1
|
Kuraishi Y, Hara K, Haba S, Kuwahara T, Okuno N, Yanaidani T, Ishikawa S, Yasuda T, Yamada M, Mizuno N. Safety and feasibility of opening window fistulotomy as a new precutting technique for primary biliary access in endoscopic retrograde cholangiopancreatography. Clin Endosc 2023; 56:490-498. [PMID: 37157966 PMCID: PMC10393574 DOI: 10.5946/ce.2022.130] [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: 04/15/2022] [Revised: 05/26/2022] [Accepted: 06/30/2022] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND/AIMS Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common and serious complication of endoscopic retrograde cholangiopancreatography. To prevent this event, a unique precutting method, termed opening window fistulotomy, was performed in patients with a large infundibulum as the primary procedure for biliary cannulation, whereby a suprapapillary laid-down H-shaped incision was made without touching the orifice. This study aimed to assess the safety and feasibility of this novel technique. METHODS One hundred and ten patients were prospectively enrolled in this study. Patients with a papillary roof size ≥10 mm underwent opening window fistulotomy for primary biliary access. In addition, the incidence of complications and success rate of biliary cannulation were evaluated. RESULTS The median size of the papillary roof was 6 mm (range, 3-20 mm). Opening window fistulotomy was performed in 30 patients (27.3%), none of whom displayed PEP. Duodenal perforation was recorded in one patient (3.3%), which was resolved by conservative treatment. The cannulation rate was high (96.7%, 29/30 patients). The median duration of biliary access was 8 minutes (range, 3-15 minutes). CONCLUSION Opening window fistulotomy demonstrated its feasibility for primary biliary access by achieving great safety with no PEP complications and a high success rate for biliary cannulation.
Collapse
Affiliation(s)
- Yasuhiro Kuraishi
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shin Haba
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takamichi Kuwahara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takafumi Yanaidani
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Sho Ishikawa
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tsukasa Yasuda
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masanori Yamada
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| |
Collapse
|
2
|
Tokmak S, Cetin MF, Torun S. Feasibility and safety of partial ampullary endoscopic mucosal resection: a novel technique for difficult biliary cannulation (with video). Surg Endosc 2023; 37:471-478. [PMID: 35999314 DOI: 10.1007/s00464-022-09539-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Biliary cannulation can be challenging even for expert endoscopists, and rescue techniques are limited. Our objective was to determine the feasibility and safety of partial ampullary endoscopic mucosal resection (PA-EMR), a novel technique for biliary cannulation. METHODS Monocentric, retrospective analysis of a prospectively maintained database in a tertiary referral university hospital. Fourteen patients who required endoscopic retrograde cholangiopancreatography (ERCP) and underwent PA-EMR between January 1, 2020 and January 31, 2021 were included. For biliary cannulation of prominent papillae, PA-EMR was performed using a standard polypectomy snare, alone or in combination with needle-knife sphincterotomy. In patients with non-prominent papilla, the papillary mucosa was elevated with the aid of methylene blue injection before resection and combined with needle-knife fistulotomy when needed. The rate of technical success and adverse events was assessed. RESULTS The bile duct cannulation success was 99% in the first attempt and 100% overall with the PA-EMR technique. Only one patient experienced mild bleeding, which spontaneously stopped. CONCLUSION PA-EMR is an effective technique that may be considered as a rescue technique for difficult biliary cannulation in expert hands. Future studies including larger cohorts and comparisons with other techniques are warranted to further confirm the feasibility and safety of this novel technique.
Collapse
Affiliation(s)
- Salih Tokmak
- Department of Gastroenterology, Internal Medicine, Duzce University, Konuralp, 81000, Duzce, Turkey.
| | - Mehmet F Cetin
- General Surgery, Duzce University, Konuralp, 81000, Duzce, Turkey
| | - Serkan Torun
- Department of Gastroenterology, Internal Medicine, Duzce University, Konuralp, 81000, Duzce, Turkey
| |
Collapse
|
3
|
Ikeda Y, Ono M, Ohmori G, Ameda S, Arihara Y, Yamada M, Abe T, Maeda M. Clinical benefit of early precut sphincintroterotomy for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography. Surg Endosc 2023; 37:120-126. [PMID: 35851815 DOI: 10.1007/s00464-022-09426-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 06/29/2022] [Indexed: 01/18/2023]
Abstract
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.
