International consensus recommendations for difficult biliary access

Early pancreatic stent placement in wire-guided biliary cannulation: A multicenter retrospective study

BACKGROUND AND AIM

Guidewire insertion to a pancreatic duct under wire-guided cannulation (WGC) during endoscopic retrograde cholangiopancreatography (ERCP) is associated with a high incidence of post-ERCP pancreatitis (PEP). Pancreatic stent placement followed by WGC (PS-WGC) is considered for these cases to reduce PEP. This study was aimed to examine the effectiveness of PS-WGC compared with repeated WGC.

METHODS

The consecutive data of patients without history of ERCP who underwent ERCP for biliary intervention were retrospectively collected from five centers. Patients without guidewire insertion to the pancreatic duct were excluded. Pancreatic stent was immediately placed after guidewire insertion to the pancreatic duct in the PS-WGC group. The association between the method of biliary cannulation (PS-WGC or repeated WGC) and PEP was analyzed using multivariable logistic regression model.

RESULTS

A total of 590 patients (183 in the PS-WGC and 407 in the repeated WGC group) were included. PS-WGC decreased PEP (8.7% vs 19%, P = 0.001) and improved its severity (moderate and severe PEP; 2.2% vs 6.4%, P = 0.04) compared with repeated WGC. PS-WGC was associated with reduction of PEP in the multivariable model (Odds ratio 0.31, P < 0.001). The rates of difficult cannulation and overall successful biliary cannulation were not different between the two groups (66% vs 70%, P = 0.39 and 98% vs 96%, P = 0.21 in the PS-WGC and repeated WGC group, respectively).

CONCLUSIONS

Pancreatic stent placement followed by WGC reduced PEP in patients with guidewire insertion to the pancreatic duct during WGC for native papilla compared with repeated WGC.

Transpancreatic Sphincterotomy Is Effective and Safe in Expert Hands on the Short Term

In cases of difficult biliary cannulation, transpancreatic sphincterotomy (TPS) can be an alternative approach of biliary access. However, its success and safety profile have not been studied in detail. A systematic review and meta-analysis were performed to study the overall cannulation success and adverse events of TPS. These outcomes were also compared to other advanced cannulation methods. A systematic literature search was conducted to find all relevant articles containing data on TPS. Successful biliary cannulation and complications rates [post-ERCP pancreatitis (PEP), bleeding, and perforation rates] were compared in the pooled analyses of prospective comparative studies. The overall outcomes were calculated involving all studies on TPS. TPS was superior compared to needle-knife precut papillotomy (NKPP) and the double-guidewire method (DGW) regarding cannulation success (odds ratio [OR] 2.32; 95% confidence interval [CI] 1.37-3.93; and OR 2.72; 95% CI 1.30-5.69, respectively). The rate of PEP did not differ between TPS and NKPP or DGW; however, TPS (only retrospective studies were available for comparison) proved to be worse than needle-knife fistulotomy in this regard (OR 4.62; 95% CI 1.36-15.72). Bleeding and perforation rates were similar among these advanced techniques. There were no data about long-term consequences of TPS. The biliary cannulation rate of TPS is higher than that of the other advanced cannulation techniques, while the safety profile is similar to those. However, no long-term follow-up studies are available on the later consequences of TPS; therefore, such studies are strongly needed for its full evaluation.

The Polymorphisms at PRSS1-PRSS2 and MORC4 Loci and the Risk of Post-ERCP Pancreatitis

Background and Aim

The risks of post-ERCP pancreatitis (PEP) are identified as patient- and procedure-related factors. However, the genetic contribution for PEP is still unclear. Recent data show that the polymorphisms of PRSS1-PRSS2 (rs10273639) and MORC4 (rs12688220) are associated with recurrent acute pancreatitis and chronic pancreatitis. We aim to evaluate the association between these polymorphisms and post-ERCP pancreatitis in order to improve better prognosis and better care for these patients.

Methods

This is a retrospective, case-control study which includes 49 cases and 97 controls that are age-, procedure-, and risk of PEP-matched with the cases in 1 : 2 fashion. The PEP was diagnosed and graded for severity according to the standard consensus, and the risk factors of PEP were identified according to the ESGE guideline. Polymorphisms at rs10273639 and rs12688220 were evaluated by TaqMan technique and were identified in 133 (40 cases and 93 controls) and 146 patients, respectively.

