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Alsakarneh S, Brotherton T, Jaber F, Madi MY, Numan L, Ahmed M, Sallam Y, Adam M, Dahiya DS, Aggarwal P, Dinary F. Needle-Knife Fistulotomy Versus Needle-Knife Papillotomy in Difficult Biliary Cannulation: A Systematic Review and Meta-Analysis. Gastroenterology Res 2024; 17:101-108. [PMID: 38993545 PMCID: PMC11236341 DOI: 10.14740/gr1726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/25/2024] [Indexed: 07/13/2024] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) is an essential endoscopic therapeutic modality for biliary and pancreatic diseases. Needle-knife fistulotomy (NKF) and papillotomy (NKP) are the two most commonly used rescue techniques for patients with difficult biliary cannulation. However, there remains a need for comparative studies on these approaches to inform clinical decision-making. This meta-analysis aimed to evaluate the efficacy and safety of NKF compared to NKP as a rescue technique in difficult biliary cannulation after failed conventional ERCP. Methods We searched PubMed, Scopus, Embase, and Web of Science databases through November 2023 to include all studies that directly compared the outcomes of NKF with NKP in difficult biliary cannulation. Single-arm studies were excluded. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data related to clinical events were calculated using the Mantel-Haenszel method within a random-effect model. The primary outcome was the biliary cannulation success rate. Results Four studies with 823 patients (n = 376 NKF vs. n = 447 NKP) were included in our analysis. There was no significant difference between the two groups in biliary cannulation success rate (91.7% vs. 86.9%, respectively; OR = 1.54, 95% CI: 0.21 - 2.49, P = 0.14; I2 = 0%). However, the overall rate of adverse events was significantly lower in the NKF group than in the NKP group (OR = 0.46, 95% CI: 0.25 - 0.84, P = 0.01). Pancreatitis (OR = 0.23, 95% CI: 0.05 - 1.11, P = 0.07) and bleeding (OR = 1.43, 95% CI: 0.59 - 3.46, P = 0.42) were similar between the two groups. No significant differences in cholangitis, cholecystitis, perforation, or mortality were observed. Conclusions Our meta-analysis indicates comparable success rates in comparing NKF and NKP techniques for difficult biliary cannulation after failed conventional ERCP cannulation. Notably, the NKF technique significantly reduces overall adverse events compared to NKP, suggesting that NKF may be preferable due to its favorable safety profile. Additional randomized controlled trials (RCTs) are warranted to evaluate the interval benefit of an NKF technique.
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Affiliation(s)
- Saqr Alsakarneh
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Tim Brotherton
- Department of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MO, USA
| | - Fouad Jaber
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Mahmoud Y. Madi
- Department of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MO, USA
| | - Laith Numan
- Department of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MO, USA
| | - Mohamed Ahmed
- Department of Gastroenterology and Hepatology, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Yazan Sallam
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Mohammad Adam
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology & Motility, The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Pearl Aggarwal
- Department of Medicine, University Hospitals, Cleveland, OH, USA
| | - Fazel Dinary
- Department of Gastroenterology and Hepatology, University Hospitals, Cleveland, OH, USA
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Tari E, Gagyi EB, Rancz A, Veres DS, Váncsa S, Hegyi PJ, Hagymási K, Hegyi P, Erőss B. Morphology of the papilla can predict procedural safety and efficacy of ERCP-a systematic review and meta-analysis. Sci Rep 2024; 14:7341. [PMID: 38538734 PMCID: PMC10973369 DOI: 10.1038/s41598-024-57758-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 03/21/2024] [Indexed: 05/25/2024] Open
Abstract
Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary therapeutic procedure for pancreaticobiliary disorders, and studies highlighted the impact of papilla anatomy on its efficacy and safety. Our objective was to quantify the influence of papilla morphology on ERCP outcomes. We systematically searched three medical databases in September 2022, focusing on studies detailing the cannulation process or the rate of adverse events in the context of papilla morphology. The Haraldsson classification served as the primary system for papilla morphology, and a pooled event rate with a 95% confidence interval was calculated as the effect size measure. Out of 17 eligible studies, 14 were included in the quantitative synthesis. In studies using the Haraldsson classification, the rate of difficult cannulation was the lowest in type I papilla (26%), while the highest one was observed in the case of type IV papilla (41%). For post-ERCP pancreatitis, the event rate was the highest in type II papilla (11%) and the lowest in type I and III papilla (6-6%). No significant difference was observed in the cannulation failure and post-ERCP bleeding event rates between the papilla types. In conclusion, certain papilla morphologies are associated with a higher rate of difficult cannulation and post-ERCP pancreatitis.
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Affiliation(s)
- Edina Tari
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Endre Botond Gagyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Selye János Doctoral College for Advanced Studies, Semmelweis University, Budapest, Hungary
| | - Anett Rancz
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Dániel Sándor Veres
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - Szilárd Váncsa
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
| | - Péter Jenő Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
| | - Krisztina Hagymási
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Surgery, Transplantation, and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
| | - Bálint Erőss
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary.
