife precut papillotomy is effective and safe for acute severe cholangitis resulting from impacted common bile duct stones at the duodenal papilla.

Biliary cannulation effectiveness and pancreatitis risk using two early precut techniques

INTRODUCTION

Precut techniques allow for successful biliary cannulation rates approaching 100% but there may be an associated increase in the risk of complications. Recently, early needle-knife precut has been shown to be a safe procedure and is now used as a pancreatitis prevention resource for difficult cannulation cases. The goal of the present study was to assess cannulation and pancreatitis rates using two early precut techniques.

PATIENTS AND METHODS

This was a retrospective study of endoscopic retrograde cholangio-pancreatography (ERCP) procedures performed from 2013 to 2016. The efficacy and safety of simple cannulation, needle-knife precut and transpancreatic precut were assessed.

RESULTS

Simple cannulation was achieved in 369 (73.4%) of 503 evaluable ERCP procedures. Needle-knife precut was successful in 51 (96.2%) of 53 attempts and transpancreatic precut was successful in 75 (96.2%) of 78 attempts. The overall cannulation rate was 98.4%. There were eleven (2.4%) pancreatitis events, six (1.8%) with simple cannulation (two severe, one fatal), five (6.3%) with transpancreatic precut (two severe) and zero events with the needle-knife precut procedure. Among the patients undergoing the precut procedure, seven experienced perforations (two severe) and there were seven bleeding events. The overall complication rate was 14.4%.

CONCLUSIONS

The complementary use of either precut technique provides a satisfactory biliary cannulation rate. However, the rates of pancreatitis and other severe complications are higher for transpancreatic versus needle-knife precut, therefore the indications for both techniques should be modified.

Endoscopic Ultrasound-guided Rendezvous Technique after Failed Endoscopic Retrograde Cholangiopancreatography: Which Approach Route Is the Best?

Objective The endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a salvage method for failed selective biliary cannulation. Three puncture routes have been reported, with many comparisons between the intra-hepatic and extra-hepatic biliary ducts. We used the trans-esophagus (TE) and trans-jejunum (TJ) routes. In the present study, the utility of EUS-RV for biliary access was evaluated, focusing on the approach routes. Methods and Patients In 39 patients, 42 puncture routes were evaluated in detail. EUS-RV was performed between January 2010 and December 2014. The patients were prospectively enrolled, and their clinical data were retrospectively collected. Results The patients' median age was 71 (range 29-84) years. The indications for endoscopic retrograde cholangiopancreatography (ERCP) were malignant biliary obstruction in 24 patients and benign biliary disease in 15. The technical success rate was 78.6% (33/42) and was similar among approach routes (p=0.377). The overall complication rate was 16.7% (7/42) and was similar among approach routes (p=0.489). However, mediastinal emphysema occurred in 2 TE route EUS-RV patients. No EUS-RV-related deaths occurred. Conclusion EUS-RV proved reliable after failed ERCP. The selection of the appropriate route based on the patient's condition is crucial.

The Role Safety Steps in Success and Complication Rate of Endoscopic Retrograde Cholangiopancreatography

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is widely used for treatment of biliary disorders. There are several studies to increase the success rate and decrease the complication rate of ERCP. In this study we aimed to evaluate the affect of safety steps in success and complication rate of ERCP.

MATERIALS AND METHODS

In this cohort study patients were evaluated under 2 groups divided as before the introduction of safety steps and after. Successful cannulation rate, difficult cannulations, and complications of the procedure were recorded.

RESULT

Failed ampullary cannulation rates were 8.2% in group 1 and 4% in group 2. In terms of postprocedural complications; in group 2 complication rates significantly decreased from 10.7% to 4.3%. Moreover, post-ERCP pancreatitis rate decreased from 9.1% in group 1 to 4% in group 2.

CONCLUSIONS

Introduction of safety steps, significantly increase the cannulation rate and decrease both overall complication rate and pancreatitis risk.

Indomethacin and diclofenac in the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis of prospective controlled trials

BACKGROUND AND AIMS

Diclofenac and indomethacin are the most studied drugs for preventing post-ERCP pancreatitis (PEP). However, there are no prospective, randomized multicenter trials with a sufficient number of patients for correct evaluation of their efficacy. Our aim was to evaluate all prospective trials published in full text that studied the efficacy of diclofenac or indomethacin and were controlled with placebo or non-treatment for the prevention of PEP in adult patients undergoing ERCP.

METHODS

Systematic search of databases (PubMed, Scopus, Web of Science, Cochrane) for relevant studies published from inception to 30 June 2016.