Results

The demographic data between 2 groups are not significantly different. The genotype frequencies of PRSS1-PRSS2 (TT, TC, and CC) are 26, 13, and 1 vs. 67, 25, and 1 in cases and controls, respectively (p = 0.642). The genotype frequencies of MORC4 in female (TT, TC, and CC) are 8, 23, and 5 vs. 12, 26, and 21 in cases and controls, respectively (p = 0.071). The genotype frequencies of MORC4 in male (T and C) are 5 and 8 vs. 21 and 17 in cases and controls, respectively (p = 0.468). The allelic frequencies of MORC4 in combination of both genders (T, C) are 44 and 41 vs. 71 and 84 in cases and control, respectively (p = 0.431). In PEP cases, the allelic frequencies of PRSS1-PRSS2 (T and C) are 59 and 13 vs. 6 and 2 in mild and moderate/severe cases, respectively (p = 0.633). The allelic frequencies of MORC4 (T and C) are 38 and 39 vs. 4 and 4 in mild and moderate/severe cases, respectively (p = 0.972).

Conclusion

Polymorphisms at PRSS1-PRSS2 and MORC4 are not associated with the risk or severity of post-ERCP pancreatitis.

Updates in Therapeutic Endoscopic Ultrasonography

The last decade has seen a dramatic rise in the possibilities of therapeutic endoscopic ultrasound (EUS). From EUS fine needle aspiration of cancerous lesion to pseudocyst drainage, it has now not only replaced some of the percutaneous techniques but has permitted to bypass all together laparoscopic approach for patient with altered anatomy or malignant gastric outlet obstruction. This review will emphasize the novel therapeutic EUS procedures added to our arsenal.

Early precut sphincterotomy does not increase the risk of adverse events for patients with difficult biliary access: A systematic review of randomized clinical trials with meta-analysis and trial sequential analysis

OBJECTIVE

The present study was conducted to investigate whether early precut sphincterotomy (EPS) itself increases the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), bleeding, and perforation, or improves the overall success rates of biliary cannulation.

METHODS

Four electronical databases were searched systematically for randomized controlled trials (RCTs) reporting the incidence of adverse events for difficult biliary access (DBA) between EPS groups and persistent cannulation attempts (PCA). The primary endpoint was the incidence of PEP. Secondary outcomes were the incidence of bleeding and perforation, and the overall success rates of biliary cannulation. The Mantel-Haenszel method was used to pool data on the outcomes into random-effect models. Heterogeneity, sensitivity, and stratified analyses were performed with Review Manager 5.3. Furthermore, we performed trial sequential analysis (TSA) to evaluate the reliability of the primary endpoint and secondary outcomes.

RESULTS

Seven RCTs (999 patients with DBA of 10450, 9.5%) were included. The incidence of PEP was significantly lower in EPS groups than PCA (risk ratio [RR] = 0.57, 95% confidence interval [CI] 0.36, 0.92, P = .02). Furthermore, TSA (TSA-adjusted 95% CI 0.30-0.82, P = .0061) and subgroup analysis stratified by the fellow involvement in initial cannulation before randomization, technique of precut, and the definition of DBA confirmed this finding. Success rates of overall cannulation (RR = 1.00, P = .94), bleeding (RR = 1.22, P = .58), and perforation (RR = 1.59, P = .32) were similar in both groups; however, the results of TSA could not confirm these findings.

CONCLUSION

Both the quality and the quantity of evidence supporting, compared with PCA, EPS itself do not increase the risk of PEP for DBA patients. Moreover, subgroup analysis demonstrated that EPS can significantly decrease the risk of PEP when it is performed by qualified staff endoscopists with using needle-knife fistulutomy earlier for patients with DBA.

Endoscopic Ultrasound-Guided Biliary Drainage

Endoscopic ultrasound (EUS)-guided biliary drainage is an emerging technique that combines the advantages of the endoscopic and percutaneous approaches, without the inconveniences and discomfort of an indwelling external catheter. There has been growing interest and experience in EUS-biliary drainage. Several different EUS-guided techniques have been developed to access the obstructed biliary tree from either the stomach or duodenum, according to the location of the stricture, the anatomy of the patient, and the experience of the endoscopist.

Biliary cannulation effectiveness and pancreatitis risk using two early precut techniques

INTRODUCTION

Precut techniques allow for successful biliary cannulation rates approaching 100% but there may be an associated increase in the risk of complications. Recently, early needle-knife precut has been shown to be a safe procedure and is now used as a pancreatitis prevention resource for difficult cannulation cases. The goal of the present study was to assess cannulation and pancreatitis rates using two early precut techniques.