Collapse
Affiliation(s)
- Yuki Ikeda
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan.
| | - Michihiro Ono
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Ginji Ohmori
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Saki Ameda
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Yohei Arihara
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Michiko Yamada
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Tomoyuki Abe
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| | - Masahiro Maeda
- Department of Gastroenterology, Steel Memorial Muroran Hospital, Muroran, 050-0076, Japan
| |
Collapse
|
4
|
An Insight on Pharmacological and Mechanical Preventive Measures of Post-ERCP PANCREATITIS (PEP)—A Review. GASTROENTEROLOGY INSIGHTS 2022. [DOI: 10.3390/gastroent13040038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
Collapse
|
5
|
Fugazza A, Troncone E, Amato A, Tarantino I, Iannone A, Donato G, D'Amico F, Mogavero G, Amata M, Fabbri C, Radaelli F, Occhipinti P, Repici A, Anderloni A. Difficult biliary cannulation in patients with distal malignant biliary obstruction: An underestimated problem? Dig Liver Dis 2022; 54:529-536. [PMID: 34362708 DOI: 10.1016/j.dld.2021.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Failed biliary cannulation still poses a major challenge in patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP). To date, there is a lack of data on rates of Difficult Biliary Cannulation (DBC) in patients with distal malignant biliary obstruction (DMBO). MATERIALS This was a retrospective study (09/2015 to 02/2019) of consecutive patients with DMBO that underwent ERCP in four Italian centers. The primary outcome was to evaluate the rate of DBC. Secondary outcomes were: cannulation failure, rate of adverse events (AEs), the predictive factors for DBC as well as for AEs. RESULTS A total of 622 patients with DMBO, were included in the study, with 351(56,4%) matching the definition of DBC. One-hundred and two ERCP-related AEs occurred in 97 of 622 patients (15,6%). Subjects with DBC showed a higher risk for AEs (p = 0.02). The lack of pancreatitis prophylaxis (p = 0.03), diagnosis of cholangiocarcinoma (p = 0.02), the use of papillotomy (OR=1.98; 95%CI = 1.14-3.45) and the combination of two or more techniques for cannulation (OR = 2.88; 95%CI = 1.04-7.97) were associated with the occurrence of AEs. CONCLUSIONS According to the results of this study, patients with DMBO carries a higher rate of DBC thus requiring alternative techniques for biliary drainage. Furthermore, DBC carries a high risk for AEs. Further prospective multicentric studies are needed to confirm these data in this specific subgroup of patients.
Collapse
Affiliation(s)
- Alessandro Fugazza
- Digestive Endoscopy Unit, Departement of Gastroenterology, Humanitas Research Hospital-IRCCS, Rozzano, Italy.
| | - Edoardo Troncone
- Department of Systems Medicine, University of Rome ``Tor Vergata'', Rome 00133, Italy
| | - Arnaldo Amato
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Ilaria Tarantino
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Andrea Iannone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Giulio Donato
- Azienda Ospedaliero Universitaria "Maggiore della Carità", Novara, Italy
| | - Ferdinando D'Amico
- Digestive Endoscopy Unit, Departement of Gastroenterology, Humanitas Research Hospital-IRCCS, Rozzano, Italy
| | - Giuseppe Mogavero
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Michele Amata
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Medical Department, Forlì-Cesena Hospitals, AUSL Romagna
| | - Franco Radaelli
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Pietro Occhipinti
- Azienda Ospedaliero Universitaria "Maggiore della Carità", Novara, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Departement of Gastroenterology, Humanitas Research Hospital-IRCCS, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Departement of Gastroenterology, Humanitas Research Hospital-IRCCS, Rozzano, Italy
| |
Collapse
|
6
|
