Can a wire-guided cannulation technique increase bile duct cannulation rate and prevent post-ERCP pancreatitis?: A meta-analysis of randomized controlled trials

Development of a Scoring System for Predicting the Difficulty of Bile Duct Cannulation and Selecting the Appropriate Cannulation Method

BACKGROUND

Selective biliary cannulation in endoscopic retrograde cholangiopancreatography can be challenging due to factors like papillary morphology. Various patterns indicate cannulation difficulty, but the combinations causing difficulty and the optimal cannulation method for each scenario are unclear.

AIMS

This study aimed to identify cannulation difficulty patterns and develop a predictive scoring system for selecting the appropriate cannulation method.

METHODS

We retrospectively compared 776 patients with naïve papilla, dividing them into conventional contrast cannulation (N = 510) and salvage technique (N = 266) groups. The salvage group included patients using pancreatic duct guidewire placement and/or wire-guided cannulation due to difficulties with the contrast method. Papillary morphology (Haraldsson's classification), periampullary diverticulum (PAD), and scope operability were analyzed using multiple regression to identify risk factors for cannulation difficulties. Factors were scored based on hazard ratios to access combinations causing difficulties.

RESULTS

The salvage group had more older patients and higher frequencies of type 2 (small), type 3 (protruding or pendulous), type 4 (creased or ridged) papillae, PAD, and poor scope operability. Significant risk factors in the multivariate analysis included type 2 [odds ratio (OR) 6.88], type 3 (OR 7.74), type 4 (OR 4.06) papillae, PAD (OR 2.26), and poor scope operability (OR 4.03). Pattern recognition scores were significantly higher in the salvage group (1.31 vs. 3.43, P < 0.0001).

CONCLUSIONS

Type 2-4 papillae, PAD, and poor scope operability are significant risk factors for cannulation difficulty. Pattern recognition scores based on these factors can predict cannulation difficulty and aid in selecting between conventional and salvage methods.

Enlarged fistulotomy of the papilla as access to the biliary tract during ERCP

BACKGROUND

Demonstration of access to the bile duct through Enlarged Papillary Fistulotomy, a method different from conventional fistulotomy.

AIMS

Demonstration of the EFP technique with dissection in layers of the papilla for accessing the common bile duct, its efficiency and safety, rescue of cases of failure in cannulation and cases of access failure by EFP in the first attempt, facilitating cannulation in the second attempt.

METHODS

Cross-sectional study, with retrospective data collection from 2233 ERCP exams with 528 EFP procedures, analysis of success and complications.

RESULTS

528 patients underwent EFP on the first attempt, with success in 465 cases (88.06%) and 63 failures (11.94%). Of these failures, 33 patients (52.38%) returned for a second EFP attempt, with success in 30 cases (90.9%) and failure in 3 cases (9.1%). Deep bile duct cannulation was achieved in 93.75% of EFP procedures, and cannulation failure occurred in 33 cases (6.25%).

CONCLUSION

EFP showed efficiency in CBD cannulation, did not induce post-ERCP pancreatitis, no cases of perforation or false tract, but resulted in higher rates of minor bleeding, rescued cases of access failure by EFP, facilitated the posterior approach on the second attempt, it is safe, effective, low risk and associated with few comorbidities.

Current state of biliary cannulation techniques during endoscopic retrograde cholangiopancreatography (ERCP): International survey study

Background and study aims Endoscopist techniques affect biliary cannulation success and the risk of adverse events during endoscopic retrograde cholangiopancreatography (ERCP). This survey study aims to understand the current practice of biliary cannulation techniques among endoscopists. Methods Practicing endoscopists were sent an anonymous 28-question electronic survey on biliary cannulation techniques and intraprocedural pancreatitis prophylactic strategies. Results The survey was completed by 692 endoscopists (6.2% females). A wire-guided cannulation technique (WGT) was the preferred initial biliary cannulation approach (95%). The preferred secondary approaches were a double-wire (DWT) (65.8%), precut needle-knife technique (NKT) (25.7%), transpancreatic sphincterotomy (5.9%) or other (2.6%). Overall, 18.1% of respondents were not comfortable with NKTs. In the setting of pancreatic duct (PD) access, 81.9% and 97% reported a threshold of three or more wire passes or contrast injections into the PD, respectively, before changing strategy, 34% reported placement of a prophylactic PD stent <50% of the time and 12.1% reported removal of the PD stent at the end of the procedure. Advanced endoscopy fellowship (AEF) training and high volume (>200 ERCPs per year) were associated with comfort with precut NKTs and likelihood of prophylactic PD stent ( P <0.001 for both). Conclusions A WGT technique followed by the DWT and NKT were the preferred biliary cannulation techniques; however, almost one-fifth of respondents were not comfortable with the NKT. There was considerable variability in secondary cannulation approaches, time spent attempting biliary cannulation and prophylactic PD stent placement, factors known to be associated with cannulation success and adverse outcomes.

Efficacy of a Newly Developed Guidewire for Selective Biliary Cannulation: A Multicenter Randomized Controlled Trial

BACKGROUND AND AIMS

Various guidewires are used for biliary cannulation, and each one has its own characteristics affecting its effectiveness. This study aimed to measure the basic properties and evaluate the effectiveness of a newly developed 0.025-inch guidewire for selective biliary cannulation.

METHODS

A total of 190 patients at five referral hospitals were randomly allocated to undergo selective biliary cannulation using the newly developed guidewire (NGW group, n = 95) or a conventional guidewire (CGW group, n = 95). The primary outcome was the selective biliary cannulation rate in naïve papillae. The secondary outcome was to measure the NGW basic properties, compare them with those of the CGW, and analyze the importance of basic property differences.

RESULTS

There were no significant differences between the groups in the baseline characteristics. The primary outcome (75.8% vs. 84.2%, p = 0.102) and adverse event rate (6.3% vs. 4.2%, p = 0.374) were similar in both groups. However, compared with the CGW group, the NGW group showed a higher number of ampulla contacts (2.58 vs. 2.02, p = 0.011) and longer cannulation time (216.5 vs. 135.1 s, p = 0.016). Furthermore, the NGW group had higher maximum friction (34.6 ± 1.34 vs. 30.2 ± 4.09), lower stiffness, and better elastic resiliency. In the multivariate analysis, a curved-tip GW (OR = 0.26, 95% CI 0.11-0.62, p = 0.002) and normal papillary shape (OR = 0.39, 95% CI 0.17-0.86, p = 0.021) were contributing factors for successful selective biliary cannulation.

CONCLUSIONS

The NGW group had high friction and low stiffness, characteristics affecting biliary cannulation. Clinically, the NGW group had similar success and adverse event rates as the CGW, but they showed a higher number of ampulla contacts and longer cannulation time.

Efficacy of a newly developed guidewire for selective biliary access

A clinical efficacy study of 0.025-inch guidewires (GWs) according to mechanical property analysis has not been reported yet. This study was designed to evaluate the clinical efficacy of a newly developed 0.025-inch GW for biliary access according to the basic mechanical property. Commercially available 0.025-inch GWs were in vitro tested based on parameters of mechanical property. Patients with naïve papilla requiring diagnostic or therapeutic ERCP were randomly assigned to an experimental 0.025-inch newly developed GW or a control 0.025-inch GW group. Technical success rate of wire-guided cannulation (WGC), difficult biliary cannulation (DBC), and adverse event rates were measured in this multicenter randomized trial. The technical success rate of primary WGC was 79.1% (151 of 191) in the experimental group and 70.8% (131 of 185) in the control group (95% two-sided confidence interval: 8.25%; p < 0.001; for a noninferiority margin of 15%). The technical success rate including cross-over to each other was also non-inferior. However, the chi-square test showed a statistical difference (81.7% vs. 68.1%; p = 0.002). Median biliary cannulation time was shorter in the experimental group (53 s vs. 77 s; p = 0.047). The rate of DBC was more frequent in the control group (34.6% vs. 50.3% p = 0.002). Multivariate analysis revealed that control group was one of contributing factors for DBC. Overall rate of post-ERCP pancreatitis was not different (4.7% vs. 8.6%; p = 0.125). WGC using a newly developed GW with superior physical performance GW in a bench test showed similar clinical efficacy and the rate of DBC was significantly lower in experimental GW.

