Safety and success of precut biliary sphincterotomy: Is it linked to experience or expertise?

Needle-Knife Fistulotomy Versus Needle-Knife Papillotomy in Difficult Biliary Cannulation: A Systematic Review and Meta-Analysis

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential endoscopic therapeutic modality for biliary and pancreatic diseases. Needle-knife fistulotomy (NKF) and papillotomy (NKP) are the two most commonly used rescue techniques for patients with difficult biliary cannulation. However, there remains a need for comparative studies on these approaches to inform clinical decision-making. This meta-analysis aimed to evaluate the efficacy and safety of NKF compared to NKP as a rescue technique in difficult biliary cannulation after failed conventional ERCP.

Methods

We searched PubMed, Scopus, Embase, and Web of Science databases through November 2023 to include all studies that directly compared the outcomes of NKF with NKP in difficult biliary cannulation. Single-arm studies were excluded. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data related to clinical events were calculated using the Mantel-Haenszel method within a random-effect model. The primary outcome was the biliary cannulation success rate.

Results

Four studies with 823 patients (n = 376 NKF vs. n = 447 NKP) were included in our analysis. There was no significant difference between the two groups in biliary cannulation success rate (91.7% vs. 86.9%, respectively; OR = 1.54, 95% CI: 0.21 - 2.49, P = 0.14; I2 = 0%). However, the overall rate of adverse events was significantly lower in the NKF group than in the NKP group (OR = 0.46, 95% CI: 0.25 - 0.84, P = 0.01). Pancreatitis (OR = 0.23, 95% CI: 0.05 - 1.11, P = 0.07) and bleeding (OR = 1.43, 95% CI: 0.59 - 3.46, P = 0.42) were similar between the two groups. No significant differences in cholangitis, cholecystitis, perforation, or mortality were observed.

Conclusions

Our meta-analysis indicates comparable success rates in comparing NKF and NKP techniques for difficult biliary cannulation after failed conventional ERCP cannulation. Notably, the NKF technique significantly reduces overall adverse events compared to NKP, suggesting that NKF may be preferable due to its favorable safety profile. Additional randomized controlled trials (RCTs) are warranted to evaluate the interval benefit of an NKF technique.

Combination of Precut Techniques in Difficult Biliary Cannulation

Background

Selective biliary cannulation (SBC) is a prerequisite for successful endoscopic retrograde cholangiopancreatography (ERCP). SBC has the potential to fail in as many as 20% of cases, even with skilled endoscopists. Precut incision techniques like needle-knife sphincterotomy (NKS) and transpancreatic septotomy (TPS) can be used in cases where standard cannulation techniques fail. However, these precut techniques may also fail in some cases. We aimed to evaluate the procedural success of the combined TPS + NKS technique in difficult biliary cannulation.

Patients and methods

The study included 289 patients who underwent ERCP with precut techniques from 2017 to 2022. Patients were classified into the following three groups and evaluated retrospectively in terms of cannulation success, and ERCP-related adverse effects: Transpancreatic septotomy, NKS, and TPS + NKS; statistical package for the social sciences (SPSS), version 29.0, software was used to analyze the data.

Results

The success rate of SBC was 69% in the TPS group, 75.3% in the NCS group, and 87% in the TPS + NCS group. There was no significant difference between the NKS and TPS + NKS groups. Cannulation success in both NKS group and NKS + TPS groups was significantly higher than in the TPS group (p < 0.001). Complication rates were similar.

Conclusion

In cases where standard sphincterotomy and precut techniques fail, a second precut technique can be used. A previous TPS does not prevent NKS.

How to cite this article

Abiyev A, Tuzcu B, Bilican G, et al. Combination of Precut Techniques in Difficult Biliary Cannulation. Euroasian J Hepato-Gastroenterol 2024;14(1):56-59.

