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Abstract
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.
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Affiliation(s)
- Robert H Hawes
- Orlando Health Digestive Health Institute, 1335 Sligh Boulevard, 3rd Floor, Orlando, FL 33806, USA; Center for Advanced Endoscopy, Research and Education (CARE); University of Central Florida College of Medicine.
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CÁCERES-ESCOBAR D, MUÑOZ-VELANDIA OM, VARGAS-RUBIO R. FACTORS ASSOCIATED WITH DIFFICULT BILIARY CANNULATION IN A TRAINING CENTER FOR ENDOSCOPIC INTERVENTION OF THE BILIARY TRACT. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:29-34. [DOI: 10.1590/s0004-2803.202200001-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/03/2021] [Indexed: 11/21/2022]
Abstract
ABSTRACT Background This paper aims to determine factors associated with difficult biliary cannulation (DBC) that are identifiable before procedures. Methods This is a nested case-control study within a historical cohort in adult patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) from 2015-2019 in the Hospital Universitario San Ignacio, Colombia. This study assessed the associations among variables that could be identified before or at the beginning of procedures and the probability of DBC. These associations were evaluated through a bivariate and multivariate analysis. The study used criteria for DBC defined by the European Society of Gastrointestinal Endoscopy. Results A total of 498 ERCP performed in 376 patients were analyzed. Of all procedures, 144 (29%) fulfilled criteria for DBC. The multivariate analysis showed an association between DBC and the acute care hospital setting (OR:2.92; CI95% 1.70-5.01; P<0.001), redundant papilla (OR:7.26; CI95% 3.38-15.61; P<0.001), or peridiverticular papilla (OR:2.45; CI95% 1.38-4.36; P=0.002). No association was found between DBC and endoscopist’s experience, bilirubin levels, or dilation of the biliary tract. Conclusion The DBC is a frequent event. Alterations in the papilla and ERCP performed in the acute care hospital setting are the principal factors associated with DBC. This information might be useful to predict DBC and establish healthcare and administrative strategies to reduce its implications.
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Shiomi H, Kutsumi H, Ryozawa S, Irisawa A, Kodama Y. Modified double-guidewire technique using a unique double-lumen sphincterotome for difficult biliary cannulation. VideoGIE 2021; 6:124-128. [PMID: 33738361 PMCID: PMC7947635 DOI: 10.1016/j.vgie.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Hideyuki Shiomi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiromu Kutsumi
- Center for Clinical Research and Advanced Medicine Establishment, Shiga University of Medical Science, Ōtsu, Shiga, Japan
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka-city, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Tabak F, Wang F, Ji GZ, Miao L. Propensity score-matched analysis for comparing transpancreatic sphincterotomy and needle-knife precut in difficult biliary cannulation. Sci Rep 2021; 11:6059. [PMID: 33723297 PMCID: PMC7961145 DOI: 10.1038/s41598-021-84655-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 02/16/2021] [Indexed: 11/24/2022] Open
Abstract
Transpancreatic sphincterotomy (TPS) can be an alternative approach of difficult biliary access in endoscopic retrograde cholangiopancreatography (ERCP). We aimed to evaluate the efficacy and safety of TPS compared to needle-knife precut (NKP), considering the early and late outcomes of both techniques. The prospectively collected clinical data, ERCP procedure findings, and outcomes of patients who underwent ERCP with difficult biliary access in our hospital from July 2016 to January 2018 were retrospectively analyzed. The patients were divided into two groups according to the applied secondary cannulation techniques. The propensity score matching (PSM) was applied to reduce the potential selection bias and unify the preventive measures of post-ERCP pancreatitis (PEP) in both groups. A total of 125 patients were enrolled in this study, with 54.4% male and a mean age of 63.29 ± 16.33 years. NKP group included 82 patients, and 43 patients received TPS. Prophylactic pancreatic stents were placed in all patients with TPS and 58.5% of patients with NKP. After applying PSM, the cohort was comprised to 86 patients with 43 patients in each TPS and NKP groups. Successful selective cannulation was achieved by 95.3% using TPS and by 93% using NKP. The mean procedure time was shorter in the TPS group without significant difference. Compared to NKP, using TPS did not affect the rate of PEP. Moreover, TPS was associated with less frequent post-ERCP bleeding and perforation, but without significant differences (all p > 0.05). Patients who received TPS or NKP had no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period. In conclusion, using TPS in difficult cannulation cases was useful to achieve success cannulation with an acceptable PEP rate and less frequent post-ERCP bleeding and perforation compared to NKP. There were no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period.
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Affiliation(s)
- Fatema Tabak
- Institute of Digestive Endoscopy and Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, Jiangsu, China
| | - Fei Wang
- Institute of Digestive Endoscopy and Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, Jiangsu, China
| | - Guo-Zhong Ji
- Institute of Digestive Endoscopy and Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, Jiangsu, China
| | - Lin Miao
- Institute of Digestive Endoscopy and Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, Jiangsu, China.