Guide Wire Selection (Straight vs. Angled) in Endoscopic Retrograde Cholangiopancreatography Using a Normal Contrast Catheter Performed by a Trainee: A Single-Center Prospective Randomized Controlled Cross-Over Study

INTRODUCTION

Wire-guided cannulation (WGC) during endoscopic retrograde cholangiopancreatography (ERCP) is a selective biliary cannulation technique aimed at improving the successful selective biliary cannulation rate and reducing the rate of post-ERCP pancreatitis (PEP) incidence. This study aimed to evaluate the effectiveness of angled-tip guidewires (AGW) vs. straight-tip guidewires (SGW) for biliary cannulation via WGC by a trainee.

METHODS

We conducted a prospective, single-center, open-labeled, randomized, and controlled trial. Fifty-seven patients were enrolled in this study and assigned randomly to two groups (Group A to S and Group S to A). In this study, we started selective biliary cannulation via WGC with an AGW or an SGW for 7 min. If cannulation was unsuccessful, the other guidewire was used, and cannulation was continued for another 7 min (cross-over method).

RESULTS

The selective biliary cannulation success rate over 14 min was significantly higher with an AGW compared with an SGW over 14 min (57.8% vs. 34.3%, p = 0.04) and for the second 7-min segment (36.4% vs. 0%, p = 0.04). No significant difference was found for adverse events such as pancreatitis between the two guidewires.

CONCLUSIONS

Our results suggest that an AGW is recommended for WGC performed by a trainee.

Steerable catheter based on wire-driven seamless artificial blood vessel tube for endoscopic retrograde transpapillary interventions

PURPOSE

Current steerable catheters (SCs) for endoscopic retrograde cholangiopancreatography (ERCP) have performance limitations caused by an asymmetric multiple-slit tube design with a small maximum bend angle, lesser curvatures, and insufficient durability. We propose a wire-driven SC for balanced bidirectional bending using artificial blood vessel material to overcome these limitations. We assess the SC prototype's steerability using phantom and animal models.

METHODS

The SC prototype employed a slit-less and multiple-lumen seamless tube with a polytetrafluoroethylene (PTFE) body with stretch-retractable porous expanded PTFE at the distal end, and loop-formed control wires. We evaluated the wire routing design using a static model. The bending performance was compared with conventional SCs. Feasibility studies were performed, including major duodenal papilla insertions and ductal branch selections in desktop phantoms and a mini-pig model.

RESULTS

The proposed design reduced the wire contact force by 48% compared to the single wire configuration. The maximum bend angle was 162°, almost twofold larger than that for conventional SCs. The lateral tip position in the bent shape was maximally 56% smaller. The tip flexibility was comparable to conventional SCs, and the insertion resistance was similar to the passive catheters. Phantom studies showed that the SC prototype could perform the large and protuberant papilla insertions and fine ductal branch selections without breaking; the animal study was completed successfully.

CONCLUSION

We propose a wire-driven SC design for ERCP using a multi-lumen seamless tube and two loop-formed control wires, different from the conventional SC design with a multiple-slit tube and single control wire. The SC prototype records balanced bidirectional bending with a maximum bending angle of ± 162° without breakage risk. The phantom and animal studies show that the prototype performance potentially facilitates papilla cannulations and intrahepatic ductal branch seeking.

Clinical benefit of early precut sphincintroterotomy for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography

OBJECTIVES

A precut procedure is sometimes required for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP). However, it is unclear whether the biliary access rate has improved for early precut procedures compared to conventional techniques. This study aimed to identify the benefit of early precut sphincterotomy in cases showing difficult biliary access.

METHODS

Between April 2017 and August 2021, consecutive patients who underwent precutting for difficult biliary cannulation were retrospectively enrolled. The outcomes of early (≤ 10 min from start of cannulation) and delayed (> 10 min) precut groups were evaluated. All adverse events were defined according to Cotton criteria.

RESULTS

A total of 70 patients were enrolled in this study. The biliary cannulation rate for a first ERCP was significantly higher in the early compared to delayed precut group (95% vs. 73.3%; P = 0.015). A difference in overall cannulation rate between the two groups was not observed (97.5% vs. 83.3%; P > 0.05). Significantly higher rates of prophylactic pancreatic stents were described in the delayed compared to early precut group (36.7% vs. 12.5%; P = 0.009). Significant differences in the frequency of pancreatitis, bleeding, penetration, and perforation were not noted between the two groups. Overall, the success rate was statistically significant between the experienced and less experienced endoscopists (87.2% vs. 63.9%; P = 0.017).

CONCLUSIONS

Early precutting within 10 min from the start of cannulation in ERCP is safe and effective in cases with a difficult biliary cannulation, and can improve the biliary cannulation rate.

A comparison of two types of contrast media used in endoscopic retrograde cholangiopancreatography: A retrospective study

BACKGROUND

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is one of the most serious complications of ERCP. Various procedures can reduce the incidence of PEP, such as wire-guided cannulation, prophylactic pancreatic stent placement, and pretreatment anal insertion of NSAIDs. Recently, iso-osmolar contrast media (IOCM) have been used for ERCP in several hospitals to reduce the risk of PEP in Japan. However, the effect of IOCM is uncertain because few reports have examined IOCM in relation to PEP.

AIM

This study aimed to investigate the relationship between contrast media used and the incidence of PEP.

METHODS

This retrospective study included all qualifying patients who had undergone ERCP at Hamamatsu University Hospital between January 2012 and January 2020. This study examined whether there was a difference in the onset of PEP between patients administered IOCM and high osmolar contrast medium (HOCM). Propensity score matching was used to analyze patient characteristics and ERCP procedures. Amidotrizoic acid was used as HOCM and iodixanol as IOCM.

RESULTS

ERCP was performed on 458 patients, and 830 procedures were conducted. After propensity score matching, 162 patients from the amidotrizoic acid group and 162 patients from the iodixanol group were selected. The incidence of PEP was 10.5% (17) in the amidotrizoic acid group and 9.3% (15) in the iodixanol group (P = 0.71). Changes in serum amylase levels post- and pre-ERCP were 240.6 ± 573.8 U/L and 142.7 ± 382.1 U/L in the amidotrizoic acid and iodixanol groups, respectively (P = 0.072).

CONCLUSION

Iodixanol had no prophylactic effect on PEP and clinical outcomes.

Interventional gastroenterology in oncology

Cancer is one of the foremost health problems worldwide and is among the leading causes of death in the United States. Gastrointestinal tract cancers account for almost one third of the cancer-related mortality globally, making it one of the deadliest groups of cancers. Early diagnosis and prompt management are key to preventing cancer-related morbidity and mortality. With advancements in technology and endoscopic techniques, endoscopy has become the core in diagnosis and management of gastrointestinal tract cancers. In this extensive review, the authors discuss the role endoscopy plays in early detection, diagnosis, and management of esophageal, gastric, colorectal, pancreatic, ampullary, biliary tract, and small intestinal cancers.