Predictive factors of needle-knife pre-cut papillotomy failure in patients with difficult biliary cannulation

Predictors of needle-knife pre-cut papillotomy (NKP) failure for patients with difficult biliary cannulation has not been reported. Between 2004 and 2016, 390 patients with difficult biliary cannulation undergoing NKP were included in this single-center study. Following NKP, deep biliary cannulation failed in 95 patients (24.4%, NKP-failure group) and succeeded in 295 patients (75.6%, NKP-success group). Patient and technique factors were used to identify the predictors of initial NKP failure. Compared with the NKP-success group, periampullary diverticulum (28.4% vs. 18%, p = 0.028), surgically altered anatomy (13.7% vs. 7.1%, p = 0.049), number of cases performed by less experienced endoscopists, and bleeding during NKP (38.9% vs. 3.4%, p < 0.001), were significantly more frequent in the NKP-failure group. On multivariate analysis, surgically altered anatomy (OR 2.374, p = 0.045), endoscopists' experience (OR 3.593, p = 0.001), and bleeding during NKP (OR 21.18, p < 0.001) were significantly associated with initial failure of NKP. In conclusion, NKP is a highly technique-sensitive procedure, as endoscopists' experience, bleeding during NKP, and surgically altered anatomy were predictors of initial NKP failure.

Fistulotomy versus standard cannulation as the primary technique for all patients undergoing ERCP with a native papilla: a protocol for a single center randomized controlled trial

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is an indispensable procedure for the management of pancreaticobiliary diseases. Post-ERCP pancreatitis (PEP) is the most common serious adverse event. One risk factor of PEP is difficulty achieving biliary access. The conventional ERCP technique involves the cannulation of the bile duct via the ampulla of Vater, followed by sphincter incision using electrocautery. Conventionally, if the standard method fails then, precut techniques have been utilized as an alternative means of gaining biliary access. The needle-knife fistulotomy (NKF) technique involves identifying the intra-duodenal segment of the bile duct and uses a needle knife to incise directly into the bile duct. This is done above and away from the natural office, thus minimizing thermal damage which may result in PEP. Our recent prospective study of 50 patients demonstrated the safety and feasibility of the NKF precut technique as a primary means of gaining biliary access. The next step is to conduct a randomized controlled trial to compare the efficacy and safety of initial NKF to the standard cannulation in a non-selective patient population undergoing ERCP.

Methods

A randomized control trial of 538 consecutive, non-selective patients with pancreaticobiliary disease undergoing ERCP at a tertiary care center in Kingston, Ontario, Canada, will be conducted. Patients will be randomized to one of two treatment groups, standard cannulation or NKF. The primary outcome of the study will be the incidence of PEP. Secondary outcomes will include rate of successful cannulation of the common bile duct (CBD), time to successful cannulation, total procedure time, difficulty of cannulation, and incidence of complications.

Discussion

This RCT will yield important answers regarding the efficacy and safety of initial NKF to the standard cannulation in a non-selective patient population undergoing ERCP. The results of our study could alter ERCP practices and outcomes if NKF is shown to reduce PEP risk.

Trial registration

ClinicalTrials.govNCT04559867. Registered on September 23, 2020

Safety and efficacy of different techniques in difficult biliary cannulation at endoscopic retrograde cholangiopancreatography

BACKGROUND

Adverse events (AEs) are commonly seen at endoscopic retrograde cholangiopancreatography (ERCP) during difficult biliary cannulation (DBC). Therefore, attaining the right technique is essential to have improved outcomes.

METHODS

Patients who had DBC over a 3-year period were assessed for outcomes. The protocol included double guidewire (DGW) technique, wire-guided cannulation (WGC) after pancreatic stent, precut sphincterotomy/fistulotomy, and EUS-guided rendezvous (RV). The success of various techniques and AE was studied.

RESULTS

As per available case analysis, a total of 3680 patient details were assessed out of which DBC was noted in 471 (12.8%) patients with a mean (SD) age of 51.5 (17.4) years; majority being 330 (70.1%) males. Most patients underwent precut sphincterotomy 230 (48.8%); however, it was not successful in the first attempt in 10 (2.1%) patients with the success rate of 220 (95.6%). The success rate of DGW cannulation was 120 (95.2%), WGC after pancreatic stent was 64 (94.1%), EUS-RV was 34 (97.1%), and wire-guided repeat ERCP after 48 h was 10 (98.3%). AEs were noted in 52 (11.1%) patients. After precut, 32 (13.9%) patients developed AE out of which post-ERCP pancreatitis was noted in 20 (8.7%). Twenty-three patients had failed biliary access after all methods and 20 (86.9%) of those received successful percutaneous transhepatic biliary drainage.

CONCLUSION

Repeat ERCP after 48 h and EUS-RV appear prudent for DBC. Precut remains one of the preferred choices for most endoscopists when there is no entrance to PD. Further utilizing an algorithmic approach can contribute to higher success rates without compromising safety.

Safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients aged 85 years and older: A single center experience

Objective: To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients (≥85 years old).

