Common bile duct pre-cut sphincterotomy: transpancreatic sphincter approach

Transpancreatic Sphincterotomy After Double Guidewire Technique Was Noninferior to Primary Transpancreatic Sphincterotomy in Difficult Biliary Cannulation

BACKGROUND

When unintentional pancreatic duct access occurs during difficult biliary cannulation, the double guidewire (DGW) or transpancreatic sphincterotomy (TPS) may be utilized. DGW can be easily switched to TPS due to the existing guidewire in the pancreatic duct. However, the efficacy of TPS after DGW, named sequential DGW-TPS technique, versus primary TPS has not been assessed.

AIMS

Our aim was to compare the benefits and adverse events of sequential DGW-TPS technique and primary TPS.

METHODS

We performed a comparative retrospective cohort study that enrolled a total of 117 patients with native papillae. The patients were divided into one of 2 groups according to the primary bile duct access technique (sequential DGW-TPS or primary TPS), both with pancreatic stenting.

RESULTS

Between November 2017 and May 2023, a total of 84 patients were grouped into sequential DGW-TPS and 33 into primary TPS. The overall post-ERCP pancreatitis (PEP) rate was 4.3% in the entire cohort, with no statistical differences were observed between the groups in terms of PEP rates (P = 0.927), PEP severity (P = 1.000), first biliary cannulation success (P = 0.621), overall cannulation success (P = 1.000), hyperamylasemia incidence (P = 0.241), elevated amylase levels (P = 0.881), and postoperative hospital stay (P = 0.185). Furthermore, these results remained consistent in multivariable regression analysis.

CONCLUSIONS

The sequential DGW-TPS technique showed a comparable safety and biliary cannulation success rate to primary TPS in difficult biliary cannulation. Given the potential long-term complications associated with TPS, DGW should be first if inadvertent pancreatic access occurs, with TPS serving as second only if DGW fails.

The impact of transpancreatic precut sphincterotomy on the quality of ERCP in a low-volume setting

BACKGROUND AND AIMS

Although quality improvement is crucial for ERCP, a low practice volume can pose challenges to achieving high-quality bile duct cannulation. Transpancreatic precut sphincterotomy (TPS) has been proven effective for advanced cannulation. However, existing data mainly come from skilled endoscopists in large medical centers. The impact of TPS on ERCP quality in a lower-volume setting deserves investigation.

METHODS

Our hospital performs approximately 200 ERCPs annually, with 1 expert endoscopist performing approximately half of them and 3 nonexpert endoscopists sharing the remaining cases. TPS was started and became our predominant advanced cannulation technique in April 2016. We retrospectively reviewed ERCP cases 3 years before and after the introduction of TPS. The primary endpoints of the study were the differences in 2 ERCP quality indicators, the bile duct cannulation rate and the incidence of post-ERCP pancreatitis (PEP).

RESULTS

A total of 701 ERCP cases with naïve papilla were analyzed, with 350 patients treated before the introduction of TPS and 351 patients treated afterward. The successful cannulation rate was significantly improved (before, 87.4%; after, 92.3%, P = .032), whereas the incidence of PEP decreased, but not significantly (before, 4.0%; after, 2.8%; P = .402). All endoscopists benefited from using TPS, with nonexperts demonstrating a significantly higher improvement in the cannulation rate (before, 85.5%; after, 93.1%; P = .019).

CONCLUSIONS

TPS can effectively enhance the quality of ERCP irrespective of practice volume.

Double guide-wire technique versus transpancreatic biliary sphincterotomy for difficult biliary cannulation: Real life experience from a referral center

BACKGROUND

During ERCP for biliary indication, when a difficult bile duct (BD) cannulation occurs, with unintended access to the main pancreatic duct (PD), both double guidewire technique (DGW) and transpancreatic biliary sphincterotomy (TPBS) can be performed. We aimed to compare the technical success and adverse events (AEs) rate of these techniques.

METHODS

A retrospective analysis of patients with naïve papillae referred to the Pancreas Institute of Verona from January 2016 and July 2021 to undergo ERCP for biliary indications was performed.

RESULTS

Overall, 202 patients (53.5% males, mean age 67.2 years) were evaluated (96 DGW, 106 TPBS). Malignant biliary stricture was the most common ERCP indication (78.2%). The rate of success in deep biliary cannulation was significantly higher in the DGW group (94.8%) compared to TPBS (79.2%) at the first attempt (p = 0.001). This result was also confirmed in the subgroup of patients with malignant distal stricture (72/77, 93.5% vs 63/80, 78.8%, p = 0.01). No significant difference in AEs rate, particularly in PEP incidence was found between the two groups.

CONCLUSIONS

DGW demonstrated a higher success rate and similar safety profile compared with TPBS in difficult biliary cannulation. Based on this retrospective study, DGW should be preferred over TPBS in case of unintended PD cannulation. Further prospective studies are needed to confirm our results.

The Safety and Efficacy of an Unflanged 4F Pancreatic Stent in Transpancreatic Precut Sphincterotomy for Patients with Difficult Biliary Cannulation: A Prospective Cohort Study

Prophylactic pancreatic stenting effectively reduces the rate and severity of post-ERCP pancreatitis (PEP) in the precut technique; however, studies on the optimal type and duration of the stent are still lacking. This prospective study evaluated the incidence and severity of PEP and the rate of spontaneous stent dislodgement in patients undergoing transpancreatic precut sphincterotomy (TPS) accompanied by prophylactic pancreatic stenting with an unflanged plastic stent (4F × 5 cm) for difficult biliary cannulation. A total of 247 patients with naïve papilla were enrolled in this study, and data were collected prospectively. In the final analysis, 170 and 61 patients were included in the standard cannulation technique and TPS groups, respectively. The incidence of PEP in the standard cannulation technique and TPS groups was 3.5% and 1.6% (p = 0.679), respectively. The technical success rate of selective biliary cannulation in the TPS group was 91.8%. The spontaneous dislodgement rate of the prophylactic plastic stent was 98.4%. In conclusion, an unflanged pancreatic stent (4F × 5 cm) placement in TPS for patients with failed standard cannulation technique is a safe and effective measure due to low adverse events and few additional endoscopic procedures for removing the pancreatic duct (PD) stent.

Basic and Advanced Biliary Cannulation: How Do I Do It?

Successful biliary cannulation of a native papilla is usually the rate-limiting step toward a successful ERCP. Standard cannulation techniques usually succeed, particularly when utilizing the wire-guided technique. There are, however, a myriad of confirmations of the major papilla as well as anatomic variants and certain pathologies which can make cannulation exceedingly difficult. For these cases, advanced cannulation techniques and techniques termed "access sphincterotomy" have been developed which should allow successful cannulation in >90% of cases. This article should help all those performing ERCP to improve their cannulation rate.