Dalal A, Gandhi C, Patil G, Kamat N, Vora S, Maydeo A. Safety and efficacy of different techniques in difficult biliary cannulation at endoscopic retrograde cholangiopancreatography. Hosp Pract (1995) 2022; 50:61-67. [PMID: 35025705 DOI: 10.1080/21548331.2022.2029451] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Adverse events (AEs) are commonly seen at endoscopic retrograde cholangiopancreatography (ERCP) during difficult biliary cannulation (DBC). Therefore, attaining the right technique is essential to have improved outcomes. METHODS Patients who had DBC over a 3-year period were assessed for outcomes. The protocol included double guidewire (DGW) technique, wire-guided cannulation (WGC) after pancreatic stent, precut sphincterotomy/fistulotomy, and EUS-guided rendezvous (RV). The success of various techniques and AE was studied. RESULTS As per available case analysis, a total of 3680 patient details were assessed out of which DBC was noted in 471 (12.8%) patients with a mean (SD) age of 51.5 (17.4) years; majority being 330 (70.1%) males. Most patients underwent precut sphincterotomy 230 (48.8%); however, it was not successful in the first attempt in 10 (2.1%) patients with the success rate of 220 (95.6%). The success rate of DGW cannulation was 120 (95.2%), WGC after pancreatic stent was 64 (94.1%), EUS-RV was 34 (97.1%), and wire-guided repeat ERCP after 48 h was 10 (98.3%). AEs were noted in 52 (11.1%) patients. After precut, 32 (13.9%) patients developed AE out of which post-ERCP pancreatitis was noted in 20 (8.7%). Twenty-three patients had failed biliary access after all methods and 20 (86.9%) of those received successful percutaneous transhepatic biliary drainage. CONCLUSION Repeat ERCP after 48 h and EUS-RV appear prudent for DBC. Precut remains one of the preferred choices for most endoscopists when there is no entrance to PD. Further utilizing an algorithmic approach can contribute to higher success rates without compromising safety.
Collapse
Affiliation(s)
- Ankit Dalal
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, India
| | - Chaiti Gandhi
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, India
| | - Gaurav Patil
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, India
| | - Nagesh Kamat
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, India
| | - Sehajad Vora
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, India
| | - Amit Maydeo
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, India
| |
Collapse
|
7
|
De la Morena Madrigal EJ, Rodríguez García I, Galera Ródenas AB, Pérez Arellano E. Initial experience with a homemade "hybrid-tome" for needle-knife precut in patients with difficult biliary cannulation. Endosc Int Open 2021; 9:E1611-E1616. [PMID: 34790522 PMCID: PMC8589536 DOI: 10.1055/a-1552-3202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 06/23/2021] [Indexed: 11/01/2022] Open
Abstract
Background and study aims Current clinical guidelines recommend needle-knife precut (NKP) as the primary and best method for performing a biliary cannulation (BC) when simple techniques fail and the criteria are met for difficult BC (DBC). However, many endoscopists avoid or defer early NKP in favor of alternative, simpler techniques that have not been shown to be either safer or more effective. Our goal is to test a device that provides the needle-knife papillotome (NKPT) with traction capability and which can facilitate the learning and execution of NKP. Patients and methods This was a descriptive bicentric observational study of a personal cohort of patients undergoing early NKP to analyse the efficacy and safety of the technique with a "hybrid-tome" (HT) built using the isolated core of a NKPT and a conventional canulotome. Results Over a 4-year period, we performed 43 NKPs with the HT, achieving BC in one or two steps in all cases. The 100 % technical success was matched by a 95 % clinical success rate. We recorded 11 adverse events (23 %): five hemorrhages, four pancreatitis, and two cholangitis. In addition to the objective data, we confirmed that HT facilitates alignment with the duodenal papilla and the execution of pre-cutting, especially if the papilla is intradiverticular or hidden by folds. Conclusions The HT tested seems to help trained endoscopists to perform NKP, especially in some anatomic situations, which can improve compliance with the guidelines recommended for early NKP in patients with DBC.