Material and Methods: Patients who underwent ERCP for any reason within 12 months were evaluated. Patients undergoing ERCP were classified as the elderly group aged 85 years and older or the controls under the age of 85 years.

Results: A total of 1225 patients, 504 males and 721 females, were included in the study. Length of hospital stay, the number of patients in whom pre- cut sphincterotomy was performed in ERCP, and mortality rate showed similar characteristics compared to the control group in patients with advanced age (≥85 years old). Except for pancreatitis, there was no significant difference between the groups in terms of complications related to the procedure. Post ERCP pancreatitis was observed significantly less in the elderly group (p= 0.042). Pre-cut sphincterotomy was required in a total of 191 (15.5%) patients. In patients who underwent pre-cut sphincterotomy and patients with cholangitis, post ERCP complication rates were not significant between the groups.

Conclusion: ERCP is a safe procedure for older patients (≥85 years old) as well as young patients.

Fistulotomy-First Approach is Safe and Effective in Endoscopic Retrograde Cholangiography: Results of a Prospective Case Series

Background and Aims

The aim of this study was to assess the safety and efficacy of using needle-knife fistulotomy (NKF) as a primary cannulation technique in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) with a native papilla.

Patients and Methods

This prospective feasibility study enrolled 50 patients between December 2018 and June 2019. The procedure was performed by two expert endoscopists (R.B. and L.H.). The primary outcome was the incidence of post-ERCP pancreatitis. Other variables assessed included the success rate of cannulation of the common bile duct (CBD), time to successful cannulation, and incidence of adverse events.

Results

Between December 2018 and June 2019, 50 patients enrolled in the study. The mean age was 63.4 years (standard deviation 18.1), and there were 26 females. Indications included biliary obstruction secondary to malignancy (n = 14) and choledocholithiasis (n = 36). Successful cannulation of the CBD through the fistulotomy occurred in 49/50 cases. The time to successful cannulation was 5.1 minutes (range 0.5 to 23 minutes). Mild acute pancreatitis occurred in two cases (4%). Post-ERCP bleeding occurred in three patients (6%)

Conclusions

In this pilot study, NKF was used as the primary biliary access technique and it was demonstrated that it appears to be at least as safe as the traditional access technique with a sphinctertome. However, its role as a primary cannulation technique requires further investigation with multicenter, randomized control studies.

Single-Operator Wire-Guided Cannulation Technique for Endoscopic Retrograde Cholangiopancreatography

Background

The aim of this prospective study was to evaluate the clinical application value of single-operator cannulation technology (SOCT) for endoscopic retrograde cholangiopancreatography (ERCP).

Material/Methods

Sixty-nine patients prepared for ERCP were prospectively recruited from February 2014 to January 2017 in the 4^th People’s Hospital of Jinan. The included 69 patients were randomly divided into an experiment group (n=36) and a control group (n=33). Patients in the experiment group underwent SOCT procedure of ERCP and patients in the control group received the regular procedure of ERCP. The cannulation time, number of cannulations, number of attempts at cannulation, and ERCP procedure-relevant complications were recorded and compared between the 2 groups.

Results

All of the included 69 patients successfully finished the ERCP procedure, with no peri-operative deaths. The median duration of cannulation for the experiment group was 7.4 (2.3~35.1) min and 7.1 (2.9~26.1) min for the control group, with no significant difference (p>0.05). The distribution of different cannulation periods and cannulation attempts were not significantly different between the 2 groups (p>0.05). The major complications relevant ERCP procedure were pancreatitis and infection. The incidence rate of pancreatitis and infection were 2.8% and 2.8% in the experiment group and 3.0% and 0.0% in control group, and the difference between groups was not significant (p>0.05).

Conclusions

Compared with regular ERCP, SOCT achieved the same effects without the help of an experienced assistant, which could make the procedure useful in primary hospitals.

Is the Isolated-Tip Needle-Knife Precut as Effective as Conventional Precut Fistulotomy in Difficult Biliary Cannulation?

Background/Aims

Needle-knife precut fistulotomy (NK-F) is a well-known freehand technique for difficult biliary cannulation (DBC). Another approach involves the use of Iso-Tome^®, a modified precutting device with an insulated needle tip to prevent direct thermal injury. This comparative study aimed to evaluate the efficacy of the Iso-Tome^® precut (IT-P) compared to that of NK-F for DBC.