An Insight on Pharmacological and Mechanical Preventive Measures of Post-ERCP PANCREATITIS (PEP)—A Review

Pancreatitis is the most common complication following endoscopic retrograde cholangio-pancreatography (ERCP). With the progress of research in many drugs and technologies, promising efficacy has been achieved in preventing post-ERCP pancreatitis (PEP). Recently, combined prevention has received more attention in order to further reduce the incidence of PEP. However, there is no review about the combined prevention of PEP. This review summarizes the medication and ERCP techniques that are used to prevent PEP and emphasizes that appropriate combination prevention approaches should be based on risk stratification.

Angled-tip vs. straight-tip guidewire in ERCP: a randomized, multicenter study

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay for interventional treatment of biliopancreatic diseases, and guidewires are decisive for successful treatment.

METHODS

A randomized, multicenter, open-label study was conducted in patients in whom a guidewire was required in ERCP. Success rate and duration of the investigation were evaluated by randomly applying hydrophilic guidewires with a straight tip (ST) or an angled tip (AT) configuration, with normal (type NF) or enhanced (type EF) flexibility. Randomization was stratified by indication, i.e., stricture of the intra-hepatic bile ducts, stricture of the extrahepatic bile ducts, obstruction by bile duct stones, or interventions involving the pancreas. Cross-over was allowed if the initially allocated guidewire did not result in treatment success.

RESULTS

Four hundred fifty-three patients were included, and 422 were finally analyzed. In 363 procedures (86%), the initially allocated wirés use resulted in treatment success. The success rate for using a guidewire with an angled tip configuration was 87.5 vs. 79.9% in a straight tip configuration (p = 0.049), and in negotiating an intrahepatic stricture the success rate was 90.7 vs. 69.1%, respectively (p = 0.008). No significant differences were observed in other indications. Procedural duration time did not differ in between the treatment groups.

CONCLUSION

ERCP guidewires with an angled tip were more frequently successful when compared to straight tipped wires and most successful in treating intrahepatic strictures. Guidewires with standard vs. enhanced tip flexibility showed equal success rates in all indications.

Impact of guidewire caliber on ERCP outcomes: Systematic review and meta-analysis comparing 0.025- and 0.035-inch guidewires

Background and study aims  The impact of guidewire caliber on endoscopic retrograde pancreatography (ERCP) outcomes are not clear. Recent studies have compared two guidewires, 0.035- and 0.025-inch, in randomized controlled trials (RCTs). We performed a systematic review and meta-analysis of available RCTs to assess if different caliber would change the outcomes in ERCP. Patients and methods  A systematic search of PubMed/Medline, Embase, Cochrane, SciELO, Global Index Medicus and Web of Science was undertaken through November 23, 2021 to identify relevant RCTs comparing the two guidewires. Binary variables were compared using random effects model and DerSimonian-Laird approach. For each outcome, risk-ratio (RR), 95 % confidence interval (CI), and P values were generated. P  < 0.05 was considered significant. Results  Three RCTs with 1079 patients (556 in the 0.035-inch group and 523 in the 0.025-inch group) were included. The primary biliary cannulation was similar in both groups (RR: 1.02, CI: 0.96-1.08, P  = 0.60). The overall rates of PEP were also similar between the two groups (RR: 1.15, CI: 0.73-1.81, P  = 0.56). Other outcomes (overall cannulation rate, cholangitis, perforation, bleeding, use of adjunct techniques) were also comparable. Conclusions  The results of our analysis did not demonstrate a clear benefit of using one guidewire over other. The endoscopist should consider using the guidewire based on his technical skills and convenience.

Basic and Advanced Biliary Cannulation: How Do I Do It?

Successful biliary cannulation of a native papilla is usually the rate-limiting step toward a successful ERCP. Standard cannulation techniques usually succeed, particularly when utilizing the wire-guided technique. There are, however, a myriad of confirmations of the major papilla as well as anatomic variants and certain pathologies which can make cannulation exceedingly difficult. For these cases, advanced cannulation techniques and techniques termed "access sphincterotomy" have been developed which should allow successful cannulation in >90% of cases. This article should help all those performing ERCP to improve their cannulation rate.

Guidewire-assisted cannulation of the common bile duct for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis

BACKGROUND

Cannulation techniques have been recognized as being important in causing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, considerable controversy exists about the usefulness of the guidewire-assisted cannulation technique for the prevention of PEP.

OBJECTIVES

To assess the effectiveness and safety of the guidewire-assisted cannulation technique compared to the conventional contrast-assisted cannulation technique for the prevention of PEP in people undergoing diagnostic or therapeutic ERCP for biliary or pancreatic diseases.

SEARCH METHODS

For the previous version of this review, we searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL and major conference proceedings, up to February 2012, with no language restrictions. An updated search was performed on 26 February 2021 for the current version of this review. Two clinical trial registries, clinicaltrials.gov and WHO ICTRP, were also searched in this update.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing the guidewire-assisted cannulation technique versus the contrast-assisted cannulation technique in people undergoing ERCP.

DATA COLLECTION AND ANALYSIS

Two review authors conducted study selection, data extraction, and methodological quality assessment independently. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi² test (P < 0.10) and I² statistic (> 50%). To explore sources of heterogeneity, we conducted a priori subgroup analyses according to trial design, publication type, risk of bias, use of precut sphincterotomy, inadvertent guidewire insertion or contrast injection of the pancreatic duct (PD), use of a PD stent, cannulation device, and trainee involvement in cannulation. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed-effect versus random-effects) and per-protocol analysis.

MAIN RESULTS

15 RCTs comprising 4426 participants were included. There was moderate heterogeneity among trials for the outcome of PEP (P = 0.08, I² = 36%). Meta-analyses suggest that the guidewire-assisted cannulation technique probably reduces the risk of PEP compared to the contrast-assisted cannulation technique (RR 0.51, 95% CI 0.36 to 0.72, 15 studies, moderate-certainty evidence). In addition, the guidewire-assisted cannulation technique may result in an increase in primary cannulation success (RR 1.06, 95% CI 1.01 to 1.12, 13 studies, low-certainty evidence), and probably reduces the need for precut sphincterotomy (RR 0.79, 95% CI 0.64 to 0.96, 10 studies, moderate-certainty evidence). Compared to the contrast-assisted cannulation technique, the guidewire-assisted cannulation technique may result in little to no difference in the risk of post-sphincterotomy bleeding (RR 0.87, 95% CI 0.49 to 1.54, 7 studies, low-certainty evidence) and perforation (RR 0.93, 95% CI 0.11 to 8.23, 8 studies, very low-certainty evidence). Procedure-related mortality was reported by eight studies, and there were no cases of deaths in both arms (moderate-certainty evidence). Subgroup analyses suggest that the heterogeneity for the outcome of PEP could be explained by differences in trial design. The results were robust in sensitivity analyses.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that the guidewire-assisted cannulation technique probably reduces the risk of PEP compared to the contrast-assisted cannulation technique. There is low-certainty evidence that the guidewire-assisted cannulation technique may result in an increase in primary cannulation success. There is low- and very low-certainty evidence that the guidewire-assisted cannulation technique may result in little to no difference in the risk of bleeding and perforation. No procedure-related deaths were reported. Therefore, the guidewire-assisted cannulation technique appears to be superior to the contrast-assisted cannulation technique considering the certainty of evidence and the balance of benefits and harms. However, the routine use of guidewires in biliary cannulation will be dependent on local expertise, availability, and cost. Future research should assess the effectiveness and safety of the guidewire-assisted cannulation technique in the context of other pharmacologic or non-pharmacologic interventions for the prevention of PEP.