PATIENTS AND METHODS

This was a retrospective study of endoscopic retrograde cholangio-pancreatography (ERCP) procedures performed from 2013 to 2016. The efficacy and safety of simple cannulation, needle-knife precut and transpancreatic precut were assessed.

RESULTS

Simple cannulation was achieved in 369 (73.4%) of 503 evaluable ERCP procedures. Needle-knife precut was successful in 51 (96.2%) of 53 attempts and transpancreatic precut was successful in 75 (96.2%) of 78 attempts. The overall cannulation rate was 98.4%. There were eleven (2.4%) pancreatitis events, six (1.8%) with simple cannulation (two severe, one fatal), five (6.3%) with transpancreatic precut (two severe) and zero events with the needle-knife precut procedure. Among the patients undergoing the precut procedure, seven experienced perforations (two severe) and there were seven bleeding events. The overall complication rate was 14.4%.

CONCLUSIONS

The complementary use of either precut technique provides a satisfactory biliary cannulation rate. However, the rates of pancreatitis and other severe complications are higher for transpancreatic versus needle-knife precut, therefore the indications for both techniques should be modified.

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.

Biliary Obstruction: Endoscopic Approaches

Painless jaundice is a harbinger of malignant biliary obstruction, with the majority of cases due to pancreatic adenocarcinoma. Despite advances in treatment, including improved surgical techniques and neoadjuvant (preoperative) chemotherapy, long-term survival from pancreatic cancer is rare. This lack of significant improvement in outcomes is believed to be due to multiple reasons, including the advanced stage at diagnosis and lack of an adequate biomarker for screening and early detection, prior to the onset of jaundice or epigastric pain. Close attention is required to select appropriate patients for preoperative biliary decompression, and to prevent morbid complications from biliary drainage procedures, such as pancreatitis and cholangitis. Use of small caliber plastic biliary stents during endoscopic retrograde cholangiopancreatography should be minimized, as metal stents have increased area for improved bile flow and a reduced risk of adverse events during neoadjuvant therapy. Efforts are underway by translational scientists, radiologists, oncologists, surgeons, and gastroenterologists to augment lifespan for our patients and to more readily treat this deadly disease. In this review, the authors discuss the rationale and techniques of endoscopic biliary intervention, mainly focusing on malignant biliary obstruction by pancreatic cancer.

The Role Safety Steps in Success and Complication Rate of Endoscopic Retrograde Cholangiopancreatography

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is widely used for treatment of biliary disorders. There are several studies to increase the success rate and decrease the complication rate of ERCP. In this study we aimed to evaluate the affect of safety steps in success and complication rate of ERCP.

MATERIALS AND METHODS

In this cohort study patients were evaluated under 2 groups divided as before the introduction of safety steps and after. Successful cannulation rate, difficult cannulations, and complications of the procedure were recorded.

RESULT

Failed ampullary cannulation rates were 8.2% in group 1 and 4% in group 2. In terms of postprocedural complications; in group 2 complication rates significantly decreased from 10.7% to 4.3%. Moreover, post-ERCP pancreatitis rate decreased from 9.1% in group 1 to 4% in group 2.

CONCLUSIONS

Introduction of safety steps, significantly increase the cannulation rate and decrease both overall complication rate and pancreatitis risk.

Endoscopic ultrasonography-guided biliary and pancreatic duct interventions

Drainage of obstructed bile duct and pancreatic duct under endoscopic ultrasonography (EUS) guidance has evolved into viable techniques suitable for patients with failed endoscopic retrograde cholangiopancreatography (ERCP) and/or altered surgical anatomy. One of the major advantages of EUS guidance is the possibility of multiple access points depending upon patient and ductal anatomy. Unlike ERCP, an approachable papilla is not a requisite for successful EUS-guided biliary or pancreatic ductal drainage. Moreover, as the access is away from the papilla, there is the possibility of reduced pancreatitis. A variety of procedures have become available for EUS-guided drainage, and it is important to develop standard terminology and procedural details. EUS-specific stents, including lumen-apposing metal stents have recently become available, and are likely to impact the outcomes of these procedures. Available data show a high success rate and acceptable adverse event rate for EUS-guided biliary drainage. Success rate appears to be low for pancreatic duct drainage because of a variety of reasons. Outcomes of EUS-guided biliary drainage appear equivalent to percutaneous drainage and ERCP. EUS-guided gallbladder drainage appears promising for patients requiring gallbladder drainage but unfit for surgery. Further large controlled studies are needed to evaluate the exact role of these procedures.