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary.
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary.
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Lyu Y, Ye S, Wang B. Impact of duodenal papilla anatomy on needle knife papillotomy safety and efficacy in patients with difficult biliary canulation. BMC Surg 2024; 24:61. [PMID: 38365675 PMCID: PMC10873970 DOI: 10.1186/s12893-024-02350-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/06/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND AND AIMS Needle-knife papillotomy (NKP) is widely performed when biliary cannulation is difficult during endoscopic retrograde cholangiopancreatography (ERCP). However, its safety and efficacy in different types of duodenal papilla are not clear. PATIENTS AND METHODS This retrospective study analyzed 217 patients with difficult biliary cannulation who underwent NKP during ERCP procedures from June 2013 to May 2022 in our institution. Patients were classified according to Haraldsson classification type of duodenal papilla: type 1, regular; type 2, small; type 3, protruding or pendulous; and type 4, creased or ridged. Outcome measures were successful biliary cannulation and incidence of adverse events. RESULTS Haraldsson classification was type 1 in 115 patients, type 2 in 29, type 3 in 52, and type 4 in 21. Biliary cannulation was successful in 166 patients (76.5%) Success rates according to Haraldsson type were as follows: type 1, 74.8%; type 2, 82.8%; type 3, 80.8%; and type 4, 66.7%. The rates did not significantly differ among the types (p = 0.48). Overall incidence of adverse events was 9.22%. Incidence of adverse events did not significantly differ among the types (p = 0.69). CONCLUSIONS NKP was useful to achieve successful cannulation in patients with difficult biliary cannulation. The rate of successful cannulation and incidence of adverse events were similar among the different types of duodenal papilla.
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Affiliation(s)
- Yunxiao Lyu
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Affiliated Dongyang Hospital of Wenzhou Medical University, 60 West Wuning Road, Dongyang, 322100, Zhejiang, P.R. China.
| | - Shenjian Ye
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Affiliated Dongyang Hospital of Wenzhou Medical University, 60 West Wuning Road, Dongyang, 322100, Zhejiang, P.R. China
| | - Bin Wang
- Department of Hepatobiliary Surgery, Dongyang People's Hospital, Affiliated Dongyang Hospital of Wenzhou Medical University, 60 West Wuning Road, Dongyang, 322100, Zhejiang, P.R. China
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Gomes A, Haidar ASR, Padilha GC, Bara J, Nonato MS, da Silva Rodrigues JM, Pinto PCC, de Oliveira Ayres R, Borghesi RA. Enlarged fistulotomy of the papilla as access to the biliary tract during ERCP. BMC Gastroenterol 2023; 23:419. [PMID: 38030984 PMCID: PMC10687980 DOI: 10.1186/s12876-023-03013-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
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.
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Affiliation(s)
- Alexandre Gomes
- Department of Surgery, Faculty of Medical Sciences and Health, Pontifical Catholic University of São Paulo (FCMB / PUC-SP), São Paulo, Brazil.
| | - Ana Sarah Rafka Haidar
- Department of Surgery, Faculty of Medical Sciences and Health, Pontifical Catholic University of São Paulo (FCMB / PUC-SP), São Paulo, Brazil
| | - Giovani Caetano Padilha
- Department of Surgery, Faculty of Medical Sciences and Health, Pontifical Catholic University of São Paulo (FCMB / PUC-SP), São Paulo, Brazil
| | - Juliana Bara
- Department of Surgery, Faculty of Medical Sciences and Health, Pontifical Catholic University of São Paulo (FCMB / PUC-SP), São Paulo, Brazil
| | - Mariana Sussai Nonato
- Department of Surgery, Faculty of Medical Sciences and Health, Pontifical Catholic University of São Paulo (FCMB / PUC-SP), São Paulo, Brazil
| | - José Mauro da Silva Rodrigues
- Department of Surgery, Faculty of Medical Sciences and Health, Pontifical Catholic University of São Paulo (FCMB / PUC-SP), São Paulo, Brazil
| | - Pérsio Campos Correia Pinto
- Department of Surgery, Faculty of Medical Sciences and Health, Pontifical Catholic University of São Paulo (FCMB / PUC-SP), São Paulo, Brazil
| | - Ricardo de Oliveira Ayres
- Department of Surgery, Faculty of Medical Sciences and Health, Pontifical Catholic University of São Paulo (FCMB / PUC-SP), São Paulo, Brazil
| | - Ronaldo Antonio Borghesi
- Department of Surgery, Faculty of Medical Sciences and Health, Pontifical Catholic University of São Paulo (FCMB / PUC-SP), São Paulo, Brazil
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Ban T, Kubota Y, Takahama T, Sasoh S, Tanida S, Ando T, Nakamura M, Joh T. A novel concept of passive loop-forming wire-guided biliary cannulation using an ultra-deep angled tip guidewire (with video). Endosc Int Open 2023; 11:E963-E969. [PMID: 37828976 PMCID: PMC10567138 DOI: 10.1055/a-2157-3941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/17/2023] [Indexed: 10/14/2023] Open
Abstract