Transpancreatic precut papillotomy versus double-guidewire technique in difficult biliary cannulation: a systematic review and meta-analysis

Background and study aims  Approximately 11 % of biliary cannulations are considered difficult. The double guidewire (DGW-T) and transpancreatic sphincterotomy (TPS) are two useful techniques when difficult cannulation exists and the main pancreatic duct is unintentionally accessed. We carried out a systematic review and meta-analysis to evaluate the effectiveness and security of both DGW-T and TPS techniques in difficult biliary cannulation. Methods  We conducted a systematic review in different databases, such as PubMed, OVID, Medline, and Cochrane Databases. Were included all RCT which showed a comparison between TPS and DGW in difficult biliary cannulation. Endpoints computed were successful cannulation rate, median cannulation time, and adverse events rate. Results  Four studies were selected (4 RCTs). These studies included 260 patients. The mean age was 64.79 ± 12.99 years. Of the patients, 53.6 % were men and 46.4 % were women. The rate of successful cannulation was 93.3 % in the TPS group and 79.4 % in the DGW-T group ( P  = 0.420). The rate of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) was lower in patients who had undergone TPS than DGW-T (TPS: 8.9 % vs DGW-T: 22.2 %, P  = 0.02). The mean cannulation time was 14.7 ± 9.4 min in the TPS group and 15.1 ± 7.4 min with DGW-T ( P  = 0.349). Conclusions  TPS and DGW are two useful techniques in patients with difficult cannulation. They both have a high rate of successful cannulation; however, the PEP was higher with DGW-T than with TPS.

Transpancreatic biliary sphincterotomy versus double guidewire in difficult biliary cannulation: a randomized controlled trial

BACKGROUND

Difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) increases the risk of post-ERCP pancreatitis (PEP). The purpose of this prospective, randomized, multicenter study was to compare two advanced rescue methods, transpancreatic biliary sphincterotomy (TPBS) and a double-guidewire (DGW) technique, in difficult common bile duct (CBD) cannulation.

METHODS

Patients with native papilla and planned CBD cannulation were recruited at eight Scandinavian hospitals. An experienced endoscopist attempted CBD cannulation with wire-guided cannulation. If the procedure fulfilled the definition of difficult cannulation and a guidewire entered the pancreatic duct, randomization to either TPBS or to DGW was performed. If the randomized method failed, any method available was performed. The primary end point was the frequency of PEP and the secondary end points included successful cannulation with the randomized method.

RESULTS

In total, 1190 patients were recruited and 203 (17.1 %) were randomized according to the study protocol (TPBS 104 and DGW 99). PEP developed in 14/104 patients (13.5 %) in the TPBS group and 16/99 patients (16.2 %) in the DGW group (P = 0.69). No difference existed in PEP severity between the groups. The rate of successful deep biliary cannulation was significantly higher with TPBS (84.6 % [88/104]) than with DGW (69.7 % [69/99]; P = 0.01).

CONCLUSIONS

In difficult biliary cannulation, there was no difference in PEP rate between TPBS and DGW techniques. TPBS is a good alternative in cases of difficult cannulation when the guidewire is in the pancreatic duct.

Propensity score-matched analysis for comparing transpancreatic sphincterotomy and needle-knife precut in difficult biliary cannulation

Transpancreatic sphincterotomy (TPS) can be an alternative approach of difficult biliary access in endoscopic retrograde cholangiopancreatography (ERCP). We aimed to evaluate the efficacy and safety of TPS compared to needle-knife precut (NKP), considering the early and late outcomes of both techniques. The prospectively collected clinical data, ERCP procedure findings, and outcomes of patients who underwent ERCP with difficult biliary access in our hospital from July 2016 to January 2018 were retrospectively analyzed. The patients were divided into two groups according to the applied secondary cannulation techniques. The propensity score matching (PSM) was applied to reduce the potential selection bias and unify the preventive measures of post-ERCP pancreatitis (PEP) in both groups. A total of 125 patients were enrolled in this study, with 54.4% male and a mean age of 63.29 ± 16.33 years. NKP group included 82 patients, and 43 patients received TPS. Prophylactic pancreatic stents were placed in all patients with TPS and 58.5% of patients with NKP. After applying PSM, the cohort was comprised to 86 patients with 43 patients in each TPS and NKP groups. Successful selective cannulation was achieved by 95.3% using TPS and by 93% using NKP. The mean procedure time was shorter in the TPS group without significant difference. Compared to NKP, using TPS did not affect the rate of PEP. Moreover, TPS was associated with less frequent post-ERCP bleeding and perforation, but without significant differences (all p > 0.05). Patients who received TPS or NKP had no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period. In conclusion, using TPS in difficult cannulation cases was useful to achieve success cannulation with an acceptable PEP rate and less frequent post-ERCP bleeding and perforation compared to NKP. There were no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period.

Biliary Cannulation in Endoscopic Retrograde Cholangiography: How to Tackle the Difficult Papilla

BACKGROUND

In the setting of a naïve papilla, biliary cannulation is a key step in successfully performing endoscopic retrograde cholangiography. Difficult biliary cannulation (DBC) is associated with an increased risk of post-ERCP pancreatitis and failure of the whole procedure.

SUMMARY

Recommendations for biliary cannulation can be divided into (a) measures to reduce the likelihood of a difficult papilla situation a priori and (b) rescue techniques in case the endoscopist is actually facing DBC. (a) Careful inspection of the papillary anatomy and optimizing its accessibility by scope positioning is fundamental. A sphincterotome in combination with a soft-tip hydrophilic guidewire rather than a standard catheter with a standard guidewire should be used in most situations. (b) The most important rescue techniques are needle-knife precut, double-guidewire technique, and transpancreatic sphincterotomy. In few cases, anterograde cannulation techniques are needed. To this regard, the EUS-guided biliary drainage followed by rendezvous is increasingly used as an alternative to percutaneous transhepatic biliary drainage. Key Messages: Biliary cannulation can be accomplished with alternative retrograde or less frequently by salvage anterograde techniques, once conventional direct cannulation attempts have failed. Considering recent favorable data for the early use of transpancreatic sphincterotomy, an adopted version of the 2016 European Society for Gastrointestinal Endoscopy (ESGE) algorithm on biliary cannulation is proposed.

Goff Septotomy Is a Safe and Effective Salvage Biliary Access Technique Following Failed Cannulation at ERCP

BACKGROUND

Biliary cannulation is readily achieved in > 85% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). When standard cannulation techniques fail, salvage techniques utilized include the needle knife precut, double wire technique, and Goff septotomy.