ERCP in critically ill patients is safe and does not increase mortality

ABSTRACT

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for minimally-invasive treatment of biliary or pancreatic tract disease. When treating patients on intensive care units (ICU) with ERCP, interventionalists are faced with considerably higher morbidity compared to patients in ambulatory settings. However, data on complications and outcome of critical ill patients undergoing emergency ERCP are limited.A retrospective analysis of 102 patients treated on ICUs undergoing 121 ERCP procedures at the University Hospital of Essen, Germany between 2002 and 2016 was performed. Indications, interventional success, outcome including survival and procedure-related complications were analyzed. Patients' condition pre-ERCP was categorized by using the "Simplified Acute Physiology Score" (SAPS 3).66/102 patients (64.7%) were referred to ERCP from surgical ICU, 36/102 (35.3%) from nonsurgical ICU. The majority of patients were male (63.7%), the mean age was 54.1 ± 14.9 [21-88] years. Indications for ERCP were biliary complications after liver transplantation (n = 34, 33.3%), biliary leakage after hepatobiliary surgery (n = 32, 31.4%), and cholangitis/biliary sepsis (n = 36; 35.3%), respectively. 117/121 (96.7%) ERCPs were successful, 1 patient (1.0%) died during ERCP. Post-ERCP pancreatitis occurred in 11.8% of interventions. The median simplified acute physiology score 3 was 65 points, predicting a risk-adjusted estimated mortality of 48.8%, corresponding to an observed mortality of 52.2% (P = n.s.).ERCP is safe in critically ill patients on ICU, it does not increase overall mortality rate and has a relatively low rate of procedure-associated complications.

Controversies in ERCP: Technical aspects

The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. While the first part focuses on indications, clinical and imaging prerequisites prior to ERCP, sedation options, post-ERCP pancreatitis prophylaxis, and other related technical topics, the second part discusses specific procedural ERCP techniques including precut techniques and their timing as well as management algorithms. In addition, reviews on controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.

Biliary cannulation with contrast and guide-wire versus exclusive guide-wire: A prospective, randomized, double-blind trial

BACKGROUND

The use of exclusive guide-wire cannulation (e-GW) instead of contrast injection reduces post-ERCP pancreatitis (PEP) and pre-cutting and increases cannulation rate. Herein, we intend to compare e-GW with the hybrid technique (GW-C and/or contrast injection).

METHODS

Prospective single-center randomized comparative study, which included all patients referred to ERCP to our unit. Patients with non-naïve papilla; previous ERCP; direct infundibulotomy, ampullectomy, Billroth II gastrectomy or pancreatic sphincterotomy and patients lost to follow up were excluded.

RESULTS

727 consecutive patients were assessed. Of these, 588 naïve papilla patients were included and randomized to receive e-GW (n = 299) or GW-C (n = 289) for selective biliary cannulation. The mean age was 60.3 years and 60.5% were women. PEP occurred in 15(5%) cases in e-GW group and 9(3.1%) in the GW-C group (p = 0.29). Time to reach deep cannulation was faster in the latter group (75% < 5 min vs. 50.2% < 5 min, p<0.001). > 10 min until cannulation was observed in 21% vs. 10% of the ERCPs (groups e-GW and GW-C, respectively, p < 0.001). Total ERCP time was also shorter in the GW-C group (12 vs. 10 min; p < 0.001). Pre-cut (23.8 vs.11.8%, p < 0.001) and pancreatic sphincterotomy as a pre-cut technique (15.8 vs. 5.6%, p < 0.001) were used more frequently in the e-GW group.

CONCLUSIONS

Compared to exclusive G-W- assisted biliary cannulation, the hybrid technique did not significantly reduce the PEP rate, however it promoted faster cannulation and, consequently, reduced the total procedure time and the use of pre-cut techniques.

Emerging Therapies to Prevent Post-ERCP Pancreatitis

PURPOSE OF REVIEW

The aim of this review is to evaluate emerging, novel therapies for the prevention of post-ERCP pancreatitis.

RECENT FINDINGS

Rectal indomethacin reduces the risk of pancreatitis in low- and average-risk patients, who comprise the majority of patients undergoing ERCP. An 8-h protocol of aggressive lactated Ringer's reduces the risk of pancreatitis in average-risk patients. Sublingual nitrate may provide additional benefit to rectal NSAIDs in preventing PEP. A tacrolimus trough > 2.5 ng/mL was recently shown to be associated with a lower risk of PEP in liver transplant patients undergoing ERCP. Routine usage of rectal indomethacin in all patients undergoing ERCP reduces the risk of PEP. Pancreatic-duct stents reduce the risk of PEP in high-risk patients. There is emerging data that aggressive hydration with lactated Ringer's and nitrates may further reduce PEP. Tacrolimus is a promising potential agent to prevent PEP but needs further clinical study.

Impact of a Novel Oblique-Tip Papillotome for Biliary Cannulation during ERCP: A Nonrandomized Coarsened Exact Matching Study

Background

We developed a novel oblique-tip papillotome (OT-papillotome) to facilitate biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP). This study was performed to evaluate the utility of the OT-papillotome for contrast-guided cannulation (CGC) and wire-guided cannulation (WGC) during ERCP, compared with standard cannulation by WGC using a standard-tip papillotome (ST-papillotome).

Methods

A prospective study was performed at two centers. CGC with the OT-papillotome (OT-CGC group) was performed at Jikei University Hospital, while WGC was done with the OT-papillotome and ST-papillotome (OT-WGC and ST-WGC groups, respectively) at the University of Malaya Medical Centre. The results of the OT-CGC and OT-WGC groups were compared with those of the ST-WGC group after performing coarsened exact matching (CEM) to reduce bias due to nonrandomized and center-based patient allocation.

Results

Eighty patients were enrolled in each of the OT-CGC, OT-WGC, and ST-WGC groups. After CEM, the successful biliary cannulation rate was significantly higher in the OT-CGC and OT-WGC groups than in the ST-WGC group, while rescue cannulation was reduced. The mean number of unintended pancreatic access events in the OT-WGC and OT-CGC groups was similar to the ST-WGC group. However, it was significantly lower in the OT-WGC group than in the OT-CGC group. Multivariate analysis revealed that the OT-papillotome was independently associated with less frequent rescue cannulation and a higher successful biliary cannulation rate.

Conclusions

Although use of the OT-papillotome in biliary cannulation did not reduce unintended pancreatic access events or PEP compared to the ST-papillotome, the OT-papillotome increased the successful biliary cannulation rate, while reducing the frequency of rescue cannulation procedures. Combining the OT-papillotome with WGC might be the best cannulation technique for minimizing unintended pancreatic access.

Is Endoscopic Balloon Dilation Still Associated With Higher Rates of Pancreatitis?: A Systematic Review and Meta-Analysis

The objective of this study was to compare the efficacy and safety of endoscopic papillary balloon dilation (EPBD), endoscopic sphincterotomy (ES), and the combination of large balloon dilation and ES (ES + EPLBD) in the treatment of common bile duct stones, with a special focus on postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Individualized search strategies were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included randomized controlled trials (RCTs) which evaluated at least one of the following outcomes: PEP, complete stone removal in the first ERCP, need for mechanical lithotripsy, recurrence of common bile duct stones, bleeding, and cholangitis. Twenty-five RCTs were selected for analysis. Pancreatitis rates were higher for EPBD than for ES (P = 0.003), as were severe pancreatitis rates (P = 0.04). However, in the 10-mm or greater balloon subgroup analysis, this difference was not shown (P = 0.82). Rates of PEP were higher in the subgroup of non-Asian subjects (P = 0.02), and the results were not robust when RCTs that used endoscopic nasobiliary drainage were omitted. The incidence of pancreatitis was comparable between EPLBD and ES + EPLBD. All 3 approaches were equally efficacious. Nevertheless, the results should be interpreted with caution, because pancreatitis is a multifactorial pathology, and RCTs can have limited generalizability.

