Biliary endoscopic retrograde cholangiopancreatography

Assessing Quality of Precut Sphincterotomy in Patients With Difficult Biliary Access: An Updated Meta-analysis of Randomized Controlled Trials

BACKGROUND

It is generally accepted that precut sphincterotomy during endoscopic retrograde cholangiopancreatography (ERCP) increases the risk of pancreatitis. However, patients with difficult biliary access may be different. We implemented a meta-analysis to explore the effects of early and delayed precut sphincterotomy on post-ERCP pancreatitis in patients with difficult biliary access.

METHODS

We searched studies in PubMed, EMBASE, and the Cochrane Central Register of Randomized Controlled Trials for meeting requirement in which precut sphincterotomy was compared with persistent standard cannulation during ERCP. The primary outcomes included the overall cannulation success rate and the incidence of post-ERCP pancreatitis. The secondary outcomes included primary cannulation success and the overall complication rate.

RESULTS

Six studies (898 patients) were included. The present meta-analysis found no significant difference in overall cannulation success rate and overall complication rate between early precut sphincterotomy and persistent standard cannulation. However, early precut sphincterotomy not only increased the primary cannulation success rate [Mantel Haenszel test relative risk, 1.87; 95% confidence interval (CI), 1.15-3.04] but also decreased the overall risk of pancreatitis (Peto odds ratio, 0.49; 95% CI, 0.30-0.80). For persistent standard cannulation, no significant difference was observed in the pancreatitis rate between no salvage precut and delayed salvage precut sphincterotomy (Peto odds ratio, 0.96; 95% CI, 0.49-1.85).

CONCLUSIONS

Compared with persistent standard cannulation, an early precut sphincterotomy exhibited a reduced risk of pancreatitis. In addition, a delayed precut sphincterotomy after persistent attempts did not increase the occurrence of pancreatitis and this is the first meta-analysis to present this conclusion.

The impact of wire caliber on ERCP outcomes: a multicenter randomized controlled trial of 0.025-inch and 0.035-inch guidewires

BACKGROUND AND AIMS

Wire-guided biliary cannulation has been demonstrated to improve cannulation rates and reduce post-ERCP pancreatitis (PEP), but the impact of wire caliber has not been studied. This study compares successful cannulation rates and ERCP adverse events by using a 0.025-inch and 0.035-inch guidewire.

METHODS

A randomized, single blinded, prospective, multicenter trial at 9 high-volume tertiary-care referral centers in the Asia-Pacific region was performed. Patients with an intact papilla and conventional anatomy who did not have malignancy in the head of the pancreas or ampulla and were undergoing ERCP were recruited. ERCP was performed by using a standardized cannulation algorithm, and patients were randomized to either a 0.025-inch or 0.035-inch guidewire. The primary outcomes of the study were successful wire-guided cannulation and the incidence of PEP. Overall successful cannulation and ERCP adverse events also were studied.

RESULTS

A total of 710 patients were enrolled in the study. The primary wire-guided biliary cannulation rate was similar in 0.025-inch and 0.035-inch wire groups (80.7% vs 80.3%; P = .90). The rate of PEP between the 0.025-inch and the 0.035-inch wire groups did not differ significantly (7.8% vs 9.3%; P = .51). No differences were noted in secondary outcomes.

CONCLUSION

Similar rates of successful cannulation and PEP were demonstrated in the use of 0.025-inch and 0.035-inch guidewires. (Clinical trial registration number: NCT01408264.).

A multicenter randomized trial comparing the use of touch versus no-touch guidewire technique for deep biliary cannulation: the TNT study

BACKGROUND AND AIMS

There are 2 techniques described for selective bile duct guidewire cannulation, the touch (T) technique (engaging the papilla with a sphincterotome and then advancing the guidewire) and the no-touch (NT) technique (engaging the papilla only with the guidewire). The aim of this prospective, multicenter randomized study was to compare the outcomes of the 2 guidewire cannulation techniques.

METHODS

Three hundred consecutive patients with naïve papillae were enrolled in 2 groups (150 to T group and 150 to NT group). A maximum of 15 biliary cannulation attempts, for no longer than 5 minutes, or a maximum of 5 unintentional cannulations of the pancreatic duct for each group were performed. If biliary cannulation failed, the patient was crossed over to the other technique with the same parameters. The primary outcome was the guidewire cannulation success rate using either the T or NT technique. Secondary outcomes were the number of attempts and cannulation duration, number of pancreatic duct cannulations, and adverse events.