METHODS

Records of patients undergoing ERCP from 2005 to 2016 were retrospectively examined using a prospectively maintained endoscopy database. Patients requiring salvage techniques for biliary access were analyzed together with a control sample of 20 randomly selected index ERCPs per study year. Demographic and clinical variables including indications for ERCP, cannulation rates, and adverse events were collected.

RESULTS

A total of 7984 patients underwent ERCP from 2005 to 2016. Biliary cannulation was successful in 94.9% of control index ERCPs, 87.2% of patients who underwent Goff septotomy (significantly higher than for all other salvage techniques, p ≤ 0.001), 74.5% of patients in the double wire group and 69.6% of patients in the needle knife precut group. Adverse event rates were similar in the Goff septotomy (4.1%) and index ERCP control sample (2.7%) groups. Adverse events were significantly higher in the needle knife group (27.2%) compared with all other groups.

CONCLUSIONS

This study represents the largest study to date of Goff septotomy as a salvage biliary access technique. It confirms the efficacy of Goff septotomy and indicates a safety profile similar to standard cannulation techniques and superior to the widely employed needle knife precut sphincterotomy. Our safety and efficacy data suggest that Goff septotomy should be considered as the primary salvage approach for failed cannulation, with needle knife sphincterotomy restricted to Goff septotomy failures.

Comparison between transpancreatic sphincterotomy and needle-knife fistulotomy in difficulty biliary access, a retrospective study in Taiwan

Background

Selective deep biliary cannulation is the first and the most important step before further biliary therapy. Transpancreatic sphincterotomy (TPS), and needle knife fistulotomy (NKF) were commonly used in patients with difficult cannulation, but few studies compare the outcome between TPS and NKF.

Methods

A total of 78 patients who met the criteria of difficult cannulation in the National Taiwan University hospital from October 2015 to October 2017 were retrospectively reviewed. Their baseline demographics, success rate of biliary cannulation, and the rate of adverse events were assessed.

Results

31 patients and 47 patients underwent TPS and NKF for difficult biliary access, respectively. The characteristics of the 2 groups were similar, but patients in TPS group had more frequent pancreatic duct cannulation. Bile duct cannulation was successful in 23 patients (74.2%) in the TPS group and 39 (83.0%) in the NKF group (P = 0.34). There was no difference between the TPS and NKF in the rate of adverse events, including post-ERCP pancreatitis (PEP) (16.1% vs. 6.4%, p = 0.17), and hemorrhage (3.2% vs. 8.5%, p = 0.35). No perforation occurred.

Conclusions

Both TPS and NKF have good biliary access rate in patient with difficult cannulation. TPS has acceptable successful rate and similar complication rate, compared with NKF.

Outcomes of precut sphincterotomy techniques in cases of difficult biliary access

GOALS

Our study aims to define success and complication rates of precut sphincterotomy with the needle-knife and transpancreatic papillary septotomy (TPS) techniques as experienced at a single, high-volume endoscopy centre.

BACKGROUND

Complication rates rise with increasing number of failed attempts at biliary cannulation; therefore, early precut sphincterotomy (PS) has been recommended. Selecting the ideal method for PS can be challenging and there is a paucity of data to help guide this decision.

STUDY

We performed a retrospective analysis over 37 months of endoscopic retrograde cholangiopancreatography (ERCP) experience at a single institution. We identified all ERCPs performed and stratified based on the presence of PS; if PS occurred, a thorough chart review was performed to identify success and complication rates. Patients received guideline-driven management for post-ERCP pancreatitis including rectal indomethacin and pancreatic duct stenting when appropriate.

RESULTS

We identified 1808 ERCP procedures performed during this time. Successful biliary cannulation was achieved in 1748 cases, yielding a success rate of 96.7% (Grades I-IV ERCP difficulty/complexity). PS was required in 232 cases (12.8%); we identified 88 TPS cases and 114 needle-knife precut sphincterotomy (NKPS) cases. Complications following PS procedures occurred in 9.1% of TPS patients and 11.4% of NKPS patients. Success rates for TPS and NKPS were 97.7% and 81.6%, respectively-a statistically significant difference (p<0.001).

CONCLUSION

This data supports TPS as a safe and effective option for biliary access in difficult cannulation settings when performed by experienced advanced endoscopists.

Transpancreatic biliary sphincterotomy for biliary access is safe also on a long-term scale

Background

Transpancreatic biliary sphincterotomy (TPBS) is an advanced cannulation method for accessing common bile duct (CBD) in endoscopic retrograde cholangiopancreatography (ERCP). If CBD cannulation is difficult, an endoscopist can open the septum between the pancreatic and biliary duct with a sphincterotome to gain access. Long-term results of this procedure are unclear. We wanted to evaluate the short- and long-term complications of TPBS on patients with native papilla and benign indication for ERCP.

Patients and Methods

ERCPs performed in Helsinki University Hospital between 2007 and 2013 were reviewed. The study group comprised 143 consecutive patients with TPBS and 140 controls (CG). Data were collected from patient records and a phone survey was performed as a follow-up ≥ 4 years after the index ERCP.

Results

Post-ERCP pancreatitis (PEP) developed in seven patients (4.9%) in TPBS and one patient (0.7%) in CG (p = 0.067). The rates of other acute complications were similar between the groups. ERCP ended with no access to CBD in four cases (2.8%) in TPBS. The median length of follow-up was 6 years in TPBS and 7 years in CG. During this period, three patients (2.1%) in TPBS and six patients (4.3%) in CG suffered from acute pancreatitis (AP) (p = 0.238). One (0.7%) patient in CG and none in TPBS developed chronic pancreatitis (CP). Abdominal pain was suffered by ten patients (6.9%) in TPBS and twelve patients (8.6%) in CG daily, whereas by six patients (4.2%) in TPBS and twelve patients (8.6%) in CG weekly.

Conclusion

TPBS is a useful procedure, with acceptable complication rates. No significant difference occurred between the groups when evaluating the short-term or long-term complications with a follow-up period of four to 10 years. Additionally, no significant differences occurred in upper abdominal pain, episodes of AP, or development of CP.

EUS-guided biliary drainage for difficult cannulation

EUS-guided biliary drainage (EUS-BD) has been recognized as a new alternative to failed ERCP. The alternatives for failed/impossible ERCP in cases of difficult and selective bile duct cannulation include percutaneous transhepatic BD (PTBD) with precut papillotomy. EUS-BD is reportedly more convenient than PTBD and more successful than precut papillotomy, suggesting that EUS-BD is the next step following failed/impossible ERCP.

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.

