Double guidewire endoscopic technique, a major evolution in endoscopic retrograde cholangiopancreatography: Results of a retrospective study with historical controls comparing two therapeutic sequential strategies

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.

Difficult biliary cannulation in patients with distal malignant biliary obstruction: An underestimated problem?

BACKGROUND

Failed biliary cannulation still poses a major challenge in patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP). To date, there is a lack of data on rates of Difficult Biliary Cannulation (DBC) in patients with distal malignant biliary obstruction (DMBO).

MATERIALS

This was a retrospective study (09/2015 to 02/2019) of consecutive patients with DMBO that underwent ERCP in four Italian centers. The primary outcome was to evaluate the rate of DBC. Secondary outcomes were: cannulation failure, rate of adverse events (AEs), the predictive factors for DBC as well as for AEs.

RESULTS

A total of 622 patients with DMBO, were included in the study, with 351(56,4%) matching the definition of DBC. One-hundred and two ERCP-related AEs occurred in 97 of 622 patients (15,6%). Subjects with DBC showed a higher risk for AEs (p = 0.02). The lack of pancreatitis prophylaxis (p = 0.03), diagnosis of cholangiocarcinoma (p = 0.02), the use of papillotomy (OR=1.98; 95%CI = 1.14-3.45) and the combination of two or more techniques for cannulation (OR = 2.88; 95%CI = 1.04-7.97) were associated with the occurrence of AEs.

CONCLUSIONS

According to the results of this study, patients with DMBO carries a higher rate of DBC thus requiring alternative techniques for biliary drainage. Furthermore, DBC carries a high risk for AEs. Further prospective multicentric studies are needed to confirm these data in this specific subgroup of patients.

Early double-guidewire versus repeated single-guidewire technique to facilitate selective bile duct cannulation: a randomized controlled trial

BACKGROUND

During endoscopic retrograde cholangiopancreatography (ERCP), access to the common bile duct (CBD) can be problematic after unintentional insertion of the guidewire into the pancreatic duct. We conducted a prospective, randomized study in order to compare biliary cannulation success rates of early double-guidewire (EDG) and repeated single-guidewire (RSG) techniques in patients with inadvertent passage of the guidewire into the pancreatic duct.

METHODS

Patients with a native papilla were randomly assigned to either the EDG or RSG groups after unintentional insertion of the guidewire into the pancreatic duct. The primary outcome was successful selective CBD cannulation within 10 minutes. The secondary outcomes were successful final selective bile duct cannulation, time to bile duct cannulation, and frequency of post-ERCP pancreatitis (PEP).

RESULTS

142 patients were randomized and selective bile duct cannulation was achieved in 57/68 patients (84 %) in the EDG group and in 37/74 patients (50 %) in the RSG group within 10 minutes (relative risk 1.34; 95 % confidence interval 1.08-6.18; P < 0.001). The overall final selective bile duct cannulation rate was 99.3 %. The time to access the CBD was shorter using the EDG technique (6.0 vs. 10.4 minutes; P = 0.002). Mild PEP was not observed more frequently in the EDG group than in the RSG group.

CONCLUSION

The EDG technique significantly increased the success rate of biliary duct cannulation within 10 minutes compared with an RSG approach.

The role of double-guidewire technique in preventing postendoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND AND STUDY AIMS

Postendoscopic retrograde cholangiopancreatography (ERCP) complications increase with repeated cannulation attempts. We evaluated several advanced biliary cannulation techniques, which have been used when the standard approach fails, to increase the success rate and decrease post-ERCP complications. We aimed to evaluate the use of double-wire technique in terms of success rates and effects on post-ERCP pancreatitis (PEP) and to assess the value of pancreatic duct stenting following needle-knife sphincterotomy in difficult biliary cannulation.

PATIENTS AND METHODS

A single-center, retrospective, randomized study was conducted on patients who underwent ERCP in Notre Dame De Secours University Hospital at Byblos, Lebanon, after obtaining the hospital's ethics committee approval. Patients were divided into three groups. The first group consisted of patients who had an ERCP and was divided into two subgroups, namely, one usingdouble-guidewire technique (DGT) only and another using an extra technique of precut with double-guidewire and pancreatic plastic stent placement. The second group of patients who had only ERCP was the control group. Finally, the third group endured the precut technique alone.

RESULTS

We could not prove any significant association between the intervention and the occurrence of pancreatitis when comparing double-wire technique plus ERCP to ERCP alone. When DGT with a pancreatic plastic stent was used, the incidence of PEP was significantly lower than that in other techniques.