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Wang X, Ren G, Xi Y, Luo H, Liang S, Wang B, Tao Q, Luo B, Qin Q, Farrell JJ, Guo X, Wu K, Pan Y. Learning curve of double-guidewire technique by trainees during hands-on endoscopic retrograde cholangiopancreatography training. J Gastroenterol Hepatol 2020; 35:2176-2183. [PMID: 32473040 DOI: 10.1111/jgh.15120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/22/2020] [Accepted: 05/25/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Double-guidewire technique (DWT) has been successfully performed by experts in difficult biliary cannulation as an advanced technique. This study aimed to define the learning curve and safety of DWT by trainees during hands-on endoscopic retrograde cholangiopancreatography (ERCP) training. METHODS Patients were eligible for inclusion in the study if the biliary cannulation was difficult and the pancreatic duct was inadvertently cannulated. DWT was performed by two trainees randomly under trainers' guidance. The primary outcome was the success rate of DWT biliary cannulation of trainees. Cumulative sum analysis was used to generate visual learning curves. RESULTS A total of 60 patients with difficult cannulation were enrolled. The main indications for ERCP were common bile duct stones (65%) and biliary stricture (31.7%). The learning curve analysis showed that to achieve a 70% rate of successful DWT, 12 procedures were needed for trainee A and 15 for trainee B. Higher targeted success rate of DWT could be achieved if the number of DWT procedures increased. Compared with the early stage of learning DWT (case 1 to 15 for each trainee), trainees had significantly higher DWT success rate in the late stage (36.7% [11/30] vs 80% [24/30], P = 0.001). The final success rate of cannulation was 98.3% (59/60). The overall rate of post-ERCP pancreatitis and adverse events was 6.7% (4/60) and 8.3% (5/60), respectively. CONCLUSIONS Double-guidewire technique was safely performed by two novel trainees during hands-on ERCP training. Fifteen procedures may be enough for trainees to achieve the competency of performing DWT. (Clinicaltrials.gov number: NCT03707613).
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Affiliation(s)
- Xiangping Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Gui Ren
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yibin Xi
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Hui Luo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Shuhui Liang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Biaoluo Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qin Tao
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bing Luo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qian Qin
- Department of General Surgery, First Affiliated Hospital of Xian Jiaotong University, Xi'an, China
| | - James J Farrell
- Department of Digestive Disease and Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Xuegang Guo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kaichun Wu
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yanglin Pan
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Wang X, Zhao J, Wang L, Ning B, Zeng W, Tao Q, Ren G, Liang S, Luo H, Wang B, Farrell JJ, Pan Y, Guo X, Wu K. Relationship between papilla-related variables and post endoscopic retrograde cholangiopancreatography pancreatitis: A multicenter, prospective study. J Gastroenterol Hepatol 2020; 35:2184-2191. [PMID: 32511794 DOI: 10.1111/jgh.15135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/23/2020] [Accepted: 06/06/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIM Papilla with hooknose or long protruding shape may increase the difficulty of cannulation during endoscopic retrograde cholangiopancreatography (ERCP). However, the relationship between papilla anatomy and complications of ERCP has not been fully understood. We aimed to investigate the effect of major duodenal papilla morphology on post-ERCP pancreatitis (PEP) and the procedure of cannulation. METHODS Patients with native papilla who underwent ERCP were recruited to this multicenter study. Papilla-related variables were collected, including the length of long axis (L), short axis (S) and opening width (OW), transverse fold, periampullary diverticulum (PAD), papilla location, orientation, swelling, and presence of duodenal stenosis. Demographic data and the procedure of cannulation were also prospectively evaluated. The primary outcome was PEP incidence. Multivariate analysis was used to identify high risk factors for PEP. RESULTS Six hundred and fifty-eight patients were enrolled. Overall PEP incidence was 4.7% (31/658). The papilla of patients complicated with PEP had higher long to short axis (L/S) ratio (odds ratio [OR] 3.84, 95% confidence interval [CI]: 1.37-10.74, P = 0.010), higher long axis to opening width (L/OW) ratio (OR 1.35, 95%CI: 1.06-1.71, P = 0.014), more transverse folds (OR 2.53, 95%CI: 1.02-6.26, P = 0.044), and less periampullary diverticulum (OR 0.21, 95%CI: 0.06-0.70, P = 0.011). Multivariate analysis revealed that the indication of common bile duct stones, normal bilirubin, inadvertent pancreatic duct cannulation > 1, L/S ratio ≥ 1.5, and absence of PAD were independent risk factors for PEP. CONCLUSION Besides patient-related and procedure-related factors, papilla-related variables, such as L/S ratio and PAD, can be considered as a third type of factors associated with PEP (Clinicaltrials.gov number: NCT03550768).