RESULTS

Our meta-analysis of 4741 patients from 17 trials showed that diclofenac or indomethacin significantly decreased the risk ratio (RR) of PEP to 0.60 (95% confidence interval [CI], 0.46-0.78; P = .0001), number needed to treat (NNT) was 20, and the reduction of RR of moderate to severe PEP was 0.64 (95% CI, 0.43-0.97; P = .0339). The efficacy of indomethacin compared with diclofenac was similar (P = .98). The efficacy of indomethacin or diclofenac did not differ according to timing (P = .99) or between patients with average-risk and high-risk for PEP (P = .6923). The effect of non-rectal administration of indomethacin or diclofenac was not significant (P = .1507), but the rectal route was very effective (P = .0005) with an NNT of 19. The administration of indomethacin or diclofenac was avoided in patients with renal failure. Substantial adverse events were not detected.

CONCLUSIONS

The use of rectally administered diclofenac or indomethacin before or closely after ERCP is inexpensive and safe and is recommended in every patient (without renal failure) undergoing ERCP. (Registration number: CRD42016042726, http://www.crd.york.ac.uk/prospero/.).

Optimal Use of Wire-Assisted Techniques and Precut Sphincterotomy

Various endoscopic techniques have been developed to overcome the difficulties in biliary or pancreatic access during endoscopic retrograde cholangiopancreatography, according to the preference of the endoscopist or the aim of the procedures. In terms of endoscopic methods, guidewire-assisted cannulation is a commonly used and well-known initial cannulation technique, or an alternative in cases of difficult cannulation. In addition, precut sphincterotomy encompasses a range of available rescue techniques, including conventional precut, precut fistulotomy, transpancreatic septotomy, and precut after insertion of pancreatic stent or pancreatic duct guidewire-guided septal precut. We present a literature review of guidewire-assisted cannulation as a primary endoscopic method and the precut technique for the facilitation of selective biliary access.

Limited precut sphincterotomy combined with endoscopic papillary balloon dilation for common bile duct stone removal in patients with difficult biliary cannulation

Background

Difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) can result in failure of common bile duct (CBD) stone removal and pancreatitis. The present study aimed to report the efficacy and safety of limited precut sphincterotomy (PS) combined with endoscopic papillary balloon dilation (EPBD) for CBD stone removal in patients with difficult biliary cannulation, and the complications associated with this combined procedure.

Methods

A total of 3305 patients underwent ERCP in our hospital between October 2009 and September 2014 and 258 were diagnosed with difficult biliary cannulation. Of these 258 patients, 58 underwent limited PS combined with EPBD for CBD stone removal, and these 58 patients were included in this retrospective study.

Results

The overall success rate was 94.8 % (55/58), and the success rate for single-session removal was 87.9 % (51/58). The mean procedure time was 41 ± 11.48 min (range, 20–72 min). Mechanical lithotripsy was needed in 10.3 % (6/58) of patients. Procedure-related complications included bleeding in 3.4 % (2/58), pancreatitis in 8.6 % (5/58) and biliary tract infection (BTI) in 1.7 % (1/58) of patients.

Conclusions

The therapeutic outcome of limited PS combined with EPBD for CBD stone removal in patients with difficult biliary cannulation was good with an acceptable complication rate. It could be an alternative to PS and “early” limited PS should be used for prompt identification of the bile duct. Limited PS combined with EPBD is safe and effective for CBD stone removal in patients with difficult biliary cannulation.

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.

Gaining competence in needle-knife fistulotomy - can I begin on my own?

BACKGROUND

While there are guidelines for appropriate training in ERCP, these are non-existent for needle-knife precut. The aim of this study was: (1) evaluate the experience curve of three endoscopists in needle-knife fistulotomy (NKF); (2) propose a minimum number of NKF procedures to attest proficiency.

METHODS

Between November 1997 and March 2011, the first 120 consecutive NKF performed by three endoscopists (A, B, and C) were selected (360 patients) from three centers. Each group of 120 patients was chronologically ordered into three subgroups of 40. The main outcomes were: NKF use, NKF success, and post-ERCP adverse events.

RESULTS

The need for NKF did not decrease over time. The NKF success rate in the first attempt for endoscopist A and C in each of the three subgroups was 85 %/85 %, 87.5 %/87.5 %, and 87.5 %/90 %, respectively. Furthermore, both demonstrated a high NKF success in their initial 20 NKFs (85 % and 80 %, respectively). Endoscopist B however presented a different pattern as the success rate initiated at 60 %, then rose to 82.5 % and 85 % for the last group (P = 0.03). Adverse events were mild (28 of the 32 occurrences) with no clear reduction with increased experience.

CONCLUSIONS

A skillful endoscopist may expect to master NKF easily with few adverse events. While some endoscopists could begin on their own because of their innate skills, a minimal training is needed for all, as we cannot predict skills in advance. We propose a minimum of 20 NKF precuts to attest a trainee's competence in this procedure.

Different Strategies for Transpancreatic Septotomy and Needle Knife Infundibulotomy Due to the Presence of Unintended Pancreatic Cannulation in Difficult Biliary Cannulation

Background/Aims

Several precut techniques have been used to gain biliary access for difficult cases. The aim of this study was to evaluate the success and complication rates of two precut techniques, transpancreatic septotomy (TPS) and needle knife infundibulotomy (NKI), in difficult biliary cannulation due to the presence of unintended pancreatic cannulation.