Transpancreatic Sphincterotomy Is Effective and Safe in Expert Hands on the Short Term

In cases of difficult biliary cannulation, transpancreatic sphincterotomy (TPS) can be an alternative approach of biliary access. However, its success and safety profile have not been studied in detail. A systematic review and meta-analysis were performed to study the overall cannulation success and adverse events of TPS. These outcomes were also compared to other advanced cannulation methods. A systematic literature search was conducted to find all relevant articles containing data on TPS. Successful biliary cannulation and complications rates [post-ERCP pancreatitis (PEP), bleeding, and perforation rates] were compared in the pooled analyses of prospective comparative studies. The overall outcomes were calculated involving all studies on TPS. TPS was superior compared to needle-knife precut papillotomy (NKPP) and the double-guidewire method (DGW) regarding cannulation success (odds ratio [OR] 2.32; 95% confidence interval [CI] 1.37-3.93; and OR 2.72; 95% CI 1.30-5.69, respectively). The rate of PEP did not differ between TPS and NKPP or DGW; however, TPS (only retrospective studies were available for comparison) proved to be worse than needle-knife fistulotomy in this regard (OR 4.62; 95% CI 1.36-15.72). Bleeding and perforation rates were similar among these advanced techniques. There were no data about long-term consequences of TPS. The biliary cannulation rate of TPS is higher than that of the other advanced cannulation techniques, while the safety profile is similar to those. However, no long-term follow-up studies are available on the later consequences of TPS; therefore, such studies are strongly needed for its full evaluation.

Biliary endoscopic sphincterotomy: Techniques and complications

Biliary endoscopic sphincterotomy (EST) refers to the cutting of the biliary sphincter and intraduodenal segment of the common bile duct following selective cannulation, using a high frequency current applied with a special knife, sphincterotome, inserted into the papilla. EST is either used solely for the treatment of diseases of the papilla of Vater, such as sphincter of Oddi dysfunction or to facilitate subsequent therapeutic biliary interventions, such as stone extraction, stenting, etc. It is a prerequisite for biliary interventions, thus every practitioner who performs endoscopic retrograde cholangiopancreatography needs to know different techniques and the clinical and anatomic parameters related to the efficacy and safety of the procedure. In this manuscript, we will review the indications, contraindications and techniques of biliary EST and the management of its complications.

Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy

The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.

Pursuing excellence in ERCP

The term "ERCP cannulation" returns 1,563 items in Pubmed. In 1980 there were 7 papers, and 92 were included in 2015. Any gastroenterologist knows ERCP is often a complex procedure, at times with uncertain results, that unfortunately leads every so often to lawsuits. Most issues derive from attempts at biliary cannulation, despite the improved instruments available since the days of the first sphincterotomy back in 1974. The initial priority goal of ERCP learning is a satisfactory rate of choledochal cannulation. Such rate has been somewhat arbitrarily set as at least 80% of successful biliary access.

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.

The rendezvous technique involving insertion of a guidewire in a percutaneous transhepatic gallbladder drainage tube for biliary access in a case of difficult biliary cannulation

Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic method and treatment approach for biliary diseases. However, biliary cannulation can be difficult in some cases. We performed ERCP in a 97-year-old woman with abdominal pain resulting from acute cholangitis caused by choledocholithiasis and observed difficult biliary cannulation. Eventually, the patient was successfully treated with the rendezvous technique. We could not cannulate the biliary duct during ERCP twice. Therefore, we placed a percutaneous transhepatic gallbladder drainage (PTGBD) tube without intrahepatic dilation. The rendezvous technique was performed using the PTGBD tube. The patient did not experience pancreatitis or perforation.

Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Medications and Techniques

Over the past 2 decades, it increasingly has been recognized that endoscopic retrograde cholangiopancreatography (ERCP) is the most predictable provocateur of acute pancreatitis, with an incidence of more than 15% in high-risk patients. For this reason, there has been considerable interest in the effect of periprocedural drug administration as well as different ERCP techniques on both the incidence and severity of post-ERCP pancreatitis. Although many agents and techniques have shown promise in small clinical studies, the majority of these have failed to yield consistent benefit in larger randomized patient groups. This review summarizes the data on medications and ERCP techniques that have been studied for the prevention of post-ERCP pancreatitis.

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.

Selective biliary cannulation techniques for endoscopic retrograde cholangiopancreatography procedures and prevention of post- endoscopic retrograde cholangiopancreatography pancreatitis

Numerous endoscopic retrograde cholangiopancreatography (ERCP) techniques have been reported to achieve selective biliary cannulation success. For standard biliary cannulation procedures, the wire-guided cannulation technique has been reported to reduce the rate of post-ERCP pancreatitis (PEP) and increase the biliary cannulation success rate, although conflicting reports exist. The pancreatic or double-guidewire technique and several precut techniques have been reported as useful techniques in difficult biliary cannulation cases. Although ERCP is a useful endoscopic procedure, the risk of adverse events, particularly post-ERCP pancreatitis, is inevitable. Previous studies and analyses have revealed the risk factors for PEP. The efficacy of prophylactic pancreatic duct stent placement and the administration of rectal nonsteroidal anti-inflammatory drugs for preventing PEP has also been reported. Herein, we reviewed reports in the literature regarding the current status of selective biliary cannulation techniques and PEP prevention.

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.

Difficult Biliary Access: Advanced Cannulation and Sphincterotomy Technique

Many devices and techniques have been developed to assist in cases of difficult biliary cannulation. Guidewire-assisted cannulation has become the first-line technique for biliary cannulation. Precut sphincterotomy can be safe and effective if used soon after encountering difficulty. Pancreatic duct stents are an important adjunct to reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis in difficult access. Ultimately, cannulation success of greater than 95% and complication rates of less than 5% is the standard that endoscopists doing ERCP should achieve.

Sequential double-guidewire technique and transpancreatic precut sphincterotomy for difficult biliary cannulation

BACKGROUND/AIMS

The double-guidewire technique (DGT) and transpancreatic precut sphincterotomy (TPS) are introduced as alternative biliary cannulation techniques for difficult biliary cannulation. This study aimed to evaluate the sequential use of DGT and TPS compared with a needle-knife precut papillotomy (NK).

PATIENTS AND METHODS

Six hundred and thirty-five consecutive patients with naοve papilla and who underwent endoscopic retrograde cholangiopancreatography (ERCP) for biliary cannulation from March 2010 to April 2014 in a single institute were analyzed. When standard techniques were unsuccessful, DGT or NK was performed. TPS was sequentially performed if DGT failed.