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Affiliation(s)
- Xiangping Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jianghai Zhao
- Department of Gastroenterology, Huaihe Hospital of Henan University, Kaifeng, China
| | - Limei Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.,Shaanxi Second People's Hospital, Xi'an, China
| | - Bo Ning
- Department of Gastroenterology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Zeng
- Department of Gastroenterology, Successful Hospital of Xiamen university, Xiamen, China
| | - Qin Tao
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Gui Ren
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Shuhui Liang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Hui Luo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Biaoluo Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - James J Farrell
- Department of Digestive Disease and Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Yanglin Pan
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xuegang Guo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kaichun Wu
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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de Araujo TB, Jotz GP, Zaki CH, Mantelli RA, Fernandes VF, Pretto GG, Volkweis BS, Corso CO, Cavazzola LT. Intraoperative cholangiography with filling defects: comparative complication analysis of postoperative transcystic duct (TCD) catheter maintenance. Surg Endosc 2020; 35:6438-6448. [PMID: 33151354 DOI: 10.1007/s00464-020-08133-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/27/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND This is a retrospective cohort of patients undergoing laparoscopic cholecystectomy with intraoperative cholangiography (IOC) with positive findings for filling defects. We comparatively assessed differences in complication risks for patients that had their cholangiography catheter maintained in its transcystic duct (TCD) position postoperatively. This is a practice proposed to overcome the limited availability of Endoscopic Retrograde Cholangiopancreatography (ERCP) as well as to avoid surgical exploration of the common bile duct. METHODS Retrospective medical record review of all positive IOC from January 2015 to December 2018 were assessed. Patients' demographic and perioperative data from the hospital stay period in which the cholecystectomy occurred until the last surgical ambulatory visit for perioperative characteristics were compared between groups (with vs. without TCD catheter). Complications were operationalized using the Clavien-Dindo scale. RESULTS Univariate analysis of complications showed a 2.4-fold risk increase in complications (95% CI 1.13-5.1) between comparison groups. Number of ERCPs (18 vs. 30), and MRCPs (5 vs. 17) were not significantly different between maintaining or not the TCD catheter postop, respectively. Stratified analysis followed by exact logistic regression supported the findings that maintaining the TCD catheter postoperatively increased complication rates (OR = 5.34, 95% CI 1.22, 29.83, p = 0.022), adjusting for potential confounders. CONCLUSION The maintenance of the TCD catheter postoperatively did not prove to be effective in significantly reducing the number of ERCP nor associated complications. Also, outcomes inherited from the practice caused adverse events that surpassed its potential benefits. Moreover, expectant follow-up is reasonable for patients with evidence of common bile duct stones, even in setting with limited resource availability. We do not recommend this practice, even in settings where there are limited resources of more modern management of choledocholithiasis.
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Affiliation(s)
- Thiago B de Araujo
- Universidade Federal de Ciências da Saúde, Programa de Pós-Graduação Ciências da Saúde, R Sarmento Leite 245, Porto Alegre, RS, 90050-170, Brazil. .,Hospital de Clínicas de Porto Alegre, Serviço de Cirurgia Geral, Porto Alegre, RS, Brazil.
| | - Geraldo P Jotz
- Universidade Federal de Ciências da Saúde, Programa de Pós-Graduação Ciências da Saúde, R Sarmento Leite 245, Porto Alegre, RS, 90050-170, Brazil
| | - Camila H Zaki
- Hospital de Clínicas de Porto Alegre, Serviço de Cirurgia Geral, Porto Alegre, RS, Brazil
| | - Rafaela A Mantelli
- Universidade Federal de Ciências da Saúde, Programa de Pós-Graduação Ciências da Saúde, R Sarmento Leite 245, Porto Alegre, RS, 90050-170, Brazil
| | - Vinicius F Fernandes
- Hospital de Clínicas de Porto Alegre, Serviço de Cirurgia Geral, Porto Alegre, RS, Brazil
| | - Guilherme G Pretto
- Hospital de Clínicas de Porto Alegre, Serviço de Cirurgia Geral, Porto Alegre, RS, Brazil
| | - Bernardo S Volkweis
- Hospital de Clínicas de Porto Alegre, Serviço de Cirurgia Geral, Porto Alegre, RS, Brazil
| | - Carlos Otavio Corso
- Hospital de Clínicas de Porto Alegre, Serviço de Cirurgia Geral, Porto Alegre, RS, Brazil
| | - Leandro T Cavazzola
- Hospital de Clínicas de Porto Alegre, Serviço de Cirurgia Geral, Porto Alegre, RS, Brazil
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Shinoura S, Tokushige A, Chinen K, Mori H, Kato S, Ueda S. Endosonographic finding of the simultaneous depiction of bile and pancreatic ducts can predict difficult biliary cannulation on endoscopic retrograde cholangiopancreatography. PLoS One 2020; 15:e0235757. [PMID: 32645076 PMCID: PMC7347092 DOI: 10.1371/journal.pone.0235757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 06/23/2020] [Indexed: 12/24/2022] Open
Abstract
Thus far, no curved linear array endoscopic ultrasound (CLAEUS) findings were established as predictors of difficult selective bile duct cannulation (SBDC). This study aimed to identify CLAEUS findings to predict endoscopic retrograde cholangiopancreatography (ERCP) cases with difficult SBDC. This single-center, retrospective cohort study was conducted between July 2014 and June 2017. This study included all consecutive patients who underwent CLAEUS prior to naïve ERCP. A CLAEUS finding of the simultaneous depiction of bile and pancreatic ducts at the second portion of the duodenum (D2) (simultaneous depiction) was selected as a possible predictor of difficult SBDC, and the κ values in the evaluation of inter- and intra-observer variabilities for “simultaneous depiction” were 0.65 and 0.77, respectively, with substantial correlation. Among the 986 patients who underwent ERCP, 80 patients were relevant for evaluation. Logistic regression analysis revealed strong association between “simultaneous depiction” and difficult SBDC (odds ratio 15.4, 95% confidence interval 4.2–56.0; p<0.001). Among patients who underwent CLAEUS prior to naïve ERCP, a strong correlation was observed between “simultaneous depiction” and the risk of difficult SBDC. An endoscopist can prepare for difficult SBDC by “simultaneous depiction.” The finding enables pertinent planning when performing ERCP, such as setting time limits and selecting alternative devices, techniques, and skilled endoscopists, for difficult SBDC with minimal complications including post-ERCP pancreatitis. However, a future prospective study is necessary to establish the procedure algorithm for suspected difficult SBDC cases based on CLAEUS.