Methods

Eighty-six patients who failed standard biliary cannulation were included. TPS was performed when we failed to achieve biliary access despite 5 minutes of attempted cannulation or when more than three attempted unintended pancreatic cannulations occurred. If deep cannulation was not achieved within 5 minutes for any duct, NKI was performed. If this failed, we crossed over to the other technique in the second attempt.

Results

The initial total success rate of biliary cannulation was 88.4% (86.6% for the TPS group and 94.7% for the NKI group, p=0.447). After crossover of the techniques, the final success rate was 95.3%. The complication rate was 20.9% in patients with TPS and 15.8% in patients with NKI (p=0.753).

Conclusions

The use of different strategies based on the presence of unintended pancreatic cannulation may help increase the success rate for difficult biliary cannulation without increasing complication rates.

Comparison of sequential pancreatic duct guidewire placement technique and needle knife precut sphincterotomy for difficult biliary cannulation

OBJECTIVE

Pancreatic duct guidewire placement (PDGP) includes double guidewire technique (DGT) and transpancreatic sphincterotomy (TPS). DGT can be switched to TPS with ease due to the existing guidewire in the pancreatic duct. In this study, we aimed to combine DGT and TPS as a single technique, named sequential PDGP, and to compare its performance with needle knife precut sphincterotomy (NKPS) in treating difficult biliary cannulation (BC).

METHODS

A total of 83 patients with difficult BC were enrolled in this study. Of these, 63 underwent sequential PDGP and 20 underwent NKPS. Cannulation success rate, cannulation time and endoscopic retrograde cholangiopancreatography (ERCP)-related complications were prospectively recorded and compared between the two groups.

RESULTS

Successful BC was achieved in 88.9% (56/63) of the patients in the sequential PDGP group compared with 70.0% (14/20) in the NKPS group (P = 0.095). Cannulation time was 7.49 ± 5.03 min in the sequential PDGP group and 10.60 ± 7.24 min in the NKPS group (P = 0.086). Post-ERCP pancreatitis occurred in 12.7% of patients in the sequential PDGP group and 10.0% in the NKPS group (P = 1.000). There was no significant difference in the rates of other complications (bleeding, perforation and cholangitis) between the two groups.

CONCLUSIONS

Sequential PDGP is a safe and effective alternative method to NKPS in cases of difficult BC. In those with failed standard cannulation, sequential PDGP can be considered when the guidewire is inadvertently inserted into the pancreatic duct or can be placed in the pancreatic duct without difficulty.

Feasibility of cap-assisted endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with altered gastrointestinal (GI) anatomy. We evaluated the feasibility of cap-assisted ERCP in patients with altered GI anatomy.

Methods

The outcome of ERCP procedures (n=136) was analyzed in 78 patients with Billroth II (B-II) gastrectomy (n=72), Roux-en-Y total gastrectomy (n=4), and hepaticoduodenostomy (n=2). The intubation rate for reaching the papilla of Vater (POV), deep biliary cannulation rate, therapeutic interventions and procedure-related complications were analyzed. All of the procedures were conducted using a cap-fitted forward-viewing endoscope.

Results

The rate of access to the POV was 97.1% (132/136). In cases with successful access, selective biliary cannulation was achieved in 98.5% (130/132) of the patients. The successful biliary cannulation rates were 100% (125/125) for B-II gastrectomy, 50% (2/4) for Roux-en-Y gastrectomy and 100% (3/3) for hepaticoduodenostomy. After selective biliary cannulation, therapeutic interventions, including stone extraction (n=57), sphincterotomy (n=54), stent placement (n=37), nasobiliary drainage (n=20), endoscopic papillary balloon dilatation (n=7) and mechanical lithotripsy (n=15), were performed successfully. The procedure-related complication rate was 8.8% (12/136), including immediate bleeding (5.9%, 8/136), pancreatitis (2.2%, 3/136), and perforation (0.7%, 1/136). There were no procedure-related deaths.

Conclusions

Cap-assisted ERCP is efficient and safe in patients with altered GI anatomy.

Is ESR Important for Predicting Post-ERCP Pancreatitis?

BACKGROUND

Pancreatitis remains the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), resulting in substantial morbidity and occasional mortality. There are notable controversies and conflicting reports about risk factors of post-ERCP pancreatitis (PEP).

AIM

To evaluate the potential risk factors for PEP at a referral tertiary center, as a sample of the Iranian population.

MATERIALS AND METHODS

Baseline characteristics and clinical as well as paraclinical information of 780 patients undergoing diagnostic and therapeutic ERCP at Taleghani hospital in Tehran between 2008 and 2012 were reviewed. Data were collected prior to the ERCP, at the time of the procedure, and 24-72 hours after discharge. PEP was diagnosed according to consensus criteria.