Methods

Patients with a naive papilla who underwent early IT-P or NK-F for DBC were enrolled. DBC was defined as failure to achieve selective biliary access by wire-guided cannulation despite 5 minutes of attempted cannulation, ≥5 papillary contacts, or a hook-nose-shaped papilla. The primary endpoint was the primary technical success rate, which was based on a noninferiority model.

Results

A total of 239 DBC cases were enrolled. The primary technical success rates were 74.7% (89/119) in the IT-P group and 91.6% (110/120) in the NK-F group (lower limit of 90% confidence interval, −0.23; p=0.927 for a noninferiority margin of 10%). The total technical success rates were 87.4% and 95.0%, respectively (p=0.038). The mean precutting times for successful biliary access were 11.2 minutes for IT-P and 7.3 minutes for NK-F (p<0.01). The procedure-related adverse event rates were 9.2% for IT-P and 5.8% for NK-F (p=0.318). The rates of post-endoscopic retrograde cholangiopancreatography pancreatitis were 4.2% and 2.5%, respectively (p=0.499).

Conclusions

IT-P failed to exhibit noninferiority compared with NK-F regarding the primary technical success rate of DBC, but there was no difference in the frequency of adverse events.

Wire-guided cannulation over a pancreatic stent method increases the need for needle-knife precutting ın patients with difficult biliary cannulations

BACKGROUND AND AIMS

Cannulation of the major papilla can be problematic, and selective biliary cannulation may fail in up to 18% of cases. Various techniques, such as double-guidewire technique (DGWT), wire-guided cannulation over a pancreatic stent (WGC-PS), the precut endoscopic sphincterotomy (needle-knife precutting technique (NKP), and transpancreatic septostomy have been used to improve the success rate of biliary cannulation. We conducted a prospective, randomized study in order to compare the biliary cannulation success rates of DGWT and WGC-PS techniques in patients with inadvertent passage of guidewire to the pancreatic duct.

METHODS

A total of 100 patients were included in the study and randomized to DGWT (n = 50) or WGC-PS (n = 50) groups. The primary outcome was successful selective cannulation, defined as deep cannulation with selective injection of radiographic contrast material into the common bile duct within 5 minutes by DGW or WGC-PS techniques without performing precut sphincterotomy.

RESULTS

Successful selective cannulation was achieved in 45 patients in the DGWT group (90%) and in 27 patients in the WGC-PS group (54%) (P < .001). Five patients (10%) in the DGWT group and 23 (46%) in the WGC-PS group required NKP for biliary access (P < .001). The overall cannulation rate was 98% for DGWT and 98% for WGC-PS (P = 1.00).

CONCLUSIONS

In patients with unintentional passage of a guidewire into the pancreatic duct during biliary cannulation attempts, the WGC-PS technique significantly increased the need for NKP compared with DGWT.

Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist

Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.

Emergency endoscopic needle-knife precut papillotomy in acute severe cholangitis resulting from impacted common bile duct stones at duodenal papilla

AIM

To evaluate the efficacy and safety of emergency endoscopic needle-knife precut papillotomy in acute severe cholangitis resulting from impacted common bile duct stones at duodenal papilla.

METHODS

Between January 2010 and January 2015, 118 cases of acute severe cholangitis with impacted common bile duct stones at the native papilla underwent emergency endoscopic retrograde cholangiopancreatography (ERCP) and early needle-knife precut papillotomy in a tertiary referral center. Precut techniques were performed according to the different locations of stones in the duodenal papilla. Clinical data about therapy and recovery of the 118 patients were recorded and analyzed.

RESULTS

One hundred and eighteen patients underwent emergency ERCP within 24 h after hospitalization, with a total success rate of 100%. The mean operating time was 6.4 ± 4.1 min. Postoperative acute physiology and chronic health evaluation (APACHE) II scores, white blood cell count and liver function improved significantly. The complication rate was 4.2% (5/118); two with hemorrhage and three with acute pancreatitis. There was no procedure-related mortality.

CONCLUSION

Emergency endoscopic needle-knife precut papillotomy is effective and safe for acute severe cholangitis resulting from impacted common bile duct stones at the duodenal papilla.

The learning curve for needle knife precut sphincterotomy revisited

Background

There is no consensus on what constitutes adequate training for needle knife precut sphincterotomy.

Objective

The purpose of this study was to determine the number of procedures required before effective and safe precut sphincterotomy can be achieved.