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Affiliation(s)
- Susumu Shinoura
- Department of Healthcare Management, School of Psychology and Healthcare Management at Akasaka, International University of Health and Welfare, Minato, Tokyo, Japan
- Department of Prevention and Analysis of Cardiovascular Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
- Department of Clinical Research and Quality Management, Center of Clinical Research and Quality Management, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Akihiro Tokushige
- Department of Prevention and Analysis of Cardiovascular Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
- Department of Digestive Diseases, Okinawa Chubu Hospital, Uruma, Okinawa, Japan
| | - Kenji Chinen
- Department of Clinical Research and Quality Management, Center of Clinical Research and Quality Management, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Hideki Mori
- Department of Clinical Research and Quality Management, Center of Clinical Research and Quality Management, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Shin Kato
- Department of Gastroenterology and Hepatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Shinichiro Ueda
- Department of Prevention and Analysis of Cardiovascular Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
- * E-mail:
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Shin SH, So H, Cho S, Kim N, Baik GH, Lee SK, Park DH. The number of wire placement in the pancreatic duct and metal biliary stent as risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis. J Gastroenterol Hepatol 2020; 35:1201-1207. [PMID: 31830336 DOI: 10.1111/jgh.14957] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/27/2019] [Accepted: 12/08/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND AIM Many post-ERCP pancreatitis (PEP) risk factors, including pancreatic duct cannulation, have been identified; however, whether the number of repeated and unintentional wire placements (WPs) in the pancreatic duct during wire-guided cannulation affects PEP risk is unknown. We aimed to identify the effects of repeated WP in the pancreatic duct and other potential risk factors on PEP incidence. METHODS We retrospectively analyzed 877 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP). We examined potential patient-related and procedure-related risk factors, and PEP incidence by univariable and multivariable logistic regression analyses. RESULTS Thirty-four patients (3.9%) had PEP. Univariable analysis revealed younger age, malignant common bile duct or ampulla of Vater stricture, two or more episodes of WPs in the pancreatic duct, and metal biliary stent as risk factors for PEP. Following multivariable analysis, two or more episodes of WPs in the pancreatic duct and metal biliary stent remained in the final model. PEP did not increase significantly in case of a one episode of WP (4.0%) compared with no episode of WP in the pancreatic duct (2.7%). However, patients with two episodes of WPs had 8.0% incidence and three or more episodes of WPs had 14.3%. CONCLUSIONS A WP in the pancreatic duct and a metal biliary stent were associated with increased PEP incidence in patients undergoing ERCP. As for the pancreatic duct wire cannulation, two or more WPs considerably increased PEP incidence. This suggests that preventive measures or alternative procedures might be considered in patients with such cases during and after ERCP.
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Affiliation(s)
- Seung Hwan Shin
- Division of Gastroenterology, Departments of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hoonsub So
- Division of Gastroenterology, Departments of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | | | - Nayoung Kim
- Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Sung Koo Lee
- Division of Gastroenterology, Departments of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Do Hyun Park
- Division of Gastroenterology, Departments of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Lee YJ, Kang DH, Kim HW, Park SB, Kim SJ, Nam HS, Ryu DG. Usefulness and Complications of Needle Knife Fistulotomy as a Rescue Procedure in Patients with Pancreaticobiliary Disease. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2020; 75:341-346. [PMID: 32581205 DOI: 10.4166/kjg.2020.75.6.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 03/18/2020] [Accepted: 04/21/2020] [Indexed: 11/03/2022]
Abstract
Background/Aims Needle knife fistulotomy (NKF) is a technique to facilitate pancreatic and biliary duct access during ERCP. The double-guidewire technique (DGT) is also used in cases of difficult cannulation, but it can increase the incidence of post-ERCP-pancreatitis (PEP). This study examined the success and complication rates of NKF after unsuccessful standard cannulation or DGT in patients with pancreaticobiliary disease. Methods The data of 209 patients who received NKF as a rescue procedure between January 2009 and December 2016 were reviewed retrospectively. The cannulation success and complication rates were assessed. Results The overall cannulation success rate was 90.4%. The success rates of patients who received NKF after standard cannulation or DGT were similar (82.6% [142/172] and 73.0% [27/37], respectively, p=0.179). Furthermore, there was no significant difference in the incidence of procedure-related adverse events between the two groups (10.5% [18/172] and 16.2% [6/37], respectively, p=0.391). Endoscopic retrograde pancreatic drainage (ERPD) insertion decreased the incidence of PEP (0% [0/16] in ERPD and 14.6% [19/130] in non-ERPD, p=0.132) among patients who received PD cannulation. Conclusions NKF is an effective and safe method that can be considered for rescue management after the initial failure of standard cannulation or DGT. NKF following standard cannulation can be preferred over NKF following DGT because of the higher success rate and the lower rate of pancreatitis, but the difference was not significant. PD stenting in patients at high risk of PEP can be considered to decrease pancreatitis.