Background and study aims Wire-guided biliary cannulation (WGBC) is a standard technique during endoscopic retrograde cholangiopancreatography-related interventions. However, no dedicated guidewire is available. We investigated a novel "passive loop-forming WGBC" concept using a 0.035-inch ultra-deep angled tip guidewire. Patients and methods This single-arm, single-center, retrospective study included consecutive 111 patients who underwent passive loop-forming WGBC as the first biliary intervention between October 2021 and December 2022. Results WGBCs were completed within 5 minutes and overall were performed at a median papillary negotiation time of 81 seconds (interquartile range [IQR], 39-170) and 114 seconds (IQR, 49-303) in 83 (74.8%) and 106 (95.5%) cases, respectively. Logistic regression analysis identified age ≥ 80 years (odds ratio [OR]: 3.56, 95% confidence interval [CI]: 1.12-11.31) and unintentional pancreatic guidewire insertion (OR: 17.67, 95% CI: 5.75-54.31) as significant risk factors for failed WGBC within 5 minutes. Among the 106 obtained cannulations, the guidewire leading part formed a small-looped tip and wide-looped body in 83 (78.3%) and 23 (21.7%) cases, respectively. Adverse events included post-procedure pancreatitis (2/111 [1.8%]) and guidewire penetration (3/111 [2.7%]). Conclusions Passive loop-forming WGBC using an ultra-deep angled tip guidewire is a feasible procedure.
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Affiliation(s)
- Tesshin Ban
- Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Japan
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Yoshimasa Kubota
- Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Japan
| | - Takuya Takahama
- Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Japan
| | - Shun Sasoh
- Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Japan
| | - Satoshi Tanida
- Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Japan
| | - Tomoaki Ando
- Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Japan
| | - Makoto Nakamura
- Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Japan
| | - Takashi Joh
- Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Japan
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Fernandes J, Canena J, Moreira M, Alexandrino G, Figueiredo L, Araújo T, Lourenço L, Horta D, Lopes L. Needle knife fistulotomy in flat and diverticular papillae: Is it time for redemption? Hepatobiliary Pancreat Dis Int 2022; 21:175-181. [PMID: 34799254 DOI: 10.1016/j.hbpd.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 10/20/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND European Society of Gastrointestinal Endoscopy (ESGE) recommends needle-knife fistulotomy (NKF) as the preferred precut technique in cases when standard cannulation techniques fail. Despite scarce scientific evidence, flat and diverticular papillae are thought not to be ideal for NKF, as they are associated with poor outcomes. The present study aimed to determine the outcomes of the use of NKF in relation to flat and intradiverticular papillae. METHODS This prospective multicenter study enrolled consecutive patients, evidencing naïve flat (group A, n = 49) or diverticular papilla (group B, n = 28), who underwent NKF after failure of standard cannulation techniques. Diverticular morphology was subdivided into intradiverticular (group B1, n = 14) and diverticular border papillae (group B2, n = 14), using a previously validated endoscopic classification of the major papilla. The success of biliary cannulation at initial endoscopic retrograde cholangiopancreatography (ERCP), overall biliary cannulation, overall cannulation time, and the rate of adverse events were assessed in the study. RESULTS The initial cannulation rates were 93.9%, 64.3% and 71.4% for group A, B1, and B2, respectively (P = 0.005); overall cannulation rates after a second ERCP were 98.0%, 92.9% and 85.7%, respectively (P = 0.134). Adverse events occurred in 11.7% of patients, with post-ERCP pancreatitis (PEP) being the most common adverse event (10.4%). Although there was a trend towards a higher incidence of PEP in flat papillae, univariate and multivariate analyses did not show any significant relationship between pancreatitis and trainee involvement, papillary morphology, nor overall cannulation time. CONCLUSIONS Although flat papillae are associated with high success rates of biliary cannulation using NKF, the rate of PEP is not negligible. NKF is feasible in diverticular papillae, but it is associated with a modest success rate in the initial ERCP.
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Affiliation(s)
- João Fernandes
- Department of Gastroenterology, Santa Luzia Hospital - Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal.
| | - Jorge Canena
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal; Department of Gastroenterology, Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal; University Center of Gastrenterology - Hospital Cuf Tejo, Lisbon, Portugal
| | - Marta Moreira
- Department of Gastroenterology, Santa Luzia Hospital - Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal
| | - Gonçalo Alexandrino
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - Luísa Figueiredo
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - Tarcísio Araújo
- Department of Gastroenterology, Santa Luzia Hospital - Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal
| | - Luís Lourenço
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - David Horta
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal; Department of Gastroenterology, Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal
| | - Luís Lopes
- Department of Gastroenterology, Santa Luzia Hospital - Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal; Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
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