RESULTS

DGT and NK were attempted in 65 and 58 patients, respectively. A sequential DGT-TPS was performed in 38 patients after a failed DGT. Biliary cannulations were successful in 42%, 74%, and 66% of the DGT, sequential DGT-TPS, and NK patients, respectively (P = 0.002). The cannulation rate was higher in the DGT ± TPS patients (85%) than in the NK patients (P = 0.014). Post-ERCP pancreatitis (PEP) developed in 26% of the successful DGT patients, 37% of the sequential DGT-TPS patients, and 10% of the NK patients (P = 0.008). Of the sequential DGT-TPS patients, the incidence of PEP was significantly reduced in patients with a pancreatic duct (PD) stent compared with patients without a PD stent (24% vs. 62%, P = 0.023).

CONCLUSIONS

Sequential DGT-TPS is a useful alternative method compared with NK for patients in whom biliary cannulation is difficult. In the sequential DGT-TPS patients, the incidence of PEP was significantly reduced with the use of a PD stent.

Safety of early transpancreatic duct precut during endoscopic retrograde cholangiopancreatography

AIM: To explore the effectiveness and safety of early transpancreatic duct precut in achieving cannulation of the common bile duct.

METHODS: One hundred and twelve patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) from October 2011 to August 2013 were randomly assigned into two groups (at a 1:3 ratio). Group A underwent precut immediately after first cannulation with guidewire sliding into the pancreatic duct, and group B underwent standard cannulation attempts for a total of 15 min. If successful cannulation of the common bile duct was achieved within this time and with the pancreatic duct inserted less than 5 times, patients were included in the subgroup B1; otherwise, a precut procedure was carried out, and the patients were included in the subgroup B2. The success rate of biliary cannulation, mean cannulation time, mean x-ray exposure time, procedure-related complication rate and risk factors for post-ERCP pancreatitis were compared among the groups.

RESULTS: The mean cannulation time and mean X-ray exposure time in group A were significantly lower than those in group B2 (7.9 min vs 16.9, 5.8 min vs 10.4 min, P < 0.05 for both).There were no significant differences between the two groups in the cannulation rates, but the post-ERCP pancreatitis rate was higher in group B2 than in group A (26.9% vs 3.4%, P = 0.02). Multivariate analysis indicated that risk factors for post-ERCP pancreatitis were more than 10 minutes of biliary cannulation attempts and more than 2 times of cannulation of the pancreatic duct.

CONCLUSION: Early transpancreatic duct precut is safe and effective during ERCP.

Transpancreatic precut sphincterotomy for biliary access: the relation of sphincterotomy size to immediate success rate of biliary cannulation

Background. Transpancreatic precut sphincterotomy (TPS) is an option for difficult common bile duct (CBD) access, and the reports are few, with immediate success rate varying from 60 to 96%. The description of relation between the size of TPS and the immediate success rate of CBD cannulation was not found in the literature. The Aim of the Study. To evaluate the relation of large TPS to immediate success rate of CBD cannulation. Methods. A retrospective analysis was performed in prospectively collected data of 20 patients. TPS was performed with traction papillotome in the main pancreatic duct (MPD) directing towards 11 o'clock. Needle knife (NK) was used to enlarge TPS in five patients, and the other 15 cases had large TPS from the beginning of sphincterotomy. Prophylactic pancreatic stent was inserted in 18 cases, with diclofenac given in 12 cases. Results. The immediate success rate of CBD cannulation was 90% and with an eventual success rate of 100%. The failure in one immediate CBD cannulation with large TPS was due to atypical location of CBD orifice, and the other failed immediate CBD cannulation was due to inadequate size of TPS. Complications included 3 cases of post-TPS bleeding and 3 cases of mild pancreatitis. Conclusion. TPS is an effective procedure in patients with difficult biliary access and can have high immediate success rate with large TPS.

Comparative analysis of endoscopic precut conventional and needle knife sphincterotomy

AIM: To compare the efficacy, complications and post-procedural hyperamylasemia in endoscopic pre-cut conventional and needle knife sphincterotomie.

METHODS: We performed a retrospective analysis of two pre-cut sphincterotomy (PS) techniques, pre-cut conventional sphincterotomy (PCS), and pre-cut needle knife (PNK). The study included 143 patients; the classic technique was used in 59 patients (41.3%), and the needle knife technique was used in 84 patients (58.7%). We analyzed the efficacy of bile duct access, the need for a two-step procedure, the rates of complications and hyperamylasemia 4 h after the procedure, “endoscopic bleeding” and the need for bleeding control. Furthermore, to assess whether the anatomy of the Vater’s papilla, indications for the procedure or the need for additional procedures could inform the choice of the PS method, we evaluated the additive hyperamylasemia risk 4 h after the procedure with respect to the above mentioned variables.

RESULTS: The bile duct access efficacy with PNK and PCS was 100% and 96.6%, respectively, and the difference between the two groups was not significant (P = 0.06). However, the needle knife technique required two-step access significantly more often, in 48.8% vs 8.5% of cases (P < 0.0001). The only complication noted was post-ercp pancreatitis (PEP), which was observed in 4/84 (4.8%) and 2/59 (3.4%) patients submitted to PNK and PSC, respectively; the difference between the two procedures was not significant (P = 0.98). An analysis of other consequences of the techniques yielded the following results in the PNK and PCS groups: hyperamylasemia 4 h after the procedure > 80 U/L, 41/84 vs 23/59 (P = 0.32); hyperamylasemia 4 h after the procedure > 240 U/L, 19/84 vs 11/59 (P = 0.71); pancreatic pain, 13/84 vs 7/59 (P = 0.71); endoscopic bleeding, 10/84 vs 8/59 (P = 0.97); and the need for bleeding control, 10/84 vs 7/59 (P = 0.79). In the next part of the study, we analyzed the influence of the method chosen on the risk of hyperamylasemia with respect to an indication for endoscopic retrograde cholangiopancreatography, papillary anatomy and concomitant procedures performed. We determined that the hyperamylasemia risk was increased by more than threefold [odds ratio (OR) = 3.38; P = 0.027] after PCS in patients with a flat Vater’s papilla and more than fivefold (OR = 5.3; P = 0.049) after the PNK procedure in patients who required endoscopic homeostasis.

CONCLUSION: PCS and PNK do not differ in terms of efficacy or complication rates, but PNK is more often associated with the necessity for a two-step procedure.

Double guidewire technique vs transpancreatic precut sphincterotomy in difficult biliary cannulation

AIM: To compare the outcomes between double-guidewire technique (DGT) and transpancreatic precut sphincterotomy (TPS) in patients with difficult biliary cannulation.

METHODS: This was a prospective, randomized study conducted in single tertiary referral hospital in Korea. Between January 2005 and September 2010. A total of 71 patients, who bile duct cannulation was not possible and selective pancreatic duct cannulation was achieved, were randomized into DGT (n = 34) and TPS (n = 37) groups. DGT or TPS was done for selective biliary cannulation. We measured the technical success rates of biliary cannulation, median cannulation time, and procedure related complications.