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Affiliation(s)
- Yong Jae Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technoloty, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dae Hwan Kang
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technoloty, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung Wook Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technoloty, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Su Bum Park
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technoloty, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Su Jin Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technoloty, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyeong Seok Nam
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technoloty, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dae Gon Ryu
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technoloty, Pusan National University Yangsan Hospital, Yangsan, Korea
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11
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Balan GG, Arya M, Catinean A, Sandru V, Moscalu M, Constantinescu G, Trifan A, Stefanescu G, Sfarti CV. Anatomy of Major Duodenal Papilla Influences ERCP Outcomes and Complication Rates: A Single Center Prospective Study. J Clin Med 2020; 9:E1637. [PMID: 32481755 PMCID: PMC7356786 DOI: 10.3390/jcm9061637] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/09/2020] [Accepted: 05/25/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) has been one of the most intensely studied endoscopic procedures due to its overall high complication rates when compared to other digestive endoscopy procedures. The safety and outcome of such procedures have been linked to multiple procedure- or patient-related risk factors. The aim of our study is to evaluate whether the morphology of the major duodenal papilla influences the ERCP outcomes and complication rates. METHODS A total of 322 patients with a native papilla have been included in the study over an eight month period. Morphology of the papilla has been classified into normal papilla and four anatomical variations (Type I-IV). All patients have been prospectively monitored over a 15 day period after ERCP. Procedural outcomes and complication rates have been registered. RESULTS Morphology of the papilla influences both overall complication rates (95%CI, p = 0.0066) and post-ERCP pancreatitis rates (95%CI, p = 0.01001) in univariate analysis. Type IV papillae have proven to be independent risk factors for post-ERCP pancreatitis in multivariate analysis (OR = 12.176, 95%CI, p = 0.005). Type I papillae have been significantly linked to difficult cannulation (AUC = 0.591, 95%CI, p = 0.008); Conclusions: In the monitored cohort morphology of the major duodenal papilla has significantly influenced both ERCP outcomes and post-procedural complication rates.
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Affiliation(s)
- Gheorghe G. Balan
- Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (G.G.B.); (M.M.); (A.T.); (C.V.S.)
| | - Mukul Arya
- New York Presbitarian Brooklyn Methodist Hospital, New York, NY 11215, USA;
| | - Adrian Catinean
- Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
| | - Vasile Sandru
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania
| | - Mihaela Moscalu
- Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (G.G.B.); (M.M.); (A.T.); (C.V.S.)
| | - Gabriel Constantinescu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Anca Trifan
- Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (G.G.B.); (M.M.); (A.T.); (C.V.S.)
| | - Gabriela Stefanescu
- Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (G.G.B.); (M.M.); (A.T.); (C.V.S.)
| | - Catalin Victor Sfarti
- Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (G.G.B.); (M.M.); (A.T.); (C.V.S.)
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12
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Affiliation(s)
- Erik Haraldsson
- Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Skaraborg Hospital, Skövde, Sweden
| | - Urban Arnelo
- Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
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13
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Haraldsson E, Kylänpää L, Grönroos J, Saarela A, Toth E, Qvigstad G, Hult M, Lindström O, Laine S, Karjula H, Hauge T, Sadik R, Arnelo U. Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP. Gastrointest Endosc 2019; 90:957-963. [PMID: 31326385 DOI: 10.1016/j.gie.2019.07.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Certain appearances of the major duodenal papilla have been claimed to make cannulation more difficult during ERCP. This study uses a validated classification of the endoscopic appearance of the major duodenal papilla to determine if certain types of papilla predispose to difficult cannulation. METHODS Patients with a naïve papilla scheduled for ERCP were included. The papilla was classified into 1 of 4 papilla types before cannulation started. Time to successful bile duct cannulation, attempts, and number of pancreatic duct passages were recorded. Difficult cannulation was defined as after 5 minutes, 5 attempts, or 2 pancreatic guidewire passages. RESULTS A total of 1401 patients were included from 9 different centers in the Nordic countries. The overall frequency of difficult cannulation was 42% (95% confidence interval [CI], 39%-44%). Type 2 small papilla (52%; 95% CI, 45%-59%) and type 3 protruding or pendulous papilla (48%; 95% CI, 42%-53%) were more frequently difficult to cannulate compared with type 1 regular papilla (36%; 95% CI, 33%-40%; both P < .001). If an inexperienced endoscopist started cannulation, the frequency of failed cannulation increased from 1.9% to 6.3% (P < .0001), even though they were replaced by a senior endoscopist after 5 minutes. CONCLUSIONS The endoscopic appearance of the major duodenal papilla influences bile duct cannulation. Small type 2 and protruding or pendulous type 3 papillae are more frequently difficult to cannulate. In addition, cannulation might even fail more frequently if a beginner starts cannulation. These findings should be taken into consideration when performing studies regarding bile duct cannulation and in training future generations of endoscopists.