RESULTS

Of the 780 patients who underwent diagnostic ERCP, pancreatitis developed in 26 patients (3.3%). In the multivariable risk model, significant risk factors with adjusted odds ratios (ORs) were age <65 years (OR = 10.647, P = 0.023) and erythrocyte sedimentation rate (ESR) >30 (OR = 6.414, P < 0.001). Female gender, history of recurrent pancreatitis, pre-ERCP hyperamylasemia, and difficult or failed cannulation could not predict PEP. There was no significant difference in the rate of PEP in wire-guided cannulation versus biliary cannulation using a sphincterotome and contrast injection as the conventional method.

CONCLUSIONS

Performing ERCP may be safer in the elderly. Patients with high ESR may be at greater risk of PEP, which warrants close observation of these patients for signs of pancreatitis after ERCP.

Early 'shallow' needle-knife papillotomy and guidewire cannulation: an effective and safe approach to difficult papilla

INTRODUCTION

Needle-knife sphincterotomy (NKS), known as 'precut', is used worldwide to facilitate access to the common bile duct when standard cannulation has failed. This procedure is considered hazardous because it is burdened with high procedural related complications (bleeding and perforation). Its right timing is still debated. In this study we report our results using a modified precut approach, early shallow needle-knife papillotomy (eSNKP) coupled with guidewire cannulation in case of difficult papilla. We evaluated its safety and effectiveness.

METHODS

From 2012 to 2014, 1034 patients underwent therapeutic ERCP. A total of 138 of them presented difficult papilla and were treated with eSNKP performed after 5 failed attempts of standard guidewire cannulation. Deep biliary cannulation rate was recorded, as well as intraoperative and postoperative complication rate.

RESULTS

Successful biliary deep cannulation was achieved in 132/138 patients (95.7%) by means of eSNKP. In 6 patients (4.3%), cannulation failed even after eSNKP. ERCP was newly performed 72 hours later with successful and immediate guidewire biliary cannulation. Overall morbidity was 10.1% (14/138). No perforation occurred. Minor bleeding occurred in 4/138 cases (2.9%) and 10/138 patients (7.2%) developed mild pancreatitis.

CONCLUSION

In case of difficult papilla, eSNKP followed by guidewire cannulation increases the successful deep biliary cannulation with low rate of complications.

Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach

BACKGROUND

A single session of EUS-guided biliary drainage (EUS-BD) may be a viable alternative to ERCP in patients with malignant distal common bile duct (CBD) obstruction. There is no study comparing EUS-BD and ERCP for the relief of distal malignant biliary obstruction.

OBJECTIVE

To compare the outcomes of self-expandable metal stent (SEMS) placement for malignant distal biliary obstruction by using ERCP and EUS-BD.

STUDY DESIGN

Multicenter, retrospective analysis.

SETTING

Tertiary referral centers.

PATIENTS

Patients with malignant distal CBD obstruction requiring SEMS placement.

INTERVENTIONS

Patients in the EUS-BD group underwent EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided antegrade (EUS-AG) procedures after 1 or more failed ERCP attempts. Patients in the ERCP group underwent retrograde SEMS placement.

MAIN OUTCOME MEASUREMENTS

Composite success (the ability to complete the intended therapeutic procedure in a single session and resulting in a greater than 50% decrease in bilirubin over 2 weeks).

RESULTS

The study included 208 patients, 104 treated with ERCP and 104 treated with EUS-BD (68 EUS-CDS, 36 EUS-AG). SEMS placement was successful in 98 patients in the ERCP group and 97 in the EUS-BD group (94.23% vs 93.26%, P = 1.00). The frequency of adverse events in the ERCP and EUS-BD groups was 8.65% and 8.65%, respectively. Postprocedure pancreatitis rates were higher in the ERCP group (4.8% vs 0, P = .059). The mean procedure times in the ERCP and EUS-BD groups were similar (30.10 and 35.95 minutes, P = .05).

LIMITATIONS

Retrospective analysis.

CONCLUSIONS

In patients with malignant distal CBD obstruction requiring SEMS placement, the short-term outcome of EUS-BD is comparable to that of ERCP.

Endoscopic prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is not an uncommon adverse event but may be an avoidable complication. Although pancreatitis of severe grade is reported in 0.1%-0.5% of ERCP patients, a serious clinical course may be lethal. For prevention of severe PEP, patient risk stratification, appropriate selection of patients using noninvasive diagnostic imaging methods such as magnetic resonance cholangiopancreatography or endoscopic ultrasonography (EUS), and avoidance of unnecessary invasive procedures, are important measures to be taken before any procedure. Pharmacological prevention is also commonly attempted but is usually ineffective. No ideal agent has not yet been found and the available data conflict. Currently, rectal non-steroidal anti-inflammatory drugs are used to prevent PEP in high-risk patients, but additional studies using larger numbers of subjects are necessary to confirm any prophylactic effect. In this review, we focus on endoscopic procedures seeking to prevent or decrease the severity of PEP. Among various cannulation methods, wire-guided cannulation, precut fistulotomy, and transpancreatic septostomy are reviewed. Prophylactic pancreatic stent placement, which is the best-known prophylactic method, is reviewed with reference to the ideal stent type, adequate duration of stent placement, and stent-related complications. Finally, we comment on other treatment alternatives, and make the point that further advances in EUS-guided techniques may afford useful PEP prophylaxis.