Wire-guided biliary cannulation: a comprehensive approach to a set of techniques

Biliary cannulation represent a challenge for the endoscopists that approach to endoscopic retrograde cholangiopancreatography, with non-negligible rate of failure even in expert hands. In order to achieve the biliary tree, two main technique are nowadays mainly used, namely the contrast-assisted cannulation and the wire-guided cannulation (WGC) techniques. The WGC technique is widely used because it seems to be related to higher success rate of cannulation of the common bile duct and, at the same time, to lower rates of complications. Particularly, this approach is associated with lower risk of post endoscopic retrograde cholangiopancreatography pancreatitis, although the pathogenesis of this adverse event is still not completely understood. The outspread of this technique among endoscopists promoted the development of different methods of performing WGC-assisted endoscopic retrograde cholangiopancreatography, such as the touch technique, the no-touch technique and the double guide-wire cannulation. Furthermore, the variety of guide wires and accessories, with their different characteristics, contribute to make the scenario extremely heterogeneous. To date, the published studies did not highlight which is the best strategy that maximizes the rate of success and minimizes the percentage of complications, even because the experience of the operator represents an important variable that conditions the outcomes. The aim of this review is to define state of the art in WGC technique, in order to better understand the possible advantages in using this approach and to bring to light the possible area that may be object of further studies.

Technical Reports of Endoscopic Retrograde Cholangiopancreatography Guidewires on the Basis of Physical Properties

Background/Aims

Using an appropriate guidewire can increase the success rate of selective cannulation in endoscopic retrograde cholangiopancreatography. The purpose of this technical study was to investigate the characteristics of each guidewire type and to evaluate its efficiency and rapidity of insertion.

Methods

We conducted a three-point bending test using a universal testing machine to investigate the flexibility and bending features of each guidewire. 3D-printed silicone tubes with various types of stricture and a hand-made biliary tree silicone model with six-stranded intrahepatic ducts were used to evaluate the success rate and insertion time of each guidewire.

Results

In the three-point bending test, the characteristics of each guidewire were classified. We found that the bending strengths and times were independent of shaft thickness. Using two in vitro biliary duct models, we determined that the success rate and total insertion time were better for guidewires with a resilient shaft and angled tip than for other types of guidewires (p<0.001). Although thickness of the guidewire affected the success rate (p<0.05), it did not affect the total insertion time (p≥0.05).

Conclusions

Among several types of guidewire, some factors (resilient shaft, highly flexible, and angled tip) appeared to be associated with the efficiency and rapidity of the guidewire insertion.

Management of difficult or failed biliary access in initial ERCP: A review of current literature

Selective bile duct cannulation is the prerequisite for all endoscopic biliary therapeutic interventions, but this cannot always be achieved easily. Despite advances and new developments in endoscopic accessories, selective biliary access fails in 5%-15% of cases, even in expert high volume centers. Various techniques - such as double-guidewire induced cannulation, pre-cut papillotomy or transpancreatic sphincterotomy with or without placement of a pancreatic stent - have been used to improve cannulation success rates. Repeated and prolonged attempts at cannulation increase the risk of pancreatitis. Repeating the ERCP within a few days after initial failed pre-cut is a successful strategy and should be tried before contemplating more invasive, alternative interventions such as percutaneous-endoscopic or endoscopic ultrasound guided rendezvous procedure, percutaneous transhepatic or surgical intervention. However, standard guidelines or sequential protocol has not been existed up to now. In certain circumstances, there are unique clinical indications for which invasive, alternative interventions should be preferred. We present and discuss the methods that can be used in difficult or failed initial ERCP, therefore to provide practical advice for endoscopists, especially those who are inexperienced.

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.

Risk Factors for Post-ERCP Pancreatitis in High-Risk Patients Receiving Post-procedure Rectal Indomethacin

BACKGROUND

Post-ERCP pancreatitis (PEP) is the most common adverse event of ERCP. Rectal indomethacin has been widely administered to decrease the incidence of PEP in high-risk patients. However, it cannot completely prevent the occurrence of PEP. The purpose of the study was to evaluate the risk factors for PEP in high-risk patients receiving post-ERCP indomethacin.

METHODS

From June 2012 to July 2015, patients undergoing ERCP and at high risk for PEP in three tertiary hospitals in China were enrolled. All patients received indomethacin after the procedure. Patient-related and procedure-related risk factors for PEP were collected. Logistic regression analysis was used to investigate the risk factors.

RESULTS

Seven hundred ninety patients at high risk for PEP received post-ERCP indomethacin. The incidence of overall PEP and moderate-to-severe PEP was 8.0 and 1.5%, respectively. In multivariate analysis, suspected sphincter of Oddi dysfunction (SOD) (OR 2.73; 95%CI 1.38-5.43; p = 0.004), the presence of hilar obstruction (OR 4.53; 95%CI 1.60-12.81; p = 0.004), number of cannulation attempts ≥ 13 (OR 2.00; 95%CI 1.07-3.77; p = 0.030), inadvertent pancreatic duct (PD) cannulation ≥ 1 (OR 2.26; 95%CI 1.04-4.90; p = 0.040), and pancreatic contrast injections ≥ 1 (OR 2.30; 95%CI 1.02-5.23; p = 0.046) were high risk factors for overall PEP. For moderate-to-severe PEP, suspected SOD (OR 4.67; 1.19-18.35; p = 0.027), the presence of hilar obstruction (OR 7.95; 1.39-44.97; p = 0.010), and more cannulation attempts (OR 3.71; 1.09-12.65; p = 0.036) were three independent risk factors.

CONCLUSIONS

A substantial number of high-risk patients had PEP even receiving post-ERCP rectal indomethacin. The independent risk factors included suspected SOD, hilar stricture, more cannulation attempts, inadvertent PD cannulation, and PD contrast injections.

TRIAL REGISTRATION

NCT02709421.

Update on the Prevention of Post-ERCP Pancreatitis

PURPOSE OF REVIEW

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure to manage pancreaticobiliary disease. Post-ERCP pancreatitis (PEP) is the most common adverse event of ERCP with a significant burden of morbidity and cost.

RECENT FINDINGS

Appropriate indication and counseling is mandatory especially for patients at increased risk for PEP such as those with suspected sphincter of Oddi dysfunction, pancreatic indications, and a prior history of PEP. Guidewire-facilitated deep cannulation is favored over contrast injection. High-quality trials support the use of rectal administered non-steroidal anti-inflammatory agents and pancreatic duct stent placement for high-risk patients. There is emerging evidence favoring the use of rectal NSAIDs and aggressive hydration in average-risk patients though further studies are required. There is also growing interest in the use of combination therapies as well such as pancreatic stents in combination with NSAIDs. The initial step towards PEP prevention involves careful patient selection and informed decision-making. Endoscopists should use several approaches to mitigate the risk of PEP, including guidewire-assisted cannulation, pancreatic stent placement, and rectal NSAIDs use for high-risk patients. The exact role of aggressive hydration and combination therapies needs to be further investigated.