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Affiliation(s)
- Erik Haraldsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Skaraborg Hospital, Skövde, Sweden
| | - Leena Kylänpää
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Grönroos
- Department of Surgery, University of Turku, and Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Arto Saarela
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Ervin Toth
- Department of Gastroenterology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Gunnar Qvigstad
- Department of Gastroenterology and Hepatology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Mari Hult
- Department of Medicine, Solna, Unit of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Outi Lindström
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Simo Laine
- Department of Surgery, University of Turku, and Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Heikki Karjula
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Riadh Sadik
- Department of Gastroenterology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Urban Arnelo
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
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Chen Q, Jin P, Ji X, Du H, Lu J. Management of difficult or failed biliary access in initial ERCP: A review of current literature. Clin Res Hepatol Gastroenterol 2019; 43:365-372. [PMID: 30314736 DOI: 10.1016/j.clinre.2018.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 08/16/2018] [Accepted: 09/10/2018] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Qinghai Chen
- Department of Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300000, PR China.
| | - Peng Jin
- Department of Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300000, PR China.
| | - Xiaoyan Ji
- Department of Emergency Ward, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300000, PR China
| | - Haiwei Du
- Department of Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300000, PR China
| | - Junhua Lu
- Department of Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300000, PR China
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15
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Lee TH, Park SH, Yang JK, Han SJ, Park S, Choi HJ, Lee YN, Cha SW, Moon JH, Cho YD. Is the Isolated-Tip Needle-Knife Precut as Effective as Conventional Precut Fistulotomy in Difficult Biliary Cannulation? Gut Liver 2019; 12:597-605. [PMID: 29730907 PMCID: PMC6143454 DOI: 10.5009/gnl17572] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/01/2018] [Accepted: 02/19/2018] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Tae Hoon Lee
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - Sang-Heum Park
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - Jae Kook Yang
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - Su Jung Han
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - Suyeon Park
- Department of Biostatistics, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Hyun Jong Choi
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Korea
| | - Yun Nah Lee
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Korea
| | - Sang-Woo Cha
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Jong Ho Moon
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Korea
| | - Young Deok Cho
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Seoul, Korea
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Eminler AT, Parlak E, Koksal AS, Toka B, Uslan MI. Wire-guided cannulation over a pancreatic stent method increases the need for needle-knife precutting ın patients with difficult biliary cannulations. Gastrointest Endosc 2019; 89:301-308. [PMID: 30148994 DOI: 10.1016/j.gie.2018.08.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/10/2018] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Ahmet Tarık Eminler
- Sakarya University Faculty of Medicine Department of Gastroenterology, Sakarya, Turkey
| | - Erkan Parlak
- Hacettepe University Faculty of Medicine Department of Gastroenterology, Ankara, Turkey
| | - Aydın Seref Koksal
- Sakarya University Faculty of Medicine Department of Gastroenterology, Sakarya, Turkey
| | - Bilal Toka
- Sakarya University Faculty of Medicine Department of Gastroenterology, Sakarya, Turkey
| | - Mustafa Ihsan Uslan
- Sakarya University Faculty of Medicine Department of Gastroenterology, Sakarya, Turkey
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17
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Zheng M, Liu X, Li N, Li WZ. Emergency endoscopic needle-knife precut papillotomy in acute severe cholangitis resulting from impacted common bile duct stones at duodenal papilla. Dig Liver Dis 2018; 50:267-270. [PMID: 29361439 DOI: 10.1016/j.dld.2017.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 11/21/2017] [Accepted: 11/21/2017] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Mingwei Zheng
- Department of Surgery, Tianjin Nankai Hospital, Tianjin, China; Tianjin Medical University, Tianjin, China.