Early precut fistulotomy for biliary access: time to change the paradigm of "the later, the better"?

BACKGROUND

The precut timing during the biliary cannulation algorithm is a subject of controversy. Some studies suggest that early institution of precut is a safe and effective strategy even though the extent to which this approach may affect the duration of the ERCP is seldom addressed.

OBJECTIVE

To assess the success, safety, and procedure duration of an early precut fistulotomy (group A) versus a classic precut strategy after a difficult biliary cannulation (group B).

DESIGN

Single-center, prospective cohort study.

SETTING

University-affiliated hospital.

PATIENTS

A total of 350 patients with a naïve papilla.

INTERVENTIONS

Standard biliary cannulation followed by needle-knife fistulotomy (NKF).

MAIN OUTCOME MEASUREMENTS

Biliary cannulation rate, NKF success, adverse events, and ERCP duration.

RESULTS

The overall cannulation rate was similar, at 96% and 94% for groups A and B, respectively. The adverse event rate was 6.2% and 6.4%, respectively, with pancreatitis as the most frequent adverse event (group A, 3.9%; group B, 5.2%). The mean ERCP duration was, however, significantly shorter in group A, both when biliary cannulation was achieved without precutting (14 minutes vs 25 minutes, P < .001) as well as when biliary cannulation was attempted after NKF (18 minutes vs 31 minutes, P < .0001).

LIMITATIONS

Single-center study design, referral center.

CONCLUSIONS

If the endoscopist is experienced in ERCP and precut techniques, an early precut strategy should be the preferred cannulation strategy because this approach is as safe and effective as the late fistulotomy approach and substantially reduces ERCP duration.

A novel dry model for practicable sphincterotomy and precut needle knife sphincterotomy

Aim. We aimed to develop a simulation dry model for endoscopic sphincterotomy (ES) and needle knife precut sphincterotomy (NKP) and to evaluate its usefulness as a training simulator. Materials and Methods. An endoscopic retrograde cholangiopancreatography trainer was used as a duodenum, bile duct, and papilla simulator. A simulated papilla was created with a piece of rolled uncured ham, and ES and NKP were performed. Hands-on training was carried out using this model, and success and failure of the procedures were evaluated. A questionnaire survey was conducted among the participants to assess the performance and usefulness of the dry model for ES and NKP training. Results. Twenty-two endoscopists participated in the hands-on training using this dry model. ES was successful in 33 out of 34 attempts (97%) whereas NKP was successful in all 7 attempts (100%). Based on the results of the questionnaire survey, the median score for realism was 7 (range: 2-9) for ES and 8 for NKP on a scale of 1 to 10. Conclusions. The dry model using an uncured ham provides a condition closely similar to actual clinical practice and is useful as a training model for ES and NKP.

One-step transfistula large versus conventional balloon dilation following precut fistulotomy in difficult biliary cannulation for the removal of biliary stones: a multicenter retrospective study

BACKGROUND AND AIM

After selective biliary access following precut fistulotomy in difficult biliary cannulations (DBC), there are several methods of completely opening the remaining papillary roof for the removal of biliary stones. We evaluated the efficacy of one-step transfistula balloon dilation following fistulotomy in DBC for the removal of biliary stones.

METHODS

This retrospective multicenter study was performed in four tertiary referral centers. Patients who underwent fistulotomy due to DBC were enrolled. Precut fistulotomy followed by conventional (≤ 10 mm) or large balloon (≥ 12 mm) dilation through the fistulotomy tract was performed to remove biliary stones. The main outcome measures were technical success and transfistula balloon dilation-related complications.

RESULTS

A total of 154 patients were enrolled. Large balloon and conventional balloon dilation were performed in 57 and 97 patients, respectively. The primary technical success of stone removal was 100% (57/57) for large balloon dilation and 96.9% (94/97) for conventional balloon dilation (P = 0.296). The mean procedure time from biliary access to removal of stones was 29.3 min in large balloon and 22.2 min in conventional balloon dilation (P = 0.042), and the mean numbers of endoscopic retrograde cholangiopancreatography sessions were 1.4 and 1.3, respectively (P = 0.175). Transfistula balloon dilation-related complications were not different between the two groups (10.5% in large balloon dilation vs 16.5% in conventional balloon dilation, P = 0.307).

CONCLUSIONS

One-step transfistula balloon dilation following precut fistulotomy in DBC may be safe and effective for the removal of biliary stones. There were no differences in therapeutic outcomes and complications between large and conventional balloon dilation.

Difficult cannulation as defined by a prospective study of the Scandinavian Association for Digestive Endoscopy (SADE) in 907 ERCPs

BACKGROUND

The definition of a "difficult" cannulation varies considerably in reports of endoscopic retrograde cholangiopancreatography (ERCP).