RESULTS: The distribution of patients after randomization was balanced, and both groups were comparable in baseline characteristics, except the higher percentage of endoscopic nasobiliary drainage in the DGT group (55.9% vs 13.5%, P < 0.001). Successful cannulation rate and mean cannulation times in DGT and TPS groups were 91.2% vs 91.9% and 14.1 ± 13.2 min vs 15.4 ± 17.9 min, P = 0.732, respectively. There was no significant difference between the two groups. The overall incidence of post- endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis was 38.2% vs 10.8%, P < 0.011 in the DGT group and the TPS group; post-procedure pancreatitis was significantly higher in the DGT group. But the overall incidence of post-ERCP hyperamylasemia was no significant difference between the two groups; DGT group vs TPS group: 14.7% vs 16.2%, P < 1.0.

CONCLUSION: When free bile duct cannulation was difficult and selective pancreatic duct cannulation was achieved, DGT and TPS facilitated biliary cannulation and showed similar success rates. However, post-procedure pancreatitis was significantly higher in the DGT group.

Use of a pancreatic duct stent or guidewire facilitates bile duct access with low rates of precut sphincterotomy: a randomized clinical trial

BACKGROUND AND STUDY AIMS

Among cases of difficult biliary cannulation, alternatives include use of a pancreatic duct stent (PDS) or guidewire (PDW) to facilitate access. We compared the effectiveness of a PDS versus a PDW to facilitate common bile duct (CBD) cannulation.

PATIENTS AND METHODS

We conducted a randomized, crossover trial at two endoscopy referral centers, limited to patients undergoing ERCP without a history of biliary sphincterotomy. After meeting predefined criteria for difficult cannulation, patients were randomized to using a PDS or PDW to facilitate CBD cannulation. Outcomes included cannulation rate within 6 min, overall cannulation rate, frequency of precut, and complication rates.

RESULTS

Among 442 eligible patients, 87 (19.7 %) met criteria for difficult cannulation. Forty two were randomized to PDW, 54 to PDS (including 9 PDW patients crossed over to PDS). The rate of CBD cannulation within 6 min was similar in the PDW (38.1 %) and PDS (51.9 %) groups (p = 0.18). In a secondary analysis limited to patients who successfully underwent PDW or PDS deployment, the rate was also comparable (PDW 59.3 %, PDS 65.1 %; p = 0.62). The overall frequency of CBD cannulation was 66.7 % in PDW and 90.7 % in PDS patients. Precut was required in 9.5 % of PDW and 25.9 % of PDS patients. Complication rates were similar, with 4 (4.6 %) patients having post-ERCP pancreatitis and 1 (1.1 %) having post-ERCP pain without confirmation of pancreatitis.

CONCLUSIONS

Use of a PDS or PDW facilitates CBD cannulation while maintaining a low complication rate and reducing the need for precut sphincterotomy in the majority of cases.

Wire assisted transpancreatic septotomy, needle knife precut or both for difficult biliary access

BACKGROUND AND AIMS

Pre-cut techniques, the most commonly described being needle knife papillotomy (NK), have been used to facilitate biliary access in failed standard biliary cannulation (BC). Transpancreatic septotomy (TS) is a pre-cut technique with limited outcome data. We aim to assess the outcomes of wire assisted transpancreatic septotomy (WTS) as the primary pre-cut technique after initial failed attempted BC and to compare these with outcomes of primary NK.

METHODS

We retrospectively reviewed all endoscopic retrograde cholangiopancreatographies (ERCPs) performed by endoscopists who performed WTS over a 3-year period. We selected cases where WTS and/or NK were performed, and these cases were reviewed to assess for procedure related complications and BC success.

RESULTS

During the study period 1336 ERCPs were performed. WTS was performed in 53 cases. In seven cases WTS and NK were performed sequentially (resulting in immediate cannulation in all these cases). Immediate BC was achieved on first attempt in 36 (68%) WTS cases and in a further 14 cases on a repeat attempt (cumulative BC rate 94%). During the same period 66 (5%) patients underwent primary NK. In these cases initial cannulation was achieved in 50 (76%) cases and cannulation on repeat attempt in six cases (cumulative success rate 85%). Complications occurred in three WTS patients (5.6%) and seven NK patients (10.6%). The differences were not statistically significant.

CONCLUSIONS

Wire assisted transpancreatic septotomy is a safe and effective alternative technique to traditional NK in patients who have failed standard BC techniques. It also allows other pre-cut techniques such as NK to be used should initial WTS be unsuccessful.

ERCP procedures in a Finnish community hospital: a retrospective analysis of 1207 cases

BACKGROUND AND AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure with a risk of serious and life-threatening complications. The most common complications are pancreatitis, haemorrhage, perforation and cholangitis. The aim of this study was to determine indications, success rates and complications in a low-volume ERCP unit in Kanta-Häme Central Hospital (KHCH).

MATERIAL AND METHODS

Data on 1207 consecutive ERCPs performed in KHCH between 2002 and 2009 was collected retrospectively from patient histories. Complications were classified according to need for intervention and length of hospitalisation.

RESULTS

Cannulation of the desired duct was successful in 89.2% of 825 ERCPs with no earlier sphincterotomy. Complete stone removal was achieved in 91.3% of procedures. Standard biliary sphincterotomy was performed in 73.8% and precut sphincterotomy in 12.0 % of cases. Cholangitis developed in 2.1%, bleeding in 1.9%, pancreatitis in 1.9%, perforation in 1.0% and cardio-pulmonary or miscellaneous complications in 4.2% of cases. The majority of complications could be managed conservatively. In procedures with no earlier sphincterotomy ERCP-related 30-day mortality was 0.2% (n=2) and overall 30-day mortality was 3.3% (n=27).

CONCLUSIONS

ERCP indications and success rates, as well as morbidity and mortality were comparable to those re-ported earlier. Although the success rate of cannulation and thereby ERCP procedures seem to be somewhat lower than in tertiary referral centres, ERCP procedures can be safely performed in a low-volume ERCP unit by concentrating procedures on a few experienced endoscopists. The success rates may be further improved with the latest cannulation techniques, used selectively in the last years of the study period.