| | - Xufeng Liu
- Department of Surgery, Tianjin Dagang Oilfield General Hospital, Tianjin, China
| | - Ning Li
- Department of Surgery, Tianjin Nankai Hospital, Tianjin, China
| | - Wei-Zhi Li
- Department of Surgery, Tianjin Nankai Hospital, Tianjin, China
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18
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Asia-Pacific consensus guidelines for endoscopic management of benign biliary strictures. Gastrointest Endosc 2017; 86:44-58. [PMID: 28283322 DOI: 10.1016/j.gie.2017.02.031] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/23/2017] [Indexed: 12/11/2022]
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19
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Tarnasky PR, Kedia P. Endoscopic retrograde cholangiopancreatography complications: Techniques to reduce risk and management strategies. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii170004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paul R. Tarnasky
- Methodist Dallas Medical Center, Methodist Digestive Institute, Dallas, TX, USA
| | - Prashant Kedia
- Methodist Dallas Medical Center, Methodist Digestive Institute, Dallas, TX, USA
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Laquiere A, Desilets E, Belle A, Castellani P, Grandval P, Laugier R, Penaranda G, Lecomte L, Boustiere C. Double guidewire endoscopic technique, a major evolution in endoscopic retrograde cholangiopancreatography: Results of a retrospective study with historical controls comparing two therapeutic sequential strategies. Dig Endosc 2017; 29:182-189. [PMID: 27638137 DOI: 10.1111/den.12740] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/14/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Endoscopic access to the common bile duct (CBD) remains difficult in 10% of cases, requiring alternative techniques .CBD access was difficult after either five unsuccessful attempts, five unintentional insertions into the pancreatic duct or >10-min-long unsuccessful attempts. This retrospective study with historical controls aimed to evaluate the benefit of the double guidewire (DGW) technique after failure of standard CBD cannulation. METHODS From January 2012 to December 2014, all patients requiring therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with difficult access to CBD were included in a Studied group. This group was compared to a historical ERCP control group from January 2009 to December 2011. In the Studied group, a sequential strategy including DGW technique was done when the guidewire was unintentionally passed into the pancreatic duct. In the control group, only pre-cut technique was used. RESULTS Among the 538 patients with naive papilla eligible for ERCP, 73 had difficult CBD access. Successful CBD access rate was higher in the Studied group: 91% (50/55) versus 67% (12/18) P = 0.0215. Complication rates were similar in both groups: 28% versus 20%, P = 0.5207. LOS was shorter in the Studied group (9.2 ± 8.5 vs 14.4 ± 7.4 days, P = 0.0028). Post-ERCP cholangitis were lower in the Studied group: 2% (1/55) versus 22% (4/18), P = 0.0118. CONCLUSION After standard cannulation failure, DGW technique increased successful CBD access rate and decreased LOS without increasing complications.
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Affiliation(s)
- Arthur Laquiere
- Hepato-Gastroenterology Department, Saint Joseph Hospital, Marseille, France
| | - Etienne Desilets
- Hepato-Gastroenterology Department, Saint Joseph Hospital, Marseille, France
| | - Arthur Belle
- Hepato-Gastroenterology Department, Saint Joseph Hospital, Marseille, France
| | - Paul Castellani
- Hepato-Gastroenterology Department, Saint Joseph Hospital, Marseille, France
| | | | - René Laugier
- Gastroenterology Department, La Timone Hospital, Marseille, France
| | | | - Laurence Lecomte
- Hepato-Gastroenterology Department, Saint Joseph Hospital, Marseille, France
| | - Christian Boustiere
- Hepato-Gastroenterology Department, Saint Joseph Hospital, Marseille, France
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Use of double wire-guided technique and transpancreatic papillary septotomy in difficult ERCP: 4-year experience. Endosc Int Open 2016; 4:E1107-E1110. [PMID: 27747287 PMCID: PMC5063748 DOI: 10.1055/s-0042-115407] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 08/02/2016] [Indexed: 02/08/2023] Open
Abstract
Background and aims: Post-ERCP complications increase with repeated attempts at cannulation. We evaluated several advanced biliary cannulation techniques applied when the standard approach fails. Methods: In total, 1873 consecutive patients underwent ERCP at our institution during the period 2010 - 2014. Guidewire-assisted (GA) cannulation with no contrast injection until deep biliary cannulation was considered the standard technique. Advanced techniques used were double wire-guided (DWG) cannulation, transpancreatic papillary septotomy (TPS), and needle-knife sphincterotomy (NKS). When GA cannulation failed, DWG cannulation was usually attempted first if the pancreatic duct (PD) wire was in place; if that failed, TPS or NKS was performed. Alternatively, TPS or NKS were performed alone. A prophylactic pancreatic stent was placed with repeated PD cannulation or PD contrast injection. During the last 2 years of review, indomethacin suppositories were given post-procedure to all patients who underwent advanced techniques. Results: The overall biliary cannulation success rate was 97 % (1823/1873). Advanced techniques were used in 12 % of ERCPs (230/1873), with 87 % (200/230) success rate. DWG was used alone or in combination with other techniques in 58 % (134/230) of advanced cases, with 68 % (91/134) success rate. Biliary cannulation was achieved in 96 % (91/95) of procedures when DWG was used alone, 76 % (26/34) with TPS alone, 80 % (37/46) for NKS alone, and 84 % (46/55) with multiple techniques. The overall rate of post-ERCP pancreatitis was 0.4 %, with all patients treated conservatively. Conclusion: In our experience at an urban tertiary care center, use of advanced techniques in difficult ERCP improved the overall success rate of biliary cannulation after standard technique failure without a significant increase in complication rate.