Methods

This retrospective study examined the cumulative experience of a single endoscopist from January 2006-December 2015. Precut sphincterotomy success and complication rates were analyzed as a function of number of procedures performed. Acceptable success and complication rates were defined as 85% and 10% respectively. A one-sided binomial test was used to test success and complication rates of every 25 precut sphincterotomies performed.

Results

The index endoscopic retrograde cholangiopancreatography was successful in 141/158 (89.2%) patients who underwent precut sphincterotomy. This increased to 148/158 (93.7%) when endoscopic retrograde cholangiopancreatography was repeated on another day. Six precut sphincterotomies were required to achieve an 85% success probability. This was maintained consistently above 85% after 13 precuts, and was significantly higher (91.2%; p = 0.029) than 85% at the 125th precut. Bleeding and pancreatitis developed in 2/158 (1.3%) and 5/158 (3.2%). Probability of either complications remained below 5% after 50 precuts. No perforation occurred.

Conclusion

At least 13 precut sphincterotomies were required to achieve a sustained success rate greater than 85%. The probability of bleeding or pancreatitis was less than 5% after 50 precut sphincterotomies.

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.

Gaining competence in needle-knife fistulotomy - can I begin on my own?

BACKGROUND

While there are guidelines for appropriate training in ERCP, these are non-existent for needle-knife precut. The aim of this study was: (1) evaluate the experience curve of three endoscopists in needle-knife fistulotomy (NKF); (2) propose a minimum number of NKF procedures to attest proficiency.

METHODS

Between November 1997 and March 2011, the first 120 consecutive NKF performed by three endoscopists (A, B, and C) were selected (360 patients) from three centers. Each group of 120 patients was chronologically ordered into three subgroups of 40. The main outcomes were: NKF use, NKF success, and post-ERCP adverse events.

RESULTS

The need for NKF did not decrease over time. The NKF success rate in the first attempt for endoscopist A and C in each of the three subgroups was 85 %/85 %, 87.5 %/87.5 %, and 87.5 %/90 %, respectively. Furthermore, both demonstrated a high NKF success in their initial 20 NKFs (85 % and 80 %, respectively). Endoscopist B however presented a different pattern as the success rate initiated at 60 %, then rose to 82.5 % and 85 % for the last group (P = 0.03). Adverse events were mild (28 of the 32 occurrences) with no clear reduction with increased experience.

CONCLUSIONS

A skillful endoscopist may expect to master NKF easily with few adverse events. While some endoscopists could begin on their own because of their innate skills, a minimal training is needed for all, as we cannot predict skills in advance. We propose a minimum of 20 NKF precuts to attest a trainee's competence in this procedure.

Endoscopic "rescue" treatment for gastrointestinal perforations, anastomotic dehiscence and fistula

Luminal perforations and anastomotic leaks of the gastrointestinal tract are life-threatening events with high morbidity and mortality. Early recognition and prompt therapy is essential for a favourable outcome. Surgery has long been considered the "gold standard" approach for these conditions; however it is associated with high re-intervention morbidity and mortality. The recent development of endoscopic techniques and devices to manage perforations, leaks and fistulae has made non-surgical treatment an attractive and reasonable alternative approach. Although endoscopic therapy is widely accepted, comparative data of the different techniques are still lacking. In this review we describe, benefits and limitations of the current options in the management of patients with perforations and leaks, in order to improve outcomes.

One-step transfistula large versus conventional balloon dilation following precut fistulotomy in difficult biliary cannulation for the removal of biliary stones: a multicenter retrospective study

BACKGROUND AND AIM

After selective biliary access following precut fistulotomy in difficult biliary cannulations (DBC), there are several methods of completely opening the remaining papillary roof for the removal of biliary stones. We evaluated the efficacy of one-step transfistula balloon dilation following fistulotomy in DBC for the removal of biliary stones.

METHODS

This retrospective multicenter study was performed in four tertiary referral centers. Patients who underwent fistulotomy due to DBC were enrolled. Precut fistulotomy followed by conventional (≤ 10 mm) or large balloon (≥ 12 mm) dilation through the fistulotomy tract was performed to remove biliary stones. The main outcome measures were technical success and transfistula balloon dilation-related complications.

