Endoscopic retrograde cholangiopancreatography catheter and accessory exchange using a short hydrophilic guide wire: a prospective study

Comparison of Physician-Controlled Maneuver and Assistant-Controlled Maneuver during Endoscopic Retrograde Cholangiopancreatography

PURPOSE

Cannulation of the major papilla is the most challenging part of endoscopic retrograde cholangiopancreatography (ERCP) for which physician-controlled wire-guided cannulation (PCWGC) and assistant-controlled wire-guided cannulation (ACWGC) are used as the cannulation techniques. PCWGC can reportedly save up to about 30% of the labor cost by reducing the number of assistants. This study aims to compare the safety and efficacy of PCWGC and ACWGC.

MATERIALS AND METHODS

Of the 2151 patients aged >20 years (4193 cases) who underwent ERCP at Yonsei University Medical Center between January 2015 and December 2016, 989 were included in this study.

RESULTS

Among efficacy outcomes, cannulation success rate, rate of precut sphincterotomy (PCWGC vs. ACWGC: 21.3% vs. 25.9%), bile duct cannulation time (PCWGC vs. ACWGC: median 3.0 minutes vs. 3.6 minutes), and total procedure time (PCWGC vs. ACWGC: median 13.6 minutes vs. 13.1 minutes) were not significantly different. Among safety outcomes, lower rates of post-ERCP pancreatitis were observed with PCWGC than with ACWGC (PCWGC vs. ACWGC: 5.8% vs. 8.8%, p=0.128). Among other post-ERCP adverse events (bleeding, perforation, and cholangitis), the difference was not significant between the groups. Radiation exposure (total dose area product, PCWGC vs. ACWGC: median 1979.9 µGym² vs. 2062.0 µGym², p=0.194) and ERCP cost excluding labor cost (PCWGC vs. ACWGC: $1576 vs. $1547, p=0.606) were not significantly different.

CONCLUSION

Requiring less assistants, PCWGC showed comparable efficacy and safety to ACWGC. PCWGC can be considered as an alternative option, especially in facilities lacking manpower and resources.

Conventional endoscopic retrograde cholangiopancreaticography vs the Olympus V-scope system

AIM

To compare the new Olympus V-scope (VS) to conventional endoscopic retrograde cholangiopancreaticography (ERCP).

METHODS

Forty-nine patients with previous endoscopic papillotomy who were admitted for interventional ERCP for one of several reasons were included in this single-centre, prospective randomized study. Consecutive patients were randomized to either the VS group or to the conventional ERCP group. ERCP-naïve patients who had not undergone papillotomy were excluded. The main study parameters were interventional examination time, X-ray time and dose, and premedication dose (all given below as the median, range) and were investigated in addition to each patient's clinical outcome and complications. Subjective scores to assess each procedure were also provided by the physicians and endoscopy assistants who carried out the procedures. A statistical analysis was carried out using the Wilcoxon rank-sum test.

RESULTS

Twenty-five patients with 50 interventions were examined with the VS ERCP technique, and 24 patients with 47 interventions were examined using the conventional ERCP technique. There were no significant differences between the two groups regarding the age, sex, indications, degree of ERCP difficulty, or interventions performed. The main study parameters in the VS group showed a nonsignificant trend towards a shorter interventional examination time (29 min, 5-50 min vs 31 min, 7-90 min, P = 0.28), shorter X-ray time (5.8 min, 0.6-14.1 min vs 6.1 min, 1.6-18.8 min, P = 0.48), and lower X-ray dose (1351 cGy/m(2), 159-5039 cGy/m(2) vs 1296 cGy/m(2), 202.2-6421 cGy/m(2), P = 0.34). A nonsignificant trend towards fewer adverse events occurred in the VS group as compared with the conventional ERCP group (cholangitis: 12% vs 16%, P = 0.12; pain: 4% vs 12.5%, P = 0.33; post-ERCP pancreatitis: 4% vs 12.5%, P = 0.14). In addition, there were no statistically significant differences in assessment by the physicians and endoscopy assistants using subjective questionnaires.

CONCLUSION

ERCP using the short-guidewire V-system did not significantly improve ERCP performance or patient outcomes, but it may reduce and simplify the ERCP procedure in difficult settings.

A prospective randomized study of thin versus regular-sized guide wire in wire-guided cannulation

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable tool in the diagnosis and management of various pancreatobiliary disorders. Our aim was to evaluate whether the combination of a thin guide wire and a thin sphincterotome would facilitate selective cannulation of the bile duct and reduce the incidence of post-ERCP pancreatitis (PEP) by reducing papillary trauma when compared with a regular-sized hydrophilic guide wire.

METHODS

Between June 2011 and February 2012, we performed 100 biliary cannulations for a native papilla in a randomized controlled trial. Having given their written informed consent, patients were randomly assigned to a 0.025-inch guide wire and sphincterotome group (n = 50) or to a 0.035-inch guide wire and sphincterotome group (n = 50). Number of cannulation attempts, number of accidental guide wire passages into the pancreatic duct, secondary cannulation techniques after failed primary cannulation, time to change the technique, and time for successful cannulation were collected in a database. Patients were followed up after ERCP, and all post-ERCP complications were recorded.

RESULTS

Primary cannulation was successful in 80 %. With accessory techniques, cannulation of the biliary duct was achieved in every case except one. There was no difference in primary cannulation rate between the 0.025-inch and 0.035-inch wire groups (n = 40 in each group). PEP was diagnosed in two patients (2.0 %), one in each study group. Postsphincterotomy bleeding occurred in one patient (1.0 %).

CONCLUSIONS

The thickness of the hydrophilic guide wire does not appear to affect either the success rate of primary cannulation or the risk of complications.