AIMS

To define a difficult cannulation, which translates into higher risk of post-ERCP pancreatitis.

PATIENTS AND METHODS

Prospective consecutive recording of 907 cannulations in Scandinavian centers done by experienced endoscopists. Inclusion: indication for biliary access in patients with intact papilla. Exclusion: acute non-biliary and chronic pancreatitis at time of procedure.

RESULTS

The primary cannulation succeeded in 74.9%, with median values for time 0.88 min (53 s), with two attempts and with zero pancreatic passages or injections. The overall cannulation success was 97.4% and post-ERCP pancreatitis (PEP) rate was 5.3%. The median time for all successful cannulations was 1.55 min (range 0.02-94.2). If the primary cannulation succeeded, the pancreatitis rate was 2.8%; after secondary methods, it rose to 11.5%. Procedures lasting less than 5 min had a PEP rate of 2.6% versus 11.8% in those lasting longer. With one attempt, the PEP rate was 0.6%, with two 3.1%, with three to four 6.1%, and with five and more 11.9%. With one accidental pancreatic guide-wire passage, the risk of the PEP was 3.7%, and with two passages, it was 13.1%.

CONCLUSIONS

If the increasing rate of PEP is taken as defining factor, the wire-guided cannulation of a native papilla can be considered difficult after 5 min, five attempts, and two pancreatic guide-wire passages when any of those limits is exceeded.

Safety and efficacy of precut needle-knife fistulotomy

OBJECTIVE. Although precut is considered an useful alternative when standard methods of biliary access have failed, there is some controversy about it's safety. The study aim was to evaluate the effectiveness of needle-knife fistulotomy (NKF) after a difficult biliary cannulation and whether common bile duct (CBD) diameter influenced complications. MATERIAL AND METHODS. Between November 2006 and December 2010, a total of 1087 consecutive patients with naive papilla were submitted to endoscopic retrograde cholangiopancreatography (ERCP) for biliary access, in an affiliated university hospital. If the biliary cannulation was unsuccessful after 12-15 min, a NKF was performed. The main outcomes were biliary cannulation rate, NKF success and post-ERCP complications. RESULTS. Biliary cannulation by standard methods was successful in 883 patients (81%). In the remaining 204 patients, NKF was performed and allowed CBD access in 166 (81%), leading to a 96% cannulation rate. A second ERCP was performed in 25 patients, with an NKF success of 90% and an overall biliary cannulation rate of 98%. The post-ERCP complication rate was 7.9% (n = 16) with a 6.4% pancreatitis rate and no deaths. The complication for patients with a CBD ≤ to 4 mm was 13.9% compared with 4.5% in the remaining patients (OR = 3.39, p = 0.024). CONCLUSIONS. NKF is a safe and highly useful method of accessing the CBD in the setting of a difficult biliary cannulation. Despite its safety profile, extra caution is needed when applying NKF to patients with thin bile ducts.

Prevention of postendoscopic retrograde cholangiopancreatography pancreatitis: the endoscopic technique

Pancreatitis is the most frequent and distressing complication of endoscopic retrograde cholangiopancreatography (ERCP). Many recent studies have reported the use of pharmacological agents to reduce post-ERCP pancreatitis (PEP); however, the most effective agents have not been established. Reduction in the incidence of PEP in high-risk patients has been reported through specific cannulation techniques such as guide wire-assisted cannulation and the use of pancreatic stents. The present review focuses on ERCP techniques for the prevention of PEP.

Needle-knife precut papillotomy for difficult biliary cannulation

AIM: To evaluate the therapeutic value of needle-knife precut papillotomy in the management of difficult biliary cannulation.

METHODS: The clinical data for 52 patients with difficult biliary cannulation who underwent needle-knife precut papillotomy at People's Hospital of Guangxi were retrospectively analyzed.

RESULTS: Needle-knife precut papillotomy was successful in 41 patients, with a success rate of 78.85%. Among those patients, 12 had duodenal papillary stone incarceration (success rate, 100%), 4 had too low duodenal opening (success rate, 80%), 4 had duodenal opening deviation (success rate, 66.67%), 1 had too small duodenal opening (success rate, 50%), 15 had narrow common bile duct opening (success rate, 71.43%), and 5 had ampullary tumors (success rate, 83.33%).

CONCLUSION: Needle-knife precut papillotomy is effective in managing difficult biliary cannulation.

Sequential algorithm analysis to facilitate selective biliary access for difficult biliary cannulation in ERCP: a prospective clinical study

Background

Numerous clinical trials to improve the success rate of biliary access in difficult biliary cannulation (DBC) during ERCP have been reported. However, standard guidelines or sequential protocol analysis according to different methods are limited in place. We planned to investigate a sequential protocol to facilitate selective biliary access for DBC during ERCP.