RESULTS

A total of 154 patients were enrolled. Large balloon and conventional balloon dilation were performed in 57 and 97 patients, respectively. The primary technical success of stone removal was 100% (57/57) for large balloon dilation and 96.9% (94/97) for conventional balloon dilation (P = 0.296). The mean procedure time from biliary access to removal of stones was 29.3 min in large balloon and 22.2 min in conventional balloon dilation (P = 0.042), and the mean numbers of endoscopic retrograde cholangiopancreatography sessions were 1.4 and 1.3, respectively (P = 0.175). Transfistula balloon dilation-related complications were not different between the two groups (10.5% in large balloon dilation vs 16.5% in conventional balloon dilation, P = 0.307).

CONCLUSIONS

One-step transfistula balloon dilation following precut fistulotomy in DBC may be safe and effective for the removal of biliary stones. There were no differences in therapeutic outcomes and complications between large and conventional balloon dilation.

Intraprocedural quality in endoscopic retrograde cholangiopancreatography: a meta-analysis

OBJECTIVES

In 2006, the American College of Gastroenterology (ACG)/the American Society for Gastrointestinal Endoscopy (ASGE) Taskforce on Quality in Endoscopy published quality indicators for the major gastrointestinal procedures. Our primary aim was to use the published literature to assess current endoscopic retrograde cholangiopancreatography (ERCP) intraprocedural performance and compare it to the targets set by the ACG/ASGE taskforce. Our secondary aim was to determine whether performance varies across different health-care settings (academic and community), study designs (prospective and retrospective), and trainee participation.

METHODS

A PubMed and EMBASE literature search from 1/1/2006 to 2/1/2013 was conducted. Articles were selected based on title, abstract, full text, and reporting of success rates for the intraprocedural quality indicators. Success rates, represented as numerical proportions, were collected from each study. For each success rate, a standard error and a 95% confidence interval (CI) was calculated. A random-effects meta-analysis model was used to weight each study, and a cumulative, weighted success rate (or effect size) for each indicator was determined. Random-effects meta-regression was then used to examine the impact of study setting, design, and trainee involvement on each quality indicator.

RESULTS

A total of 8,005 articles were initially retrieved. Following the application of predefined criteria, 52 articles remained. The cumulative, weighted bile duct cannulation success rate was 89.3% (95% CI 0.866-0.919); pancreatic duct cannulation was 85.0% (95% CI 0.813-0.886); precut utilization rate was 10.5% (95% CI 0.087-0.123); common bile duct stone extraction rate was 88.3% (95% CI 0.825-0.941); and the rate of successful biliary stenting below the common bile duct bifurcation was 97.5% (95% CI 0.967-0.984). Subgroup analysis with meta-regression showed no statistically significant differences between academic and community settings, prospective and retrospective study designs, and trainee participation on success across bile duct cannulation, precut utilization, and common bile duct stone extraction (insufficient observations/variance for pancreatic duct cannulation and biliary stent placement).

CONCLUSIONS

ERCP intraprocedural quality is in good standing. On the basis of this analysis, the two targets that could be potentially revised are precut utilization and biliary stenting. This analysis was confined to the published literature and therefore, in general, reflects the ERCP performance of institutions, primarily academic, that are conducting clinical research. Thus, it is difficult to generalize this performance assessment to the broader ERCP community as a whole.

Single-operator wire-guided cannulation technique enables easier cannulation of endoscopic retrograde cholangiopancreatography

BACKGROUND

The single-operator wire-guided cannulation technique in endoscopic retrograde cholangiopancreatography (ERCP) has been rarely reported.

AIMS

This study was undertaken to determine the safety and efficiency of a single-operator wire-guided cannulation technique.

METHODS

Four hundred sixty-five consecutive patients referred for ERCP were included in this prospective study and randomly divided into two groups. A new single-operator wire-guided cannulation technique was performed by the same experienced endoscopist, with experienced assistants (group A) and inexperienced ones (group B). The number of attempts at cannulation, cannulation time, success rate, and procedure-related complications were compared between the two groups.

RESULTS

Successful cannulation was achieved in 460 out of the 465 patients (98.92 %). The incidences of post-ERCP pancreatitis, bleeding, infection, and perforation were 5.16, 0.64, 1.08, and 0 %, respectively. There were no severe complications or death. The cannulation time, number of attempts at cannulation and complications were not significantly different between the two groups (all P > 0.05).

CONCLUSIONS

The single-operator wire-guided cannulation technique was feasible, safe and efficient. It doesn't require an experienced assistant and precise coordination between the assistant and endoscopist during cannulation.