RESULTS

The primary cannulation rate was significantly higher in the T group compared with the NT group (88% vs 54%, P < .001), and the cannulation rate was significantly higher using the T technique compared with the NT technique also after crossover (77% vs 17%, P < .001). The mean number of cannulation attempts was 4.6 in the T group versus 5.5 in the NT group (P = .006), and the duration of cannulation before crossover (P < .001) and overall cannulation duration after crossover (P < .001) were significantly lower in the T group. The number of unintended pancreatic duct cannulations was statistically higher using the T technique compared with the NT technique (P = .037). The rates of adverse events did not significantly differ between the 2 groups.

CONCLUSIONS

Our results clearly indicated that the T technique is superior to the NT technique for biliary cannulation. (Clinical trial registration number: NCT01954602.).

Early Precut Sphincterotomy Does Not Increase Risk During Endoscopic Retrograde Cholangiopancreatography in Patients With Difficult Biliary Access: A Meta-analysis of Randomized Controlled Trials

BACKGROUND & AIMS

Use of precut sphincterotomy during endoscopic retrograde cholangiopancreatography (ERCP) can increase the odds for cannulation success but is associated with increased risk of post-ERCP pancreatitis. Earlier, rather than delayed, use of precut sphincterotomy for cases with difficult biliary access might reduce this risk. We performed a meta-analysis of randomized controlled trials to determine how early use of precut sphincterotomy affects the risk of pancreatitis and rate of cannulation success compared with persistent standard cannulation.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane central register of controlled trials, along with meeting abstracts, through August 2014 for randomized controlled trials in which early precut sphincterotomy was compared with persistent standard cannulation in adults with difficult biliary access. Outcomes considered included primary cannulation success, overall cannulation success, incidence of post-ERCP pancreatitis, and overall adverse event rate. Findings from a random-effects model were expressed as pooled risk ratios (RRs) with 95% confidence intervals (CIs).

RESULTS

We analyzed data from 5 studies (523 participants). The incidence of post-ERCP pancreatitis and success of overall cannulation did not differ significantly between the early precut and persistent standard therapy groups. Early use of precut sphincterotomy was associated with increased odds for primary cannulation success (RR, 1.32; 95% CI, 1.04-1.68). In subgroup analysis of studies that involved only fully qualified biliary endoscopists (not fellows), we found a significant reduction in risk of pancreatitis among patients receiving early precut vs the standard technique (RR, 0.29; 95% CI, 0.10-0.86).

CONCLUSION

Compared with standard therapy, early use of precut sphincterotomy did not increase the risk of post-ERCP pancreatitis in a meta-analysis. When the procedure is performed by qualified biliary endoscopists, early precut can reduce the risk of post-ERCP pancreatitis. Rates of primary cannulation increase with early precut. Further studies are needed to confirm these findings.

Effect of rectal indomethacin for preventing post-ERCP pancreatitis depends on difficulties of cannulation: results from a randomized study with sequential biliary intubation

GOALS AND BACKGROUND

The greatest challenges for endoscopists performing biliary therapy in endoscopic retrograde cholangiopancreatography (ERCP) are to achieve selective biliary cannulation and prevent post-ERCP pancreatitis (PEP). Nonsteroidal anti-inflammatory drugs have proven prophylactic effect in PEP. However, the patient population that would benefit from this approach has not been defined.

STUDY

A total of 539 patients undergoing our cannulation protocol with early precut were randomized into a placebo-controlled, prospective, double-blind study to rectally receive either 100 mg indomethacin or placebo. The effect of indomethacin on PEP was stratified based on difficulties of cannulation and analyzed in patients with different risks.

RESULTS

In 70.3% of patients, biliary intubation was successful in the first 5 atraumatic attempts, PEP rate was low, and indomethacin was ineffective (7.4% in the placebo group and 5.2% in the indomethacin group, P=0.406). In the next phase of intubation using guidewire, the success rate increased up to 83.5%, and PEP rate rose up to 8.7%, the effect of indomethacin was significant (11.9% vs. 5.4%, P=0.018). Applying early precut success rate of biliary cannulation increased up to 98.1% and overall indomethacin diminished the frequency of PEP from 13.8% to 6.7% (P=0.007). Preventive effect of indomethacin was demonstrated in cases with defined procedure-related risk (28.3% vs. 13.8%, P=0.028) and with defined patient-related risk (16.3% vs. 7.0%, P=0.004), but not in patients without risk factors.

CONCLUSIONS

Rectally administered 100 mg indomethacin results in significantly lower PEP rate, particularly in cases with difficult cannulation and with identifiable patient-related or procedure-related risk factors.

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.