Collapse
Affiliation(s)
- Emilio J. De la Morena Madrigal
- Digestive Medicine and Endoscopy Division, Academical Hospital “la Zarzuela,” Francisco de Vitoria University, Madrid, Spain,Digestive Endoscopy Unit, Academical Hospital “la Moncloa,” Madrid, Spain
| | - Isabel Rodríguez García
- Digestive Medicine and Endoscopy Division, Academical Hospital “la Zarzuela,” Francisco de Vitoria University, Madrid, Spain
| | - Ana Belén Galera Ródenas
- Digestive Medicine and Endoscopy Division, Academical Hospital “la Zarzuela,” Francisco de Vitoria University, Madrid, Spain
| | - Elena Pérez Arellano
- Digestive Medicine and Endoscopy Division, Academical Hospital “la Zarzuela,” Francisco de Vitoria University, Madrid, Spain
| |
Collapse
|
8
|
Fernandes J, Canena J, Alexandrino G, Figueiredo L, Rafael M, Moreira M, Araújo T, Lourenço L, Horta D, Familiari P, Dinis-Ribeiro M, Lopes L. Outcomes of single-endoscopist-performed needle-knife fistulotomy for selective biliary access in 842 consecutive patients: learning curve and changes over a 14-year period in a retrospective study. Scand J Gastroenterol 2021; 56:1363-1370. [PMID: 34355615 DOI: 10.1080/00365521.2021.1958369] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Needle-knife fistulotomy (NKF) has emerged as the preferred precut technique. From a late strategy, NKF has shifted to an early rescue technique and has been used recently as a primary method for biliary access. It is unknown how these changes have affected NKF outcomes. We analyzed the outcomes of NKF over time in a large cohort of patients. METHODS Multicenter retrospective cohort study of 842 patients who underwent NKF for biliary access between 2006 and 2019. Patients were divided into four study periods according to a late or early cannulation strategy and to the use of post-ERCP pancreatitis prophylaxis (Period 1-Period 4). We assessed outcomes of NKF, learning curves and shifts over time. RESULTS Bile duct access was obtained in 88.0% of the patients. The initial cannulation rate increased significantly from 77.5% in P1 to 92.0% in P4 (p < .001). An endoscopist can obtain 80% success rate after performing 100 NKF procedures (95% CI: 0.79-0.86) and a 95% success rate after 830 procedures (95% CI: 0.92-0.98). Adverse events and pancreatitis were observed in 6.5% and 4.9% of patients respectively. The rate of pancreatitis was not significantly different during the 4 periods (p = .190). A decline in the pancreatitis rate was observed from 2006 until 2016 (no trainees) and then an increase until 2019 (trainees involved). The presence of trainees increased the rate of pancreatitis in the last period by 9.9%. CONCLUSIONS The success of NKF has increased significantly over the years, initially in a rapid manner and then more slowly. It is associated with a low rate of complications, which tend to decrease with experience. The involvement of trainees is associated with an increased rate of pancreatitis.
Collapse
Affiliation(s)
- João Fernandes
- 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
| | - Jorge Canena
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal.,Department of Gastroenterology, Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal.,Cintesis, Center for Health Technology and Services Research, Porto, 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
| | - Maria Rafael
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - Marta Moreira
- Department of Gastroenterology, Santa Luzia Hospital, Unidade Local de Saúde Alto Minho, Viana do Castelo, 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
| | - Pietro Familiari
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy
| | - Mário Dinis-Ribeiro
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy.,Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, 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
| |
Collapse
|
9
|
Troubleshooting Difficult Bile Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or EUS-Guided Rendezvous Technique? GASTROENTEROLOGY INSIGHTS 2021. [DOI: 10.3390/gastroent12040039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Despite experienced hands and availability of various well-designed catheters and wires, selective bile duct cannulation may still fail in 10–20% of cases during endoscopic retrograde cholangiopancreatography (ERCP). In case standard ERCP cannulation technique fails, salvage options include advanced ERCP cannulation techniques such as double-guidewire technique (DGW) with or without pancreatic stenting and precut papillotomy, percutaneous biliary drainage (PBD), and endoscopic ultrasound-guided Rendezvous (EUS-RV) ERCP. If the pancreatic duct is inadvertently entered during cannulation attempts, DGW technique is a reasonable next step, which can be followed by pancreatic stenting to reduce risks of post-ERCP pancreatitis (PEP). Studies suggest that early precut papillotomy is not associated with a higher risk of PEP, while needle-knife fistulotomy is the preferred method. For patients with critical clinical condition who may not be fit for endoscopy, surgically altered anatomy in which endoscopic biliary drainage is not feasible, and non-communicating multisegmental biliary obstruction, PBD has a unique role to provide successful biliary drainage efficiently in this particular population. As endoscopic ultrasound (EUS)-guided biliary drainage techniques advance, EUS-RV ERCP has been increasingly employed to guide bile duct access and cannulation with satisfactory clinical outcomes and is especially valuable for benign pathology at centres where expertise is available. Endoscopists should become familiar with each technique’s advantages and limitations before deciding the most appropriate treatment that is tailored to patient’s anatomy and clinical needs.