Optimal timing for precutting in cases with difficult biliary cannulation

BACKGROUND AND STUDY AIMS

 In endoscopic retrograde cholangiopancreatography (ERCP), precutting is widely used when achieving biliary cannulation is difficult. However, no consensus has been reached with regard to the best time to initiate precutting.

PATIENTS AND METHODS

 We retrospectively examined 63 patients who underwent precutting for naïve papilla with difficulty in biliary cannulation between 2009 and 2016. The outcomes of the early precut group (≤ 20 min from cannulation until initiating precutting) and the late precut group (> 20 min) were compared.

RESULTS

 Of the 63 patients, 17 (27 %) were in the early precut group and 46 (73 %) were in the late precut group; median time until the initiating precutting was 28 minutes (7 - 50). No significant difference was observed between the two groups in terms of clinical features (age, sex, and indication for ERCP), precutting method, and rate of pancreatic duct stent placement. Significantly higher rates of successful biliary cannulation were observed in the early precut group (16/17; 94 %) than in the late precut group (32/46; 70 %) ( P  < 0.05). In 13 patients in whom precutting was commenced after 40 minutes, the rate of successful biliary cannulation was very low at 53 % (7/13). No significant difference was found between the two groups in terms of incidence of complications (pancreatitis in 5 patients and bleeding in 1 patient).

CONCLUSION

 In actual clinical practice, precutting is commenced approximately 30 minutes after cannulation; however, to successfully achieve biliary cannulation, precutting is recommended to be performed within 20 minutes. Precutting is effective when little inflammation and swelling of the ampulla of Vater is observed. This study was limited in that it was single-center, retrospective and had a small subject sample.

The impact of wire caliber on ERCP outcomes: a multicenter randomized controlled trial of 0.025-inch and 0.035-inch guidewires

BACKGROUND AND AIMS

Wire-guided biliary cannulation has been demonstrated to improve cannulation rates and reduce post-ERCP pancreatitis (PEP), but the impact of wire caliber has not been studied. This study compares successful cannulation rates and ERCP adverse events by using a 0.025-inch and 0.035-inch guidewire.

METHODS

A randomized, single blinded, prospective, multicenter trial at 9 high-volume tertiary-care referral centers in the Asia-Pacific region was performed. Patients with an intact papilla and conventional anatomy who did not have malignancy in the head of the pancreas or ampulla and were undergoing ERCP were recruited. ERCP was performed by using a standardized cannulation algorithm, and patients were randomized to either a 0.025-inch or 0.035-inch guidewire. The primary outcomes of the study were successful wire-guided cannulation and the incidence of PEP. Overall successful cannulation and ERCP adverse events also were studied.

RESULTS

A total of 710 patients were enrolled in the study. The primary wire-guided biliary cannulation rate was similar in 0.025-inch and 0.035-inch wire groups (80.7% vs 80.3%; P = .90). The rate of PEP between the 0.025-inch and the 0.035-inch wire groups did not differ significantly (7.8% vs 9.3%; P = .51). No differences were noted in secondary outcomes.

CONCLUSION

Similar rates of successful cannulation and PEP were demonstrated in the use of 0.025-inch and 0.035-inch guidewires. (Clinical trial registration number: NCT01408264.).

Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy

The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.

Effectiveness of a novel highly flexible-tip guidewire on selective biliary cannulation compared to conventional guidewire: Randomized controlled study

BACKGROUND AND AIM

Endoscopic access to the common bile duct remains difficult in 10% of cases undergoing endoscopic retrograde cholangiopancreatography (ERCP). In the current study, we evaluated the effectiveness of a stiff-shaft and flexible-tip guidewire (Visiglide2^® ) for selective biliary access.

METHODS

We conducted a prospective, randomized controlled study in a single center involving patients with a naïve papilla who required biliary cannulation. We randomly allocated the patients to the Visiglide 2 group (group V) or to the conventional guidewire group (group C). Primary success rate of biliary cannulation, cannulation time, number of papillary attempts, number of pancreatic duct cannulations, total procedure time and final success rate were recorded during the endoscopic procedure.

RESULTS

Total of 100 patients were enrolled and assigned to groups V (n = 50) and C (n = 50). Primary selective biliary cannulation of group V tended to show a higher success rate than that of group C (group V, 96% (48/50); group C, 86% (43/50); P = 0.08). Final success rate for biliary cannulation was 100% in both groups. Mean times for biliary cannulation were 174.9 s for group V and 363.5 s for group C (P = 0.04). Number of papillary attempts for cannulation was significantly fewer in group V (1.84) than in group C (3.44; P < 0.01).

CONCLUSION

Use of Visiglide 2 guidewire might facilitate selective biliary cannulation compared to conventional guidewire in terms of reducing cannulation time and papilla attempts.

Prospective randomized trial of EUS-assisted ERCP without fluoroscopy versus ERCP in common bile duct stones

BACKGROUND AND AIMS

ERCP with stone removal is the standard treatment for common bile duct stones (CBDSs). Radiation exposure is a risk to the endoscopist and patient. EUS-guided ERCP without fluoroscopy (EGEWF) in patients with CBDSs is feasible, but the efficacy and safety compared with ERCP is unknown. We aimed to compare the efficacy and safety of EGEWF with ERCP in CBDS removal.

METHODS

A prospective randomized study was done in 114 patients with CBDSs who met inclusion criteria. These patients were equally randomized into the EGEWF and ERCP groups. In the EGEWF group, ERCP was performed by cannulation without fluoroscopy. Balloon sweeping was done after sphincterotomy to clear the stones until the number of stones matched the number detected by EUS and the stone clearance (SC) was confirmed by cholangiography. In the ERCP group, ERCP was performed in the standard manner. The cannulation rates, SC rates, total procedure and fluoroscopic times, and adverse event rates were analyzed.

RESULTS

After exclusion of 3 patients, 55 were in the EGEWF group and 56 in the ERCP group. Demographic data, laboratory data, stone characteristics, CBD diameter, and number of patients with periampullary diverticulum were not different between the 2 groups. The cannulation success rates in the EGEWF (96.35%) and ERCP (100%) groups were similar (P = .243). The SC rate in the EGEWF group (85.5%) was inferior to the ERCP group (100%) (P = .002). The SC rate based on the number of stones retrieved that matched the number by EUS was correct in 94%. More than 2 stones may increase the failure rate of SC in EGEWF. The adverse event rates and the total procedure times were not different between the groups.

CONCLUSIONS

EGEWF was inferior to ERCP in terms of SC; however, no radiation exposure is beneficial for selected patients. (Clinical trial registration number: NCT02870686.).

A prospective randomized study of loop-tip versus straight-tip guidewire in wire-guided biliary cannulation

BACKGROUND

Wire-guided cannulation has been widely accepted as a useful technique for achieving selective biliary access because it has significantly increased the success rate of biliary cannulation compared with conventional contrast-assisted cannulation. Unlike conventional guidewires with a straight tip, a loop-tip guidewire (LGW) has a closed distal loop that may facilitate less traumatic access through the epithelial folds of the intra-duodenal biliary segments. The aim of this study was to compare the performance of a LGW with a straight-tip guidewire (SGW) in achieving successful selective biliary cannulation.

METHODS

From December 2014 to December 2015, we performed 192 wire-guided biliary cannulations for a naïve papilla in a randomized controlled trial. Patients were randomly assigned to the LGW group (n = 96) or the SGW group (n = 96). Our study protocol did not include crossover to the other guidewire arm if randomized wire-guided cannulation proved unsuccessful within the first 10 min.