CONCLUSION

DGT has a neutral effect on the reduction of PEP compared with the classic ERCP, but the technique can decrease the time of examination and increase success in difficult cases. ERCP using the double-guidewire with placement of a pancreatic plastic stent can contribute to decreasing PEP.

Double Guidewire Technique Using an Uneven Double Lumen Catheter for Endoscopic Ultrasound-Guided Interventions

BACKGROUND

Endoscopic ultrasonography (EUS)-guided interventions are often performed using a single guidewire (SGW), but there are a few reports on the use of double guidewire (DGW) technique to facilitate multiple drainage placement during EUS-guided drainage of pancreatic fluid collections. This DGW technique may have advantages other than multiple drainage placement during EUS-guided interventions such as scope stabilization, support for stone extraction and device insertion.

METHODS

Consecutive patients who underwent EUS-guided interventions between Feb 2012 and Apr 2019 were retrospectively reviewed. The rate and reasons of DGW technique, and clinical outcomes were evaluated. DGW technique was performed, using an uneven double lumen cannula (UDLC), which facilitates insertion of 0.025-in. and 0.035-in. guidewires.

RESULTS

A total of 249 EUS-guided interventions were analyzed, and DGW technique was utilized primarily in 65 cases (25.7%) and as a salvage after failed SGW technique in 18 cases (7.1%). The reasons for DGW technique were 60 multiple drainage placement, 10 scope stabilization, 7 device insertion, 5 safety guidewire, and 4 antegrade stone removal. Insertion of UDLC and DGW was successful in 100%. Technical success rate of preplanned interventions was 92.7% (96.9% in primary DGW and 77.8% in salvage DGW technique). Adverse events were observed in 19.5% after DGW but were not related to DGW technique.

CONCLUSIONS

DGW technique using UDLC during EUS-guided interventions was technically feasible and safe. In addition to multiple drainage insertion, it can potentially support complex EUS-guided interventions.

Reducing the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis using 4-Fr pancreatic plastic stents placed with common-type guidewires: Results from a prospective multinational registry

BACKGROUND AND AIM

Pancreatic plastic stents (PPS) can reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Prospective multicenter documentation of PEP rate after PPS placement is scarce. A new 4-Fr stent designed to be deployed over a 0.035-inch guidewire was used to assess the effectiveness of PEP prophylaxis.

METHODS

High-PEP-risk patients received a 4-Fr PPS for primary or secondary prophylaxis at seven centers in four countries. Patients were followed until spontaneous PPS migration, endoscopic stent removal, or for 4 months, whichever came first. Main outcome was PEP rate.

RESULTS

One hundred six (106) patients received PPS for PEP prophylaxis [61 (58%) primary, 45 (42%) secondary prophylaxis]. Median age was 54 years. Eighty-one (76%) PPS were placed using a 0.035-inch guidewire. By investigator choice 99 (93%) stents were single pigtail. Median stent length was 8 cm (range 3-12 cm). Technical success achieved in 100% of cases. Two patients in the primary prophylaxis group (3%, 95% CI 0.4-11%) experienced mild/moderate PEP. Seventy-eight PPS available for analysis underwent spontaneous migration after a median of 29 days. There were no reports of stent-induced ductal trauma. Post-hoc analysis of migration rate by PPS length showed no statistically significant trend.

CONCLUSIONS

Among high-risk patients in the primary prophylaxis group, observed rates of PEP are low (3%, 95% CI 0.4-11%) with the use of prophylactic 4-Fr pancreatic duct stents compatible with a 0.035-inch guidewire. This low rate is not unequivocally due to the prophylactic stent.

Advances in management of difficult biliary access

Since the first report of endoscopic retrograde cholangio-pancreatography (ERCP) in 1986 for the diagnosis of biliary-pancreatic disease, ERCP has become an important means for the diagnosis and treatment of biliary-pancreatic disease. At present, although the success rate of endoscopic selective biliary cannulation is more than 90%, there are still 5%-10% of cases with failed cannulation, for which assistive technology is needed as a supplementary to achieve successful cannulation. Repeated attempts correlate with a higher success rate of cannulation, but also extend the operating time and increase the incidence of complications. In recent years, the concept of difficult biliary cannulation has been put forward and gradually accepted by endoscopic physicians. In the cases of difficult biliary cannulation, endoscopic physicians can adjust the cannulation strategy in time to improve the success rate and reduce the complication rate. This paper summarizes the literature published recently to make a systematic review of the advances in the management of difficult biliary cannulation.