Collapse
|
10
|
Efficacy and safety of primary, early and late needle-knife fistulotomy for biliary access. Sci Rep 2021; 11:16658. [PMID: 34404873 PMCID: PMC8371017 DOI: 10.1038/s41598-021-96142-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/02/2021] [Indexed: 11/08/2022] Open
Abstract
European Society of Gastrointestinal Endoscopy recommends needle-knife fistulotomy (NKF) as the preferred precut technique. However, there is little information on whether NKF performed at different times is associated with different success and adverse event rates. We compared the outcomes of 3 different timings of NKF. This was an observational study conducted at 4 institutions and this was a retrospective analysis of prospectively collected data. We included 330 consecutive patients submitted to NKF attempt for biliary access. Patients were divided into three groups: NKF as an initial procedure for biliary access (group A, n = 121); early NKF defined as after 5 min, 5 attempts, or 2 pancreatic passages (group B, n = 99); and late NKF: after at least 10 min of unsuccessful standard biliary cannulation (group C, n = 110). We assessed the success rate of biliary cannulation at initial ERCP, time to perform NKF until biliary cannulation, overall biliary cannulation rate (second ERCP when initial failure), adverse event rate, and predictors of post-ERCP pancreatitis (PEP). The initial cannulation rate was 98%, 91% and 94% for groups A, B and C respectively, p = 0.08, whereas overall biliary cannulation rate was 100%, 95% and 98%, p = 0.115. The adverse event rate/PEP was 4.1%/2.5%, 7.1%/4% and 10.9%/8.2%, for groups A, B and C respectively, (p = 0.197 and p = 0.190). Median time for creating the fistula was A = 4.0 min, B = 3.2 min, and C = 5.6 min, p < 000.1. Each additional minute spent attempting cannulation increased the odds ratio (OR) for PEP by 1.072, and patients with 3 or more risk factors for pancreatitis had a higher chance of PEP. In conclusion, the timing of NFK does not appear to influence success rates but late NFK is associated with a higher time to create a fistula and an increased risk of pancreatitis. Primary NFK is associated with a high rate of success and a low rate of PEP and deserves additional investigation.
Collapse
|
11
|
Fung BM, Pitea TC, Tabibian JH. Difficult Biliary Cannulation in Endoscopic Retrograde Cholangiopancreatography: An Overview of Advanced Techniques. EUROPEAN MEDICAL JOURNAL. HEPATOLOGY 2021; 9:73-82. [PMID: 34621528 PMCID: PMC8494186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) plays a significant role in the treatment of a vast array of pancreatobiliary diseases. However, despite significant progress in the optimisation of ERCP methods and accessories, the technical and clinical success of ERCP can vary significantly due to a variety of patient and operator factors. Over the past several decades, a number of advanced techniques have been developed to improve cannulation success rates, including the use of double-guidewire, pancreatic duct accessory-assisted, precut, and rendezvous techniques. Here, the authors provide an update and overview of the existing advanced techniques used in cases of difficult biliary cannulation, as well as the approach to their selection.