RESULTS

There was no significant difference in primary successful biliary cannulation between the two groups (LGW group: 86.5%; SGW group: 77.1%; p = 0.134). The rate and the mean number of unintentional pancreatic duct cannulations during wire-guided biliary cannulation were significantly lower in the LGW group than in the SGW group (LGW group: 14.6%; SGW group: 28.1%; p = 0.034; LGW group: 0.2 ± 0.5; SGW group: 0.6 ± 1.3; p = 0.007). Post-ERCP pancreatitis developed in 5.2% of patients in the LGW group and 8.3% of patients in the SGW group (p = 0.567).

CONCLUSIONS

The biliary cannulation rate of the LGW was not significantly different from those of conventional guidewires. Use of the LGW was associated with a lower rate of unintentional pancreatic duct cannulation during wire-guided biliary cannulation than use of the SGW.

Editorial: Guidewire Trauma: A Key Component of Post-ERCP Pancreatitis That Is Best Controlled by the Endoscopist

Recent studies have revealed that deep pancreatic duct wire passage, even in the absence of contrast injection, is a major technique-related culprit in post-ERCP pancreatitis, unless followed by placement of a pancreatic stent. As guidewire cannulation becomes increasingly widespread, precise control of the guidewire is thus critical. The first randomized trial to compare endoscopist-controlled wire guided vs. assistant-controlled bile duct cannulation has shown a significant reduction in post ERCP pancreatitis when the physician manipulates the wire. Though there is no single universal solution to post-ERCP pancreatitis, careful attention to wire contol is emerging as an important aspect of safety in ERCP.

Intravenous injection of low-dose flurbiprofen axetil for preventing post-ERCP pancreatitis in high-risk patients: An interim analysis of the trial

Background and study aims: Several meta-analyses and randomized control trials have demonstrated the efficacy of rectal nonsteroidal anti-inflammatory drugs for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Diclofenac or indomethacin was administered at a dose of 100 mg in those studies, which may be too high for Asian population. In addition, rectal administration can be considered complicated. Patients and methods: This study was a prospective, randomized, placebo-controlled trial. Patients with a PEP risk score ≥ 1 were randomly assigned to receive intravenous injection of 50 mg flurbiprofen axetil (flurbiprofen group) or saline only (placebo group). The primary outcome was reduced PEP. The secondary outcome was amylase level after 2 hours of ERCP as a predictor of PEP. (Clinical Trials.gov, ID UMIN000011322) Results: In total, 144 patients were enrolled from August 2013 to March 2015. We performed an interim analysis of the first 100 patients: 47 received flurbiprofen axetil and 53 received placebo. PEP occurred in 11 patients (11 %): 2 of 47 (4.3 %) in the flurbiprofen group and 9 of 53 (17 %) in the placebo group (P = 0.042). Relative risk reduction was 62.4 %. Hyperamylasemia did not differ significantly (17.0 % vs. 26.4 %, P = 0.109). This analysis resulted in early termination of the study for ethical reasons. Conclusions: Intravenous injection of low-dose flurbiprofen axetil after ERCP can reduce the incidence of PEP in high-risk patients.

Selective biliary cannulation techniques for endoscopic retrograde cholangiopancreatography procedures and prevention of post- endoscopic retrograde cholangiopancreatography pancreatitis

Numerous endoscopic retrograde cholangiopancreatography (ERCP) techniques have been reported to achieve selective biliary cannulation success. For standard biliary cannulation procedures, the wire-guided cannulation technique has been reported to reduce the rate of post-ERCP pancreatitis (PEP) and increase the biliary cannulation success rate, although conflicting reports exist. The pancreatic or double-guidewire technique and several precut techniques have been reported as useful techniques in difficult biliary cannulation cases. Although ERCP is a useful endoscopic procedure, the risk of adverse events, particularly post-ERCP pancreatitis, is inevitable. Previous studies and analyses have revealed the risk factors for PEP. The efficacy of prophylactic pancreatic duct stent placement and the administration of rectal nonsteroidal anti-inflammatory drugs for preventing PEP has also been reported. Herein, we reviewed reports in the literature regarding the current status of selective biliary cannulation techniques and PEP prevention.

Perforation of the Papilla of Vater in Wire-Guided Cannulation

Background. WGC in ERCP is considered a safe technique, although rare complications can occur. One unique complication of WGC is the perforation of the papilla of Vater by the guidewire. Subjects and Methods. Of 2032 patients who underwent ERCP at our department between January 2010 and December 2014, we selected 208 patients who underwent WGC for naïve papilla as subjects. A detailed examination of patients in whom a perforation occurred was conducted, and risk factors for perforations were investigated. Results. The perforation was observed in 7 of 208 patients (3.4%). All patients recovered with conservative treatment without the need for surgery. The perforation rate was significantly higher in the patients with juxtapapillary duodenal diverticula than those without diverticula (12.5% versus 0.6%, p < 0.001). Cannulation of the bile duct was ultimately achieved in 5 of 7 patients; PSP was performed for 4 of these patients. Conclusion. Caution must be exercised when dealing with patients who have a juxtapapillary duodenal diverticula because they are at higher risk of perforations. Because these are small perforations made by a wire, most of them heal with conservative treatment. However, perforations can make cannulation difficult, and PSP may be useful for deep cannulation.

[Methods of acute pancreatitis prevention after endoscopic transpapillary interventions]

AIM

To optimize preventive methods of acute postoperative pancreatitis in endoscopic transpapillary interventions.

MATERIAL AND METHODS

It is performed parallel unblinded randomized investigation. The first group included 98 patients who underwent endoscopic transpapillary interventions and thoracic epidural analgesia (TEA). The second group consisted of 97 patients in whom opiate analgesic intramuscularly and indomethacin per rectum were applied.

RESULTS

Study revealed that acute pancreatitis has been diagnosed significantly more seldom in patients after TEA than in the second group (OR 0.22, CI 95%, 0.06-0.83). Thus in TEA-group pancreatitis was verified in 3.1% (3 of 98 patients), in the second group - in 12.4% (12 of 97 patients). Incidence of pancreatitis decreased from 23.3% (10 of 43) to 4.3% (2 of 46) among high risk patients (OR 0.15, 95% CI 0.03-0.75).

CONCLUSION

TEA is effective and justified preventive method in patients with high risk of postoperative pancreatitis. In low risk patients use of indomethacin per rectum is preferred compared with TEA due to its invasiveness.

0.025-inch vs 0.035-inch guide wires for wire-guided cannulation during endoscopic retrograde cholangiopancreatography: A randomized study

AIM: To compare the clinical outcomes between 0.025-inch and 0.035-inch guide wires (GWs) when used in wire-guided cannulation (WGC).

METHODS: A single center, randomized study was conducted between April 2011 and March 2013. This study was approved by the Medical Ethics Committee at our hospital. Informed, written consent was obtained from each patient prior to study enrollment. Three hundred and twenty-two patients with a naïve papilla of Vater who underwent endoscopic retrograde cholangiopancreatography (ERCP) for the purpose of selective bile duct cannulation with WGC were enrolled in this study. Fifty-three patients were excluded based on the exclusion criteria, and 269 patients were randomly allocated to two groups by a computer and analyzed: the 0.025-inch GW group (n = 109) and the 0.035-inch GW group (n = 160). The primary endpoint was the success rate of selective bile duct cannulation with WGC. Secondary endpoints were the success rates of the pancreatic GW technique and precutting, selective bile duct cannulation time, ERCP procedure time, the rate of pancreatic duct stent placement, the final success rate of selective bile duct cannulation, and the incidence of post-ERCP pancreatitis (PEP).

