Safety of Erlangen precut papillotomy: an analysis of 1044 consecutive ERCP examinations in a single institution

The Relation between Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis and Different Cannulation Techniques: The Experience of a High-Volume Center from North-Eastern Romania

BACKGROUND

Despite numerous advances that have aimed to increase the safety of endoscopic retrograde cholangiopancreatography (ERCP), post-ERCP pancreatitis (PEP) still remains a major issue. We aimed to assess the rate of PEP as well as the relation to the cannulation techniques in our unit, a high-volume center in north-eastern Romania.

METHODS

ERCPs performed in our unit from March to August 2022 were retrospectively included. Data concerning demographic information, presence of difficult cannulation, the technique used for cannulation, as well as immediate complications, were gathered from the electronic database.

RESULTS

233 ERCPs were included. PEP was diagnosed in 23 (9.9%) of cases. Precut sphincterotomy (PS), transpancreatic sphincterotomy (TPBS), and a combination of TPBS and PS were performed in 6.4%, 10.3%, and 1.7% of cases, respectively, while an Erlangen precut papillotomy was performed in one case. Both in patients with PS and TPBS the rate of PEP was 20%. When the two techniques were associated, the rate of PEP was 25%. TPBS and PS represented risk factors for PEP (OR 1.211 for a CI of 0.946-1.551, p = 0.041, and OR 1.124 for a CI of 0.928-1.361, p = 0.088, respectively). No PEP-associated deaths were found.

CONCLUSIONS

Both PS and TPBS presented a similar risk of PEP.

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

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

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.

Safety and efficacy of a newly developed baby-sphincterotome for cannulation and precut in cases of failed selective wire-guided bile duct access: a prospective 8-year clinical evaluation

BACKGROUND

Precut sphincterotomy (PCS) is a well-established alternative after repeated unsuccessful attempts of common bile duct (CBD) cannulation using standard catheters and/or guide-wire. Commonly used instruments for precutting are the needle-knife and a modified traction-type sphincterotome. In 1996, a so-called 'baby-sphincterotome' with a preshaped, small-caliber 3 Fr tip was developed, which enables cannulation and precutting in one step.

OBJECTIVE

A clinical evaluation was carried out and the complication rates were determined at a tertiary referral hospital.

DESIGN

Prospective clinical evaluation.

INTERVENTIONS

During an 8-year period, a total of 5389 endoscopic retrograde cholangiopancreatographies were performed at our hospital. In total, 1886 patients fulfilled the inclusion criteria for this prospective study. The baby-sphincterotome was used in 345 of 1886 patients (mean age 63.4 ± 16.4 years, 203 women) after five unsuccessful attempts of CBD cannulation using a hydrophilic guide-wire. After two more failed CBD cannulations with the baby-sphincterotome, PCS was performed using the same device.

MAIN OUTCOME MEASUREMENTS

The success rates of biliary access, postendoscopic retrograde cholangiopancreatography pancreatitis, and bleeding were assessed.

RESULTS

Initially, the success rate of CBD cannulation on using the baby-sphincterotome was 28% (96/345 patients). Postinterventional pancreatitis occurred in two of 96 patients (2%) and minor bleeding occurred during traction-type sphincterotomy in four of 93 patients (4%). In the remaining 249 patients precut with a baby-sphincterotome, CBD cannulation was achieved in 219 cases (88%), although with pancreatitis and severe bleeding in 4% each. In 30 of 249 patients (12%), a second or a third (n=5) intervention was necessary, with a success rate of 73% (22/30 cases) after PCS.

LIMITATIONS

This was a single-centre, uncontrolled study.

CONCLUSION

The newly developed baby-sphincterotome enables bile duct access in a single session in 91% of the patients when guide-wire cannulation has failed. Direct cannulation was possible in about one-quarter of the patients, whereas PCS with the new device showed a high efficacy and a low complication rate.

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.

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

PURPOSE

To evaluate the success and complication rates of early precut papillotomy in difficult biliary cannulations performed by an average endoscopist skilled in ERCP.

METHODS

We studied 146 consecutive ERCPs during a 27-month period. Precutting was instituted if cannulation failed after 10-15 min. Standard papillotomy was performed in the rest. The analysis was divided into initial period (1st year) and subsequent period (following 15 months).

RESULTS

The success rate of cannulation was 95% (139/146). Standard papillotomy was performed in 103/146 (71%) patients. In the remainder, cannulation was successful after precutting in 36/43 (84%) patients. The complication rate was 10% (8/103 in the standard vs. 7/43 in the precut group, P = 0.14). All complications of the standard group were mild. In the precut group, there were three moderate to severe complications. There were no differences between the two periods.

CONCLUSIONS

Precut papillotomy can be an effective and relatively safe procedure when performed by an average endoscopist skilled in ERCP. Although the complication rate of precutting tended to be higher than standard papilotomy, this was reasonable since it increased the success of selective biliary cannulation in 25% of cases. Complication rates did not improve with experience.

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.

Duodenal perforations after endoscopic retrograde cholangiopancreatography: experience and management

OBJECTIVE

The aim of this study was to summary the experiences and lessons from periduodenal perforations related to endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST).

METHODS

A retrospective review from 2004 to 2007 identified 9 patients (0.37%) of periduodenal perforation related to ERCP/EST. Charts were reviewed for the following parameters: clinical presentation of patients, ERCP findings, diagnostic methods, treatment (surgical or conservative procedures), complications, and outcome.

RESULTS

Nine patients who had periampullary perforations received ERCP/EST for common bile duct stones. Cannulation was considered difficult in 7 of 9 patients, and the precut technique was used. The diagnosis was made due to subcutaneous emphysema or peritonitis, and 3 patients received emergent operations (e.g., external biliary or retroperitoneal drainage), and 1 patient had a reoperation for a retroperitoneal sealed abscess. Their median length of hospital stay was 50 days. The other 6 were treated conservatively with nasal-duodenal and nasal-biliary drainage. Their median length of hospital stay was 13 days. There was no mortality.

CONCLUSIONS

The precut technical may be a risk factor of duodenal perforation. Early diagnosis of duodenal perforation is essential for an optimum outcome, and subcutaneous emphysema may be a sensitive sign. Although the management of perforation after ERCP/EST is still controversial, a selective management is proposed, based on the features of classification type. Nevertheless, duodenal and biliary drainage is essential in both surgical and conservative therapy.