Collapse
Affiliation(s)
- Brian M. Fung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arizona College of Medicine – Phoenix, Arizona, USA,Banner – University Medical Center Phoenix, Arizona, USA
| | | | - James H. Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA,David Geffen School of Medicine at UCLA, Los Angeles, California, USA,Correspondence to
| |
Collapse
|
12
|
Bhandari P, Longcroft-Wheaton G, Libanio D, Pimentel-Nunes P, Albeniz E, Pioche M, Sidhu R, Spada C, Anderloni A, Repici A, Haidry R, Barthet M, Neumann H, Antonelli G, Testoni A, Ponchon T, Siersema PD, Fuccio L, Hassan C, Dinis-Ribeiro M. Revising the European Society of Gastrointestinal Endoscopy (ESGE) research priorities: a research progress update. Endoscopy 2021; 53:535-554. [PMID: 33822332 DOI: 10.1055/a-1397-3005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND One of the aims of the European Society of Gastrointestinal Endoscopy (ESGE) is to encourage high quality endoscopic research at a European level. In 2016, the ESGE research committee published a set of research priorities. As endoscopic research is flourishing, we aimed to review the literature and determine whether endoscopic research over the last 4 years had managed to address any of our previously published priorities. METHODS As the previously published priorities were grouped under seven different domains, a working party with at least two European experts was created for each domain to review all the priorities under that domain. A structured review form was developed to standardize the review process. The group conducted an extensive literature search relevant to each of the priorities and then graded the priorities into three categories: (1) no longer a priority (well-designed trial, incorporated in national/international guidelines or adopted in routine clinical practice); (2) remains a priority (i. e. the above criterion was not met); (3) redefine the existing priority (i. e. the priority was too vague with the research question not clearly defined). RESULTS The previous ESGE research priorities document published in 2016 had 26 research priorities under seven domains. Our review of these priorities has resulted in seven priorities being removed from the list, one priority being partially removed, another seven being redefined to make them more precise, with eleven priorities remaining unchanged. This is a reflection of a rapid surge in endoscopic research, resulting in 27 % of research questions having already been answered and another 27 % requiring redefinition. CONCLUSIONS Our extensive review process has led to the removal of seven research priorities from the previous (2016) list, leaving 19 research priorities that have been redefined to make them more precise and relevant for researchers and funding bodies to target.
Collapse
Affiliation(s)
- Pradeep Bhandari
- Department of Gastroenterology, Portsmouth University Hospital NHS Trust, Portsmouth, UK
| | | | - Diogo Libanio
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.,Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.,Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
| | - Eduardo Albeniz
- Gastroenterology Department, Endoscopy Unit, Complejo Hospitalario de Navarra, Navarrabiomed-UPNA-IdiSNA, Pamplona, Spain
| | - Mathieu Pioche
- Gastroenterology Division, Edouard Herriot Hospital, Lyon, France
| | - Reena Sidhu
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Cristiano Spada
- Digestive Endoscopy and Gastroenterology, Fondazione Poliambulanza, Brescia, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Ospedale dei Castelli, Ariccia, Rome, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Digestive Endoscopy Unit, IRCSS Humanitas Research Hospital, Milan, Italy
| | - Rehan Haidry
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - Marc Barthet
- Department of Gastroenterology, Hôpital Nord, Assistance publique des hôpitaux de Marseille, Marseille, France
| | - Helmut Neumann
- Department of Medicine I, University Medical Center Mainz, Mainz, Germany.,GastroZentrum Lippe, Bad Salzuflen, Germany
| | - Giulio Antonelli
- Gastroenterology and Digestive Endoscopy Unit, Ospedale dei Castelli, Ariccia, Rome, Italy.,Nuovo Regina Margherita Hospital, Rome, Italy.,Department of Translational and Precision Medicine, "Sapienza" University of Rome, Rome, Italy
| | | | - Thierry Ponchon
- Gastroenterology Division, Edouard Herriot Hospital, Lyon, France
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Mario Dinis-Ribeiro
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.,Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
| |
Collapse
|
13
|
Canena J, Lopes L, Fernandes J, Costa P, Arvanitakis M, Koch AD, Poley JW, Jimenez J, Dominguez-Munõz E, Familiari P, Bruno MJ, Dinis-Ribeiro M. Influence of a novel classification of the papilla of Vater on the outcome of needle-knife fistulotomy for biliary cannulation. BMC Gastroenterol 2021; 21:147. [PMID: 33794778 PMCID: PMC8017832 DOI: 10.1186/s12876-021-01735-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/23/2021] [Indexed: 02/03/2023] Open
Abstract