Methods

This prospective clinical study enrolled 711 patients with naïve papillae at a tertiary referral center. If wire-guided cannulation was deemed to have failed due to the DBC criteria, then according to the cannulation algorithm early precut fistulotomy (EPF; cannulation time > 5 min, papillary contacts > 5 times, or hook-nose-shaped papilla), double-guidewire cannulation (DGC; unintentional pancreatic duct cannulation ≥ 3 times), and precut after placement of a pancreatic stent (PPS; if DGC was difficult or failed) were performed sequentially. The main outcome measurements were the technical success, procedure outcomes, and complications.

Results

Initially, a total of 140 (19.7%) patients with DBC underwent EPF (n = 71) and DGC (n = 69). Then, in DGC group 36 patients switched to PPS due to difficulty criteria. The successful biliary cannulation rate was 97.1% (136/140; 94.4% [67/71] with EPF, 47.8% [33/69] with DGC, and 100% [36/36] with PPS; P < 0.001). The mean successful cannulation time (standard deviation) was 559.4 (412.8) seconds in EPF, 314.8 (65.2) seconds in DGC, and 706.0 (469.4) seconds in PPS (P < 0.05). The DGC group had a relatively low successful cannulation rate (47.8%) but had a shorter cannulation time compared to the other groups due to early switching to the PPS method in difficult or failed DGC. Post-ERCP pancreatitis developed in 14 (10%) patients (9 mild, 1 moderate), which did not differ significantly among the groups (P = 0.870) or compared with the conventional group (P = 0.125).

Conclusions

Based on the sequential protocol analysis, EPF, DGC, and PPS may be safe and feasible for DBC. The use of EPF in selected DBC criteria, DGC in unintentional pancreatic duct cannulations, and PPS in failed or difficult DGC may facilitate successful biliary cannulation.

Evaluation of early precut with needle-knife in difficult biliary cannulation during ERCP

BACKGROUND

There is scarce information on whether performing the precut procedure early rather than after several cannulation attempts is associated with different success and complication rates.

OBJECTIVE

The aim of this retrospective study was is to compare the early precut technique with the standard one in terms of the results and complications.

METHODS

The contemporary success rate and postoperative complications in 792 endoscopic retrograde cholangiopancreatography cases were frequently observed during the period from June 2007 to May 2011, and 56 of these cases were carried out with precut biliary sphincterotomy after the standard sphincterotomy had failed.

RESULTS

The success rate for standard sphincterotomy was 89.8%: 51 out of 56 cases were carried out with precut biliary sphincterotomy and succeeded. The total success rate was 96.3%. The difference was significant (χ2=25.62, p<0.01) compared to the success rate of first cannulation, while the difference in complication rates between precut and standard sphincterotomy was minor (9.9 vs. 12.5%, p>0.05).

CONCLUSION

Early precut with a needle-knife in a difficult biliary cannulation was safe and effective if performed by experienced endoscopists.

ERCP features and outcome in patients with periampullary duodenal diverticulum

Background. Although periampullary diverticulum is usually asymptomatic and discovered incidentally in patients during endoscopic retrograde cholangiopancreatography (ERCP), it may lead to post-ERCP morbidity. We compared baseline characteristics and clinical data as well as ERCP results in patients with and without periampullary diverticulum. Methods. Clinical, laboratory, and ERCP data of 780 patients referred to the Taleghani Hospital, as a great referral endoscopy center, in Iran were prospectively analyzed. Results. The periampullary diverticulum was identified in 44 patients (5.6%). Cannulation of common bile duct was more failed in patients with diverticulum compared to others (35.5% versus 11.5, P < 0.001). Patients with diverticulum had eight times more often common bile duct stone compared to patients without diverticulum (54.5% versus 12.2%, P < 0.001). Post-ERCP complications were observed in 2.3% and 4.2% of patients with and without diverticulum, respectively, which did not significantly differ in both groups. Conclusion. Because of more failure cannulation in the presence of periampullary diverticulum, ERCP requires more skills in these patients. Prevalence of common bile duct stone was notably higher in patients with diverticulum; therefore, more assessment of bile stone and its complications in these patients is persistently recommended.

Difficult biliary access at ERCP

Endoscopic retrograde cholangiopancreatography allows intervention for a variety of diseases of the biliary tract. Cannulation of the bile duct is the prerequisite step for biliary intervention. Although obtaining biliary access is straightforward in many cases, it can occasionally be challenging. Multiple devices, all with additional wire-guided techniques, have been developed to aid cannulation. More advanced techniques have also been developed to aid biliary access if it is unsuccessful with standard devices. Multimodality techniques can be used if other approaches fail. This article provides an evidence-based discussion of these approaches, and provides insight into their appropriate application.

Needle knife sphincterotomy does not increase the risk of pancreatitis in patients with difficult biliary cannulation

BACKGROUND & AIMS

Biliary cannulation is unsuccessful during 5%-10% of endoscopic retrograde cholangiopancreatography (ERCP) procedures. Needle knife sphincterotomy (NKS) can improve success of cannulation but is often used as a last resort and is associated with post-ERCP pancreatitis (PEP). We evaluated the safety and efficacy of performing NKS during early stages of difficult cannulation and the relationship between difficult cannulation and the risk of PEP.