Success rate and cannulation time between precut sphincterotomy and double-guidewire technique in truly difficult biliary cannulation

BACKGROUND AND AIM

Precut sphincterotomy (PS) is usually indicated in failed standard biliary cannulation (BC). PS requires experienced endoscopists, and contains significant risk. Double-guidewire (DG) cannulation seems to be easier, and might be useful after failed standard BC. We aimed to compare cannulation time, success rate, and complication rates between the two techniques.

METHODS

Patients who failed standard BC within 10 min by the expert were defined as truly difficult BC and randomized into both groups. In the DG group, the first guidewire was left in the pancreatic duct, and then a catheter, pre-inserted with another guidewire, was used for the BC. In the PS group, a fistulotomy technique was used.

RESULTS

From June 2008 to October 2009, 534 patients underwent endoscopic retrograde cholangiopancreatography. Forty-four patients (8.2%) who failed standard BC were randomized into the DG group (n = 23) and the PS group (n = 21). Median cannulation times and success rates in the DG and PS groups were 172 versus 394 s (P < 0.001), and 73.9% versus 80.9% (P = 0.724), respectively. The pancreatitis rate and serum amylase at 24 h in the DG and PS groups were 21.7% versus 14.3% (P = 0.701) and 937 versus 195 mg/dL (P = 0.020), respectively. Two from each group developed mild bleeding. No perforation occurred.

CONCLUSION

In truly difficult BC, the DG technique requires a significant shorter duration for BC, with a comparable success rate to the PS technique. The post-procedure serum amylase level in the DG group was significantly higher, and there was a trend of more pancreatitis.

Complications of endoscopic retrograde cholangiopancreatography (ERCP) and their risk factors

PURPOSE

Determination of the type and frequency of complications developing after diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) as well as the risk factors predisposing to them.

MATERIAL/METHODS

The retrospective study, including 734 ERCP performed in 550 patients, with 404 (55%) ES (endoscopic sphincterotomy) during a 4-year period.

RESULTS

Among 734 ERCP procedures, 76.4% (561) had both diagnostic and therapeutic purpose, 15.2% (112) were only diagnostic. Complications developed after 26 procedures (3.5%): acute pancreatitis (AP) in 8 patients (1.09%), cholangitis in 7 (0.95%) and delayed bleeding in 11 (1.5%) patients. After 49 (6.7%) ES immediate bleeding was observed. The risk factors for AP were: unintentional pancreatic duct contrasting, mechanical lithotripsy, the use of the "pre-cut" technique and bile duct dilatation. Cholangitis was more common in cases with difficult cannulation at older age and with lower baseline bilirubin level. The risk factors for delayed bleeding were: location of the ampulla of Vater in the diverticulum and the use of the "precut" technique. Immediate bleeding was more frequent after revision of bile ducts with Dormia's basket or with balloon, after introduction of contrast medium to the pancreatic duct or in ductal cholelithiasis.

CONCLUSIONS

ERCP performed in the endoscopy unit of a specialist hospital department is a relatively safe procedure, with a low burden of complications as compared to the benefits it provides to appropriately qualified patients.

Precut fistulotomy for difficult biliary cannulation: is it a risky preference in relation to the experience of an endoscopist?

BACKGROUND

Several studies have reported on the correlation between the experience level of an endoscopist and the outcomes of precut procedures. However, there are limited data on the early use of the precut fistulotomy in relation to the experience of an endoscopist.

AIM

To evaluate the efficacy and safety of precut fistulotomy in difficult biliary cannulation after ERCP training.

METHODS

Two endoscopists, one at each tertiary referral center, performed the precut fistulotomy for difficult biliary cannulation between September 2008 and February 2010. The technical success, complications, and clinical outcomes in three groups were recorded prospectively over time.

RESULTS

A total of 159 (23.1%) patients underwent precut fistulotomy. The mean procedure time was decreased as the number of procedures increased (p < 0.01). The success rates of selective biliary cannulation in the three groups were 86.8, 86.8, and 88.7% respectively, for the first attempt (p = 0.77) and 93.7% for the second attempt. Post-ERCP pancreatitis developed in nine (5.7%) patients, which was not statistically significant between the three groups. As the frequency of papillary contacts increased, post-ERCP pancreatitis tended to increase (p = 0.017). In the multivariate analysis, more than 15 attempts at cannulating the major papilla prior to fistulotomy was a risk factor for pancreatitis (odds ratio 4.8, 95% CI 1.178-19.580, p = 0.029).