Background Existing proposed classification systems for the Papilla of Vater (PV) suboptimally account for all relevant, encountered PV appearances, are too complex or have not been assessed for intra- or interobserver variability. We proposed a novel endoscopic classification system for PV, determined its inter- and intraobserver rates and used the classification system to assess whether the success and complications of needle-knife fistulotomy (NKF) are influenced by the morphology of the PV. Methods The classification system was developed by expert endoscopists. To evaluate the inter- and intraobserver agreement, an online questionnaire was sent to 20 endoscopists from several countries (10 experts and 10 nonexperts) that included 50 images of papillae of Vater divided among various categories. Four weeks later, a second survey, with the images from the first questionnaire randomly reordered, was sent to the same endoscopists. The inter- and intraobserver agreements among the experts and nonexperts was calculated. Using the proposed classification system, all 361 consecutive patients who underwent NKF for biliary access to a naïve papilla were prospectively enrolled in the study. Results The novel classification system comprises 7 categories: type I, flat type, lacking an oral protrusion; type IIA, prominent tubular nonpleated type, with an oral protrusion and < 1 transverse fold over the oral protrusion; type IIB, prominent tubular pleated type, with an oral protrusion and > 2 transverse folds over the oral protrusion; type IIC: prominent bulging type, with an enlarged and bulging oral protrusion; type IIIA, diverticular-intradiverticular type, with a papillary orifice inside the diverticulum; type IIIB: diverticular-diverticular border type, with a papillary orifice less than 2 cm from the diverticular border; type IV: unclassified papilla, with no morphology classified in the other categories. The interobserver agreement between experts was substantial (K = 0.611, 95% CI 0.498–0.709) and was higher than that between nonexperts (K = 0.516; 95% CI 0.410–0.636). The intraobserver agreement was substantial among both experts (K = 0,651; 95% CI 0.586–0.715) and nonexperts (K = 0.646, 95% CI 0.615–0.677). In a multivariate model, type IIIA and IIIB were the only independent risk factors for difficult rescue NKF biliary cannulation (P = 0.003 and P = 0.019, respectively), and type I and type IIB were the only independent risk factors for a prolonged cannulation time using NKF (P < 0.001 and P = 0.005, respectively). Conclusions The novel endoscopic classification system for PV is highly reproducible among experienced ERCPists according to the substantial level of agreement between experts. However, nonexperts require further training in its use. Using the novel classification system, we identified different types of papillae significantly associated with a lower efficacy of NKF and a prolonged time to obtain successful biliary cannulation using NKF.
Collapse
Affiliation(s)
- Jorge Canena
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, IC 19, 2720276, Amadora, Portugal. .,Department of Gastroenterology, Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal. .,University Center of Gastroenterology, Hospital Cuf Tejo, Lisbon, Portugal. .,Cintesis - Center for Health Technology and Services Research, Porto, 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
| | - João Fernandes
- Department of Gastroenterology, Santa Luzia Hospital - Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal
| | - Patrício Costa
- 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
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatology and Digestive Oncology, Erasme University Hospital Université Libre de Bruxelles, Brussels, Belgium
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Javier Jimenez
- Endoscopy Unit. Hospital Marques de Valdecilla, Santander, Spain
| | - Enrique Dominguez-Munõz
- Gastroenterology Department, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Pietro Familiari
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Mário Dinis-Ribeiro
- Cintesis - Center for Health Technology and Services Research, Porto, Portugal.,Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
| |
Collapse
|
14
|
Op den Winkel M, Schirra J, Schulz C, De Toni EN, Steib CJ, Anz D, Mayerle J. Biliary Cannulation in Endoscopic Retrograde Cholangiography: How to Tackle the Difficult Papilla. Dig Dis 2021; 40:85-96. [PMID: 33684915 DOI: 10.1159/000515692] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/04/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND In the setting of a naïve papilla, biliary cannulation is a key step in successfully performing endoscopic retrograde cholangiography. Difficult biliary cannulation (DBC) is associated with an increased risk of post-ERCP pancreatitis and failure of the whole procedure. SUMMARY Recommendations for biliary cannulation can be divided into (a) measures to reduce the likelihood of a difficult papilla situation a priori and (b) rescue techniques in case the endoscopist is actually facing DBC. (a) Careful inspection of the papillary anatomy and optimizing its accessibility by scope positioning is fundamental. A sphincterotome in combination with a soft-tip hydrophilic guidewire rather than a standard catheter with a standard guidewire should be used in most situations. (b) The most important rescue techniques are needle-knife precut, double-guidewire technique, and transpancreatic sphincterotomy. In few cases, anterograde cannulation techniques are needed. To this regard, the EUS-guided biliary drainage followed by rendezvous is increasingly used as an alternative to percutaneous transhepatic biliary drainage. Key Messages: Biliary cannulation can be accomplished with alternative retrograde or less frequently by salvage anterograde techniques, once conventional direct cannulation attempts have failed. Considering recent favorable data for the early use of transpancreatic sphincterotomy, an adopted version of the 2016 European Society for Gastrointestinal Endoscopy (ESGE) algorithm on biliary cannulation is proposed.