New cannulation method for pancreatic duct cannulation-bile duct guidewire-indwelling method

The patient was a 58-year-old male with symptomatic alcoholic chronic pancreatitis. Since a 10 mm calculus was observed in the pancreatic body and abdominal pain occurred due to congestion of pancreatic juice, endoscopic retrograde cholangiopancreatography was conducted for assessment of the pancreatic duct and treatment of pancreatic calculus. Pancreatogram was slightly and insufficiently obtained by injecting the contrast media via the common channel of the duodenal main papilla. We tried to cannulate selectively into the pancreatic duct for a clear image. However, the selective cannulation of the pancreatic duct was difficult because of instability of the papilla. On the other hand, selective cannulation of the bile duct was relatively easily achieved. Therefore, after the imaging of the bile duct, a guidewire was retained in the bile duct to immobilize the duodenal papilla and cannulation of the pancreatic duct was attempted. As a result, selective pancreatic duct cannulation became possible. It is considered that the bile duct guidewire-indwelling method may serve as one of the useful techniques for cases whose selective pancreatic duct cannulation is difficult (“selective pancreatic duct difficult cannulation case”).

Contemporary use of endoscopic retrograde cholangiopancreatography (ERCP): a Norwegian prospective, multicenter study

OBJECTIVE

Novel imaging modalities have supplanted endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of hepatobiliary pancreatic diseases, but the use of ERCP as a diagnostic and therapeutic tool in current clinical practice is not well known. The main objective of this study was to describe and evaluate contemporary use of ERCP in Norway.

MATERIAL AND METHODS

Prospective and consecutive data were collected between January 2007 and December 2009 from voluntary institutional reports of ERCP activity at participating hospitals in the Gastronet database.

RESULTS

A total of 3840 procedures at 14 hospitals were registered during the study period. Data from 3809 procedures (53% females) were available for evaluation. Patients were ≥60 years of age in 2567 (67%) procedures. High co-morbidity (ASA score ≥3) was present in 32% of patients. The main indication for ERCP was evaluation and therapy of bile duct-related disorders. Successful bile duct cannulation was achieved in 93%. Pre-cut sphincterotomy was performed in 5% of procedures, and a guide wire to facilitate duct access was employed in 63%. Sphincterotomy, treatment for common bile duct stones (CBDS), and an insertion or change of bile duct stents were the most commonly employed procedures. Complications occurred in 10% of the patients, with a procedure-related mortality of 1%.

CONCLUSIONS

In Norway, ERCP is predominantly performed for CBDS and biliary strictures in elderly patients with associated co-morbidity. Patient selection, indications, and procedures are in concert with international guidelines and recommendations. Disease patterns in Norway differ slightly from those observed in central Europe and North America.

Difficult biliary cannulation during ERCP: how to facilitate biliary access and minimize the risk of post-ERCP pancreatitis

Endoscopic retrograde cholangio-pancreatography (ERCP) is one of the most technically challenging procedures in therapeutic endoscopy; difficulties in biliary cannulation and post-ERCP pancreatitis are still significant problems. Deep cannulation of Vater's papilla may fail in up to 5% of cases; selective biliary cannulation reportedly fails in 15-35% of cases, even in experienced hands; repeated and prolonged attempts at cannulation increase the risk of post-procedure pancreatitis. Therefore, cannulation technique plays a pivotal role in successful cannulation and occurrence of post-procedure pancreatitis. This review presents and discusses the techniques that can be used for achieving biliary cannulation after an initial failure and for minimizing the risk of pancreatitis, including guide wire assisted technique, needle knife precutting, trans-pancreatic sphincterotomy, and pancreatic stenting.

Difficult biliary cannulation

Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure routinely performed by endoscopists. ERCP cannulation requires the insertion of a subcentimeter catheter through a tiny orifice at a distance of almost a meter from the operator. Only after successful cannulation of the bile duct can the real "business" of ERCP be performed (eg, sphincterotomy, stone extraction, stent placement). Selective bile duct cannulation is all the more exacting due to the occasional anatomic challenge (eg, postsurgical anatomy, duodenal stricture) or wayward catheter. Serious morbid complications can and do occur, even in the hands of the most gifted and facile endoscopists. Although there are some "tricks" to facilitate successful cannulation of the bile duct, experience "trumps" all tricks. Of greatest importance when faced with a difficult cannulation is the recognition of one's personal limitations.

Success and complication rates of two precut techniques, transpancreatic sphincterotomy and needle-knife sphincterotomy for bile duct cannulation

BACKGROUND

The majority of literature on the precut technique is concerned with needle-knife sphincterotomy, whereas the comparison of transpancreatic sphincterotomy and needle-knife sphincterotomy has been rarely reported. Aim The aim of the study was to compare the success and the complication rates of transpancreatic sphincterotomy with needle-knife sphincterotomy.

METHODS

During May 2006 and April 2007, 3,178 consecutive endoscopic retrograde cholangiopancreatography (ERCP) procedures were performed in a prospective multicenter study on ERCP-related complications. From the files of these patients, data of cases undergoing precut sphincterotomy, including transpancreatic sphincterotomy and needle-knife sphincterotomy, were retrospectively extracted and analyzed.

RESULTS

Overall, 216 patients with precut sphincterotomy were identified; 140 cases received transpancreatic sphincterotomy, and 76 received needle-knife sphincterotomy. There was no significant difference in the initial and eventual success rates between transpancreatic and needle-knife sphincterotomy (82.9% vs. 90.8% and 90.0% vs. 90.8%, respectively). The overall incidences of complications and acute pancreatitis were not significantly different between the two groups (14.3% vs. 18.4% and 11.4% vs. 11.8%, respectively).

Management of difficult bile duct cannulation in ERCP

In Encoscopic Retrograde Cholangiopancreatography (ERCP), the main concern is to gain access into the bile duct while avoiding the pancreatic duct because of the risk of post-ERCP pancreatitis. Difficult cannulation is defined as a situation where the endoscopist, using his/her regularly used cannulation technique, fails within a certain time limit or after a certain number of unsuccessful attempts. Different methods have been developed to manage difficult cannulation. The most common solution is to perform a precut papillotomy either with a needle knife or with a sphincterotome with or without a guide wire. This review describes different methods to overcome cases of difficult cannulation. We will discuss the success rate and complication rates associated with different methods of reaching the biliary tract.

Pancreatic sphincterotomy versus needle knife precut in difficult biliary cannulation

BACKGROUND

In endoscopic retrograde cholangiopancreaticography (ERCP) difficult cannulation is an independent risk factor for complications.

METHODS

Altogether 6,209 ERCPs were performed in Helsinki University Central Hospital in the period 1996-2006. In 558 cases (9%) without a previous sphincterotomy, direct access into the biliary duct could not be achieved. In this group access was attempted by first performing a pancreatic sphincterotomy in 351 difficult cannulation cases (63%). A needle knife precut without a pancreatic sphincterotomy was performed in 178 cases (32%). All the necessary clinical and laboratory information was available for 262 of the 351 patients who had undergone a pancreatic sphincterotomy and for 157 of the 178 patients who had been subjected to needle knife precutting, and these data were further evaluated in this study.