RESULTS: The primary success rates of selective bile duct cannulation with WGC were 80.7% (88/109) and 86.3% (138/160) for the 0.025-inch and the 0.035-inch groups, respectively (P = 0.226). There were no statistically significant differences in the success rates of selective bile duct cannulation using the pancreatic duct GW technique (46.7% vs 52.4% for the 0.025-inch and 0.035-inch groups, respectively; P = 0.884) or in the success rates of selective bile duct cannulation using precutting (66.7% vs 63.6% for the 0.025-inch and 0.035-inch groups, respectively; P = 0.893). The final success rates for selective bile duct cannulation using these procedures were 92.7% (101/109) and 97.5% (156/160) for the 0.025-inch and 0.035-inch groups, respectively (P = 0.113). There were no significant differences in selective bile duct cannulation time (median ± interquartile range: 3.7 ± 13.9 min vs 4.0 ± 11.2 min for the 0.025-inch and 0.035-inch groups, respectively; P = 0.851), ERCP procedure time (median ± interquartile range: 32 ± 29 min vs 30 ± 25 min for the 0.025-inch and 0.035-inch groups, respectively; P = 0.184) or in the rate of pancreatic duct stent placement (14.7% vs 15.6% for the 0.025-inch and 0.035-inch groups, respectively; P = 0.832). The incidence of PEP was 2.8% (3/109) and 2.5% (4/160) for the 0.025-inch and 0.035-inch groups, respectively (P = 0.793).

CONCLUSION: The thickness of the GW for WGC does not appear to affect either the success rate of selective bile duct cannulation or the incidence of PEP.

Effectiveness of the J-Tip Guidewire for Selective Biliary Cannulation Compared to Conventional Guidewires (The JANGLE Study)

BACKGROUND

Wire-guided cannulation has become a common biliary cannulation technique worldwide. Different guidewires with various tip shapes and materials have been reportedly used for wire-guided cannulation. However, there are apparently no studies reporting changes in the biliary cannulation rate according to the type of guidewire used.

AIMS

We evaluated the effectiveness of the J-tip guidewire for biliary cannulation.

METHODS

We conducted a prospective, multicenter, controlled study involving patients with a native papilla who required biliary cannulation. We allocated the patients to the J-tip guidewire or angled-tip guidewire groups (groups J and A, respectively). If biliary cannulation was not achieved within 10 min, the GW was changed and cannulation was continued.

RESULTS

Groups J and A consisted of 66 and 65 enrolled patients, respectively. The biliary cannulation rate with a single guidewire for the first 10 min was 84.8 % (56/66) for group J and 80.0 % (52/65) for group A. The final success rate for biliary cannulation was 100 % in both groups. The mean times necessary for biliary cannulation were 285.8 and 267.6 s in group J and group A, respectively. The incidence rates of complications (i.e., all mild pancreatitis) were 3.0 % (2/66) and 6.2 % (4/65) in group J and group A, respectively. The mean amylase concentrations were 168.0 and 297.7 IU/L in group J and group A, respectively. There were no significant differences in any results between both groups.

CONCLUSION

The biliary cannulation rate of the J-tip guidewire was not significantly different from those of standard guidewires.

Effect of rectal indomethacin for preventing post-ERCP pancreatitis depends on difficulties of cannulation: results from a randomized study with sequential biliary intubation

GOALS AND BACKGROUND

The greatest challenges for endoscopists performing biliary therapy in endoscopic retrograde cholangiopancreatography (ERCP) are to achieve selective biliary cannulation and prevent post-ERCP pancreatitis (PEP). Nonsteroidal anti-inflammatory drugs have proven prophylactic effect in PEP. However, the patient population that would benefit from this approach has not been defined.

STUDY

A total of 539 patients undergoing our cannulation protocol with early precut were randomized into a placebo-controlled, prospective, double-blind study to rectally receive either 100 mg indomethacin or placebo. The effect of indomethacin on PEP was stratified based on difficulties of cannulation and analyzed in patients with different risks.

RESULTS

In 70.3% of patients, biliary intubation was successful in the first 5 atraumatic attempts, PEP rate was low, and indomethacin was ineffective (7.4% in the placebo group and 5.2% in the indomethacin group, P=0.406). In the next phase of intubation using guidewire, the success rate increased up to 83.5%, and PEP rate rose up to 8.7%, the effect of indomethacin was significant (11.9% vs. 5.4%, P=0.018). Applying early precut success rate of biliary cannulation increased up to 98.1% and overall indomethacin diminished the frequency of PEP from 13.8% to 6.7% (P=0.007). Preventive effect of indomethacin was demonstrated in cases with defined procedure-related risk (28.3% vs. 13.8%, P=0.028) and with defined patient-related risk (16.3% vs. 7.0%, P=0.004), but not in patients without risk factors.

CONCLUSIONS

Rectally administered 100 mg indomethacin results in significantly lower PEP rate, particularly in cases with difficult cannulation and with identifiable patient-related or procedure-related risk factors.

Preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: What can be done?

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography. The incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis varies substantially and is reported around 1%-10%, although there are some reports with an incidence of around 30%. Usually, PEP is a mild or moderate pancreatitis, but in some instances it can be severe and fatal. Generally, it is defined as the onset of new pancreatic-type abdominal pain severe enough to require hospital admission or prolonged hospital stay with levels of serum amylase two to three times greater than normal, occurring 24 h after ERCP. Several methods have been adopted for preventing pancreatitis, such as pharmacological or endoscopic approaches. Regarding medical prevention, only non-steroidal anti-inflammatory drugs, namely diclofenac sodium and indomethacin, are recommended, but there are some other drugs which have some potential benefits in reducing the incidence of post-ERCP pancreatitis. Endoscopic preventive measures include cannulation (wire guided) and pancreatic stenting, while the adoption of the early pre-cut technique is still arguable. This review will attempt to present and discuss different ways of preventing post-ERCP pancreatitis.

Wire-guided cannulation versus contrast-guided cannulation in pediatric endoscopic retrograde cholangiopancreatography

BACKGROUND/AIM

Wire-guided cannulation (WGC) of the common bile duct may be associated with fewer complications and higher success rate compared with contrast-guided cannulation (CGC) in adults. Data in children are lacking. The aim of this study was to compare the successful cannulation and complication rate of WGC and CGC in pediatric endoscopic retrograde cholangiopancreatography (ERCP).

PATIENTS AND METHODS

We report a retrospective cohort study comparing WGC to CGC in a pediatric cohort. We reviewed the medical records of 167 children who underwent ERCP over a 10-year time period (CGC, 1999-2003, WGC, 2003-2009). Indications, findings, and success were analyzed.

RESULTS

A total of 93 patients (56%) underwent WGC and 74 (44%) CGC. Children in the WGC group were younger (9.5 ± 4.7 vs. 11.5 ± 4.6 years in CGC; P = 0.006) and underwent more therapeutic ERCP interventions (70% vs. 40% in CGC), whereas diagnostic ERCP was more common in the CGC group (60%; P < 0.005). The overall success (96%) and complication rate (8%) were identical in both groups but a trend toward a reduction in the complication rate over time was noted in the WGC group. Post-ERCP pancreatitis (PEP) was documented in one patient in the WGC group (1.1%) and three patients (4.2%) in the CGC group (P-NS).

CONCLUSION

The success and complication rate in both CGC and WGC are comparable in children but considering the patient and procedure complexity and the trend toward lower PEP in the WGC group, WGC may be the preferable cannulation technique for ERCP in children.