METHODS

We performed a prospective trial of consecutive patients with an intact papilla who were undergoing ERCP at tertiary referral center; 73 patients were defined as having difficult biliary cannulation according to predefined cannulation parameters. These patients were randomly assigned to groups that received either NKS or continued standard cannulation. Main outcome measures were PEP and successful biliary cannulation.

RESULTS

Of 464 patients with an intact papilla undergoing ERCP, 73 met the criteria for difficult cannulation. Cannulation success in difficult cannulation cases was 86%, with a PEP rate of 19%. There was no difference in eventual cannulation success between the groups. However, 65% of the patients assigned to the standard cannulation group required crossover to NKS. There was no significant difference in development of PEP among patients in the early NKS group (20.5%) vs standard cannulation (17.6%). Pancreatic duct stents were inserted in 23 of the patients in the early NKS arm and in 15 in the standard cannulation arm. The number of cannulation attempts (more than 7) increased the risk of PEP (P < .01). On the basis of multivariate analysis, independent risk factors for PEP were failure of early cannulation and failure of biliary cannulation.

CONCLUSIONS

Early application of NKS during difficult cannulation does not increase the risk of PEP. The risk of PEP increases greatly after 7-8 attempts at or failure of cannulation. Further studies are required to assess whether early implementation of NKS during difficult cannulation reduces the development of PEP. Australia and New Zealand Clinical Trials registry: ANZTRN 12,612,000,060,842.

Needle-knife fistulotomy in patients with periampullary diverticula and difficult bile duct cannulation

BACKGROUND AND AIM

Needle-knife fistulotomy has commonly been used for overcoming difficult bile duct cannulation. Periampullary diverticula (PAD) can be an impediment to endoscopic retrograde cholangiopancreatography (ERCP) procedures. There are little data on needle-knife fistulotomy in patients with PAD. We evaluated the efficacy and safety of needle-knife fistulotomy between patients with and without PAD.

METHODS

  Data from December 2005 to October 2010 were reviewed. Patients who underwent needle-knife fistulotomy were divided into the group with PAD and the group without PAD (control group). The technical success and complications were compared.

RESULTS

A total of 3012 ERCP cases were analyzed. Needle-knife fistulotomy was performed in 154 out of 3012 cases (5.1%) with 138 of these patients (89.6%) experiencing successful bile duct cannulation. The overall cannulation success rate was not significantly different between PAD group (n=33) and control group (n =121) (93.9% vs 88.4%; P=0.523). There was no significant difference in pancreatitis, bleeding and perforation between the two groups.

CONCLUSIONS

  Needle-knife fistulotomy can be performed effectively and safely in patients with periampullary diverticula and difficult bile duct cannulation.

Prophylactic temporary 3F pancreatic duct stent to prevent post-ERCP pancreatitis in patients with a difficult biliary cannulation: a multicenter, prospective, randomized study

BACKGROUND

Post-ERCP pancreatitis (PEP) is the most common and serious complication of ERCP. Difficult biliary cannulation can be a procedure-related risk factor for PEP. Recent studies reported that a prophylactic pancreatic stent (PS) can reduce the frequency and severity of PEP.

OBJECTIVE

To evaluate the efficacy and usefulness of a temporary 3F PS to prevent PEP in patients with difficult biliary cannulations.

DESIGN

A multicenter, prospective, randomized study.

SETTING

Two tertiary-care academic medical centers.

PATIENTS

In total, 101 patients with a difficult biliary cannulation were randomly divided into the 3F PS placement group (PS group, n = 50) or the nonstent (NS) group (NS group, n = 51).

INTERVENTIONS

Endoscopic placement of a 3F unflanged PS.

MAIN OUTCOME MEASUREMENTS

The incidence and severity of PEP in the 2 groups, spontaneous dislodgment of stents, and procedure-related complications.

RESULTS

The technical success rate of 3F PS placement was 96% (48/50). The lengths of the stents were 4 cm (n = 21), 6 cm (n = 15), and 8 cm (n = 12). Spontaneous stent dislodgment within 7 days occurred in 94% of patients (45/48). The mean duration until spontaneous dislodgment was 3.5 days. The incidence rate of PEP was 12% (6/50: mild, 5; moderate, 1) in the PS group and 29.4% (15/51: mild, 12; moderate, 2; severe, 1) in the NS group. Severe pancreatitis occurred in only 1 patient in the NS group. In a multivariate analysis, prophylactic placement of PS was the only prophylactic factor for PEP (odds ratio, 0.126; 95% CI, 0.025-0.632, P = .012).

LIMITATIONS

No comparative results for stent size and diameter and a low-risk cohort group.

CONCLUSIONS

Prophylactic temporary 3F PS placement in patients with a difficult biliary cannulation during ERCP seems to be a safe and effective method for reducing PEP and results in a high rate of spontaneous passage of stents without complications.