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Lee TH, Park SH. Optimal Use of Wire-Assisted Techniques and Precut Sphincterotomy. Clin Endosc 2016; 49:467-474. [PMID: 27642848 PMCID: PMC5066416 DOI: 10.5946/ce.2016.103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/19/2016] [Accepted: 08/19/2016] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital, Soon Chun Hyang University College of Medicine, Cheonan, Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital, Soon Chun Hyang University College of Medicine, Cheonan, Korea
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Kawakami H, Kubota Y, Kawahata S, Kubo K, Kawakubo K, Kuwatani M, Sakamoto N. Transpapillary selective bile duct cannulation technique: Review of Japanese randomized controlled trials since 2010 and an overview of clinical results in precut sphincterotomy since 2004. Dig Endosc 2016; 28 Suppl 1:77-95. [PMID: 26825609 DOI: 10.1111/den.12621] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/21/2016] [Accepted: 01/24/2016] [Indexed: 12/20/2022]
Abstract
In 1970, a Japanese group reported the first use of endoscopic retrograde cholangiopancreatography (ERCP), which is now carried out worldwide. Selective bile duct cannulation is a mandatory technique for diagnostic and therapeutic ERCP. Development of the endoscope and other devices has contributed to the extended use of ERCP, which has become a basic procedure to diagnose and treat pancreaticobiliary diseases. Various techniques related to selective bile duct cannulation have been widely applied. Although the classical contrast medium injection cannulation technique remains valuable, use of wire-guided cannulation has expanded since the early 2000s, and the technique is now widely carried out in the USA and Europe. Endoscopists must pay particular attention to a patient's condition and make an attendant choice about the most effective technique for selective bile duct cannulation. Some techniques have the potential to shorten procedure time and reduce the incidence of adverse events, particularly post-ERCP pancreatitis. However, a great deal of experience is required and endoscopists must be skilled in a variety of techniques. Although the development of the transpapillary biliary cannulation approach is remarkable, it is important to note that, to date, there have been no reports of transpapillary cannulation preventing post-ERCP pancreatitis. In the present article, selective bile duct cannulation techniques in the context of recent Japanese randomized controlled trials and cases of precut sphincterotomy are reviewed and discussed.
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Affiliation(s)
- Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Yoshimasa Kubota
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Shuhei Kawahata
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Kimitoshi Kubo
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masaki Kuwatani
- Division of Endoscopy, Hokkaido University Hospital, Sapporo, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan.,Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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24
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Lee YJ, Park YK, Lee MJ, Lee KT, Lee KH, Lee JK. Different Strategies for Transpancreatic Septotomy and Needle Knife Infundibulotomy Due to the Presence of Unintended Pancreatic Cannulation in Difficult Biliary Cannulation. Gut Liver 2016; 9:534-9. [PMID: 25963080 PMCID: PMC4477998 DOI: 10.5009/gnl14223] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background/Aims Several precut techniques have been used to gain biliary access for difficult cases. The aim of this study was to evaluate the success and complication rates of two precut techniques, transpancreatic septotomy (TPS) and needle knife infundibulotomy (NKI), in difficult biliary cannulation due to the presence of unintended pancreatic cannulation. Methods Eighty-six patients who failed standard biliary cannulation were included. TPS was performed when we failed to achieve biliary access despite 5 minutes of attempted cannulation or when more than three attempted unintended pancreatic cannulations occurred. If deep cannulation was not achieved within 5 minutes for any duct, NKI was performed. If this failed, we crossed over to the other technique in the second attempt. Results The initial total success rate of biliary cannulation was 88.4% (86.6% for the TPS group and 94.7% for the NKI group, p=0.447). After crossover of the techniques, the final success rate was 95.3%. The complication rate was 20.9% in patients with TPS and 15.8% in patients with NKI (p=0.753). Conclusions The use of different strategies based on the presence of unintended pancreatic cannulation may help increase the success rate for difficult biliary cannulation without increasing complication rates.
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Affiliation(s)
- Yoon Jung Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Kyung Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Ji Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Taek Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Hyuck Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Kyun Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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25
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Mammen A, Haber G. Difficult Biliary Access: Advanced Cannulation and Sphincterotomy Technique. Gastrointest Endosc Clin N Am 2015; 25:619-30. [PMID: 26431594 DOI: 10.1016/j.giec.2015.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Many devices and techniques have been developed to assist in cases of difficult biliary cannulation. Guidewire-assisted cannulation has become the first-line technique for biliary cannulation. Precut sphincterotomy can be safe and effective if used soon after encountering difficulty. Pancreatic duct stents are an important adjunct to reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis in difficult access. Ultimately, cannulation success of greater than 95% and complication rates of less than 5% is the standard that endoscopists doing ERCP should achieve.
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Affiliation(s)
- Anish Mammen
- Lenox Hill Hospital, 100 East 77th St., New York, NY 10075, USA
| | - Gregory Haber
- Division of Gastroenterology, The Center for Advanced Therapeutic Endoscopy, Lenox Hill Hospital, 100 East 77th St., New York, NY 10075, USA.
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26
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Han SJ, Lee TH. [Can Endoscopic Ultrasonography-guided Biliary Drainage Using Self-expandable Metal Stents in Malignant Distal Biliary Obstruction Be a Substitute When Endoscopic Retrograde Cholangiopancreatography Has Failed?]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 66:64-6. [PMID: 26410898 DOI: 10.4166/kjg.2015.66.1.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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27
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Park SH, Lee TH. Confrontational Strategy Is Essential for Being Effective Precut Papillotomy. Gut Liver 2015; 9:435-6. [PMID: 26087859 PMCID: PMC4477986 DOI: 10.5009/gnl15203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, Korea
| | - Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan, Korea
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