CONCLUSIONS

After therapeutic ERCP training involving at least 100 ERCPs, including at least half that were therapeutic cases and more than ten that were precut papillotomies, a precut fistulotomy can be performed safely and effectively in low-risk patients.

Endoscopic ultrasound does not accurately stage early adenocarcinoma or high-grade dysplasia of the esophagus

BACKGROUND & AIMS

Patients with esophageal high-grade dysplasia or mucosal esophageal cancer can be successfully treated by endoscopy. We performed a systematic review of the literature to determine whether endoscopic ultrasound (EUS) correctly predicts the T-stage of early esophageal cancers, compared with pathology specimens obtained by using endoscopic mucosal resection (EMR) or surgery.

METHODS

Standard systematic review methods were used to perform reference searches, determine eligibility, abstract data, and analyze data. When possible, individual patient-level data were abstracted, in addition to publication-level aggregate data.

RESULTS

Twelve studies had sufficient information to abstract and review for quality; 8 had individual patient-level data (n = 132). Compared with surgical or EMR pathology staging, EUS had T-stage concordance of 65%, including all studies (n = 12), but only 56% concordance when limited to individual patient-level data. Factors such as initial biopsy pathology (high-grade dysplasia vs early-stage cancer) did not appear to affect the concordance of staging between EUS and EMR/surgical staging.

CONCLUSIONS

EUS is not sufficiently accurate in determining the T-stage of high-grade dysplasias or superficial adenocarcinomas; other means of staging, such as EMR, should be used.

An analysis of the efficacy and safety of a strategy of early precut for biliary access during difficult endoscopic retrograde cholangiopancreatography in a general hospital

OBJECTIVE

The use of early precut during endoscopic retrograde cholangiopancreatography (ERCP) is controversial because of its association with a higher risk of complications. This study examined the efficacy and safety of a strategy of early precut for biliary access during difficult ERCP in a general hospital.

METHODS

Data from January 2007 to June 2009 were reviewed. Criteria for performing early precut were: (i) inadvertent guidewire cannulation of pancreatic duct on three occasions; (ii) biliary stone impacted at papilla; (iii) inability to achieve deep cannulation within 10 min. Study exclusion criteria were: (i) the inability to visualize the papilla because of anatomical distortions; (ii) complete tumour occlusion of distal bile duct; (iii) failure to adhere to inclusion criteria. The efficacy and safety of this strategy of early precut for biliary access was analyzed.

RESULTS

A total of 765 ERCP cases were analyzed. A precut was performed in 55 out of 765 cases (7.2%). There were no significant differences in terms of age, gender and diagnoses between the precut and no precut groups. After precut immediate biliary cannulation was achieved in 89% of patients and this increased to 98.2% with a repeat ERCP. The overall complication rate after ERCP was 2.1% (bleeding: 0.7%; pancreatitis: 1.3%; perforation: 0.3%). The only complication after the precut was pancreatitis, and this was not significantly different from the group without a precut (1.8 vs 1.3%).

CONCLUSION

The strategy of early precut for biliary access was safe and effective.

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.

Quantitative assessment of technical proficiency in performing needle-knife precut papillotomy

BACKGROUND

Although needle-knife precut papillotomy (NKPP) is considered a useful alternative for achieving selective biliary cannulation, controversy remains regarding the technical proficiency needed to perform the procedure and its safety. This study evaluated whether procedural experience with NKPP predicted either successful cannulation or the development of complications.

METHODS

This study retrospectively investigated 104 patients, out of 589 consecutive patients with native papillary, who underwent NKPP performed by a single endoscopist between October 2002 and July 2006. To demonstrate changes in NKPP, the 104 patients were divided chronologically into two groups according to periods: period A (October 2002 to September 2004) and period B (October 2004 to July 2006).

RESULTS

Of the 104 consecutive patients who underwent NKPP, 41 (41/267, 15%) were treated in period A and 63 (63/322, 20%) in period B. There was no significant difference in the overall success rate between periods A (90%) and B (98%) (p = 0.08). However, the initial success rate was higher in period B (95%) than in period A (80%) (p < 0.05). The complication rates were not significantly different between the two groups (10% vs 16%; p = 0.56). Although all complications involved pancreatitis, severe pancreatitis was not observed.

CONCLUSION

Whereas the initial success rate for NKPP can increase with procedural experience, the complication rate does not seem to decrease. Furthermore, the need for NKPP does not appear to decrease with increasing endoscopic retrograde cholangiopancreatography (ERCP) experience.