RESULTS

The pancreatic sphincterotomy technique was successful in 255 cases (97.3%). Post-ERCP pancreatitis developed in 8.8% of the pancreatic sphincterotomy group. In 147 patients, biliary cannulation was successful following a pancreatic sphincterotomy, and the post-ERCP pancreatitis rate for those patients was 9.3%. In 108 patients, a needle knife papillotomy, in addition to a pancreatic sphincterotomy, was necessary and resulted in a post-ERCP pancreatitis rate of 8.2%. In the needle knife precut group only, post-ERCP pancreatitis developed in 5.1% of cases. Biliary cannulation succeeded less frequently following needle knife precutting than following the pancreatic sphincterotomy technique (71.3% versus 97.3%, p<0.001). There was no significant difference in the post-ERCP pancreatitis rate between the precut and pancreatic sphincterotomy techniques (p=0.16).

CONCLUSIONS

In difficult cannulation, a pancreatic sphincterotomy to achieve deep biliary duct cannulation can be performed with a high success rate (failure rate less than 3%). The corresponding success rate using the needle knife precut technique is 71%. In both methods the risk for post-ERCP pancreatitis is comparable to that of a standard biliary sphincterotomy.

Transpancreatic precut sphincterotomy for cannulation of inaccessible common bile duct: a safe and successful technique

OBJECTIVE

Obstruction of the biliary tract can lead to severe complications. The common treatment of patients with biliary tract obstruction is the decompression by endoscopic procedures. However, cannulation of the common bile duct can be difficult under certain instances because of anatomical variations or obstruction at the biliary entrance level. Needle-knife or precut sphincterotomy has been described as technique to facilitate biliary access in patients with difficult bile duct cannulation. In the current study, we evaluated success and complication rates of a wire-guided transpancreatic precut technique at our hospital.

METHODS

Between January 2003 and June 2006, a total of 108 patients with jaundice but with inaccessible bile ducts using classic techniques (failed primary cannulation or failed needle-knife papillotomy) underwent a wire-guided transpancreatic precut sphincterotomy. Precuts were performed using a soft guide wire placed in the pancreatic duct without injection of contrast fluid into the pancreatic duct.

RESULTS

We studied cannulation success and complications associated with postprocedural hospitalization. Bile duct cannulation was successful in 103 (95.4%) of the 108 patients. Five patients (4.6%) required a percutaneous transhepatic biliary drainage. In 108 patients, there were 12 patients (11.1%) with procedure-related complications including acute pancreatitis (n = 6) and bleeding (n=6). Four patients had a mild and transient pancreatitis (pain improvement after 2 days), 2 had severe pancreatitis that was reversible after 7 days of conservative treatment. In 4 cases, a blood transfusion (each with 2 erythrocyte concentrates) became necessary. Perforations and other severe procedure-related deaths did not occur.

CONCLUSIONS

Transpancreatic precut sphincterotomy using a soft guide wire is a safe and effective procedure in patients with difficult bile duct access where classic sphincterotomy or needle-knife procedures fail.

Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla

BACKGROUND & AIMS

Therapeutic endoscopic retrograde cholangiopancreatography requires selective cannulation of the relevant ductal system. The aim of this study was to evaluate the efficacy and safety of 3 different precutting techniques for difficult bile duct access on the basis of the characteristics of the major duodenal papilla (MDP).

METHODS

The patients were classified into small MDP, large MDP, or swollen MDP groups on the basis of the characteristics of the MDP. The precutting technique was based on MDP characteristics: transpancreatic sphincterotomy for small MDPs, needle-knife precut sphincterotomy for large MDPs, and needle-knife fistulotomy for swollen MDPs. The success rate of bile duct cannulation and the complication rates were compared.

RESULTS

A total of 86 patients (58 men; mean age, 76 years) with difficult bile duct cannulation required precutting technique; 48 had transpancreatic sphincterotomy, 30 had needle-knife precut sphincterotomy, and 8 had needle-knife fistulotomy. With precutting, the procedure was successful in 46 of 48 (96%), 27 of 30 (90%), and 8 of 8 patients (100%), respectively. The overall success rate of biliary cannulation after 2 endoscopic retrograde cholangiopancreatography attempts was 100%. The overall complication rate was 4.7% (4 of 86) (2 mild bleeding and 2 mild pancreatitis).

CONCLUSIONS

Selection of the precutting technique on the basis of the characteristics of the MDP resulted in a high degree of success and a low complication rate in cases of difficult bile duct cannulation.

Suprapapillary puncture of the common bile duct for selective biliary access: a novel technique (with videos)

BACKGROUND

Selective cannulation of the bile duct while avoiding the potential mechanisms that initiate the cascade of pancreatic injury may prevent or minimize post-ERCP pancreatitis. This could be accomplished by suprapapillary needle puncture of the bile duct with a specially designed needle.

OBJECTIVES

The aim of this study is to describe a new technique to perform selective biliary cannulation by using a novel needle-puncture device and its outcome in 28 patients with suspected biliary pathology.

DESIGN

This is a single-center, prospective pilot study of suprapapillary puncture of bile duct for both diagnosis and therapy of biliary pathology.

SUBJECTS

Thirty patients were enrolled: 28 patients underwent suprapapillary puncture to gain biliary access, and 2 patients with a large periampullary diverticulum were excluded.

INTERVENTIONS

After successful biliary cannulation by using a suprapapillary puncture technique and balloon dilation of the tract if necessary, stone removal, plastic stent insertion, and metal stent insertion were attempted.

MAIN OUTCOME MEASUREMENTS

Successful biliary cannulation, time for cannulation, outcome of therapy (clearing the stones or providing stent drainage with stent insertion), and complications were recorded. At 60 days, the suprapapillary puncture was evaluated to check the status of drainage.

RESULTS

Suprapapillary puncture was successful in 25 of the 28 patients, and, in 1 patient, it was successful after a week. It was useful in demonstrating a normal bile duct in 9 of 11 patients with suspected biliary pathology. Subsequent therapy was successful in the management of 11 patients with stones, benign biliary pathology in 2 patients, and malignant biliary pathology in 3 of 4 patients. None of the patients developed post-ERCP pancreatitis. Complications included small perforations that resolved with conservative management (n = 2), minor bleeding (n = 2), and submucosal injection (n = 1). At 60 days, all the puncture sites healed in patients who did not undergo dilation, while those with dilation of the tract had a patent orifice, with excellent flow of bile.

CONCLUSIONS

Suprapapillary puncture for biliary cannulation is a useful technique for selective cannulation of the bile duct and avoids injury to the pancreas but with higher complication rates. Further studies will be needed to define its safety and its relative benefits compared with conventional access methods.