EUS-guided biliary rendezvous using a short hydrophilic guidewire

BACKGROUND AND STUDY AIMS: EUS-guided rendezvous technique for biliary access requires expert manipulation of the guidewire across the downstream stricture or papilla. Published literature reports usage of the long-wire system to prevent loss of wire during scope exchange. We studied the efficacy of using a short hydrophilic guidewire in EUS-guided rendezvous. PATIENTS AND METHODS: This is a retrospective study conducted in a tertiary care referral centre. 15 patients underwent EUS-guided biliary rendezvous with short wire. EUS-guided transduodenal/transgastric puncture of the biliary system was performed, followed by anterograde placement of a hydrophilic short-wire (260 cm) across the downstream stricture and/or papilla. Retrograde access was then achieved by retrieving the trans-papillary wire, followed by standard ERCP intervention. Main outcome measurements were rates of procedural success and complications. RESULTS: EUS-guided biliary rendezvous was successful in 14 patients (93.3%). Failure was seen in one patient due to a tight malignant biliary stricture. One patient had peri-choledochal bile tracking which did not require any specific treatment. CONCLUSIONS: Short-wire system in EUS-guided biliary rendezvous is highly effective and safe. It is a useful salvage procedure for biliary cannulation in patients with accessible papilla.

EUS-guided biliary rendezvous using a short hydrophilic guidewire

BACKGROUND AND STUDY AIMS: EUS-guided rendezvous technique for biliary access requires expert manipulation of the guidewire across the downstream stricture or papilla. Published literature reports usage of the long-wire system to prevent loss of wire during scope exchange. We studied the efficacy of using a short hydrophilic guidewire in EUS-guided rendezvous. PATIENTS AND METHODS: This is a retrospective study conducted in a tertiary care referral centre. 15 patients underwent EUS-guided biliary rendezvous with short wire. EUS-guided transduodenal/transgastric puncture of the biliary system was performed, followed by anterograde placement of a hydrophilic short-wire (260 cm) across the downstream stricture and/or papilla. Retrograde access was then achieved by retrieving the trans-papillary wire, followed by standard ERCP intervention. Main outcome measurements were rates of procedural success and complications. RESULTS: EUS-guided biliary rendezvous was successful in 14 patients (93.3%). Failure was seen in one patient due to a tight malignant biliary stricture. One patient had peri-choledochal bile tracking which did not require any specific treatment. CONCLUSIONS: Short-wire system in EUS-guided biliary rendezvous is highly effective and safe. It is a useful salvage procedure for biliary cannulation in patients with accessible papilla.

A new guidewire cannulation technique in ERCP: successful deep biliary access with triple-lumen sphincterotome and guidewire controlled by the endoscopist

BACKGROUND

Current studies have addressed ways to improve the success of selective biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP). The objective of this study was to assess the efficacy of deep bile duct access using a short-wire system with sphincterotome and guidewire controlled only by the endoscopist.

METHODS

This was a prospective study of 70 patients with biliary diseases subjected to ERCP. Biliary cannulation was performed by the endoscopist without direct cooperation of the assistant in two centers with different experience in ERCP. The RX Biliary System™ was used in all patients. Efficacy (success rate and time to cannulation) of deep bile duct access and procedure-related complications were determined.

RESULTS

Overall guidewire cannulation was successful in 65 of 70 patients (92.9%). Nonintentional pancreatic duct cannulation with the guidewire was performed in 22 patients (31.4%). Additional techniques were needed in 18 patients (25.7%): guidewire into the pancreatic duct in 11 patients (15.7%); contrast-medium was used in 13 patients (18.6%); and precut was performed in 3 patients (4.3%). Attempts at papilla cannulation numbered<10 in 48 patients (68.6%), and time to biliary cannulation was <10 min in 42 patients (60%). Minor complications occurred in five patients (7.1%). There were no significant differences between patients in both centers.

CONCLUSIONS

The short-wire system allows the endoscopist to have access to the bile duct with a high success rate--early and safely--without the direct participation of the assistant.

ERCP wire systems: The long and the short of it

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

Endoscopist administered sedation during ERCP: impact of chronic narcotic/benzodiazepine use and predictive risk of reversal agent utilization

OBJECTIVES

When administered by endoscopists conventional sedation regimens for endoscopic retrograde cholangipancreatography (ERCP) consist of intravenous (IV) benzodiazepines and opiates. As yet, standardized dosing regimens for individual patients do not exist. The aims of this study were to (a) determine sedative doses in patients with and without a history of narcotic or benzodiazepine use, (b) assess the frequency of reversal agent utilization, and (c) assess potential predictive factors for reversal agent utilization.

METHODS

Clinical data from January 1, 2004, to December 31, 2005, were abstracted from a computerized endoscopy database to determine: demographics, median sedation dosages, risk of reversal agent use, and clinical outcome related to sedation. Univariate and logistic regression analysis were performed to assess independent predictive factors for reversal agent utilization.

RESULTS

Of 3,179 patients undergoing ERCP, 3,058 received sedation directed by the endoscopists. Meperidine and midazolam IV were given at a median dose of 125 mg and 7 mg, respectively, during a mean procedure time of 42 min. One hundred eighty-six patients reported routine use of narcotics or benzodiazepines (6%). These patients were younger, predominantly female, required higher doses of meperidine and midazolam, and received IV promethazine during procedural sedation more frequently than patients not using narcotics or benzodiazepines. One hundred twenty-four patients required reversal agents (4%). They were relatively older, required significantly higher doses of meperidine and received promethazine more frequently than the nonreversed group.

CONCLUSIONS

In a single, high volume ERCP center, endoscopist administered sedation was provided in 96% of cases. Patient age >or=80 yr, dose of meperidine, and the use of promethazine were independent risk factors for the need of reversal agents.