Collapse
Affiliation(s)
- Mark Op den Winkel
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Jörg Schirra
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Christian Schulz
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Enrico N De Toni
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Christian J Steib
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - David Anz
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Julia Mayerle
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
15
|
Liu Y, Liu W, Hong J, Li G, Chen Y, Xie Y, Zhou X. Causes and Countermeasures of Difficult Selective Biliary Cannulation: A Large Sample Size Retrospective Study. Surg Laparosc Endosc Percutan Tech 2021; 31:533-538. [PMID: 33605680 DOI: 10.1097/sle.0000000000000924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/15/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Selective biliary cannulation is a difficult part of endoscopic retrograde cholangiopancreatography (ERCP). Therefore, endoscopists have focused on how to improve the cannulation success rate and reduce the postoperative complication rate. This study aims to provide practical advice on safe operation for endoscopists. MATERIALS AND METHODS Data from the ERCP database of our medical center from January 2008 to December 2017 were retrospectively reviewed. All patients underwent ERCP for the first time. Data pertaining to diseases, anatomic factors, difficult cannulation rates, cannulation success rates, and postoperative complication rates for various assistive cannulation techniques were analyzed by using the Pearson χ2 tests and Fisher exact tests. RESULTS The difficult cannulation rate was 8.1%. The main influencing factors were benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy. The postoperative complication rates and overall cannulation success rates of 7 assistive techniques were not statistically different (P>0.05), but the overall complication rates were statistically different (P<0.05). Needle-knife precut sphincterotomy had the highest rate of complications. CONCLUSIONS Benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy were the main factors of difficult selective biliary cannulation. The overall incidence of needle-knife precut sphincterotomy complications was higher than that of other techniques, but various assistive techniques were safe and effective in our single center.
Collapse
Affiliation(s)
- Yang Liu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province
| | - Wei Liu
- Department of Gastroenterology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong Province, China
| | - Junbo Hong
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province
| | - Guohua Li
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province
| | - Youxiang Chen
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province
| | - Yong Xie
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province
| | - Xiaojiang Zhou
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province
| |
Collapse
|
16
|
Pereira Lima JC, Arciniegas Sanmartin ID, Latrônico Palma B, Oliveira Dos Santos CE. Risk Factors for Success, Complications, and Death after Endoscopic Sphincterotomy for Bile Duct Stones: A 17-Year Experience with 2,137 Cases. Dig Dis 2020; 38:534-541. [PMID: 32187605 DOI: 10.1159/000507321] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/17/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) complications are well-studied. However, risk factors for complications and success after endoscopic sphincterotomy (EST) for duct stones are poorly determined. This study aimed to verify risk factors for mortality, complications, and success after EST. METHODS A multivariate analysis was carried out in a dataset of ERCPs performed during 17 years. RESULTS A total of5,226 ERCPs were performed, of which 2,137 were in patients with bile duct stones (1,458 women and 679 men; mean age = 57 years) who underwent EST with attempted stone removal. There were 171 (8%) complications, with pancreatitis in 87 (4.1%), bleeding in 48 (2.2%), other complications in 36 (1.8%), and mortality of 0.6%. Successful stone(s) removal was obtained in 2,028 cases (94.9%). On multivariate analysis, mortality was associated with age >60 years (1 vs. 0.2%), cholangitis (4.3 vs. 0.3%), and EST-related complications (5.8 vs. 0.2%). Complications were associated with unsuccessful stone removal (13.4 vs. 7.5%) and difficult cannulation (13.9 vs. 5.4%). An unsuccessful EST was independently related to difficult cannulation (86.2 vs. 98.7%), precutting (79.4 vs. 96.4%), and complications (86.5 vs. 95.6%). CONCLUSIONS Risk factors for complications after EST for stones are delayed bile duct cannulation and failed stone retrieval. Mortality is higher in older patients, those who presented with an EST-related complication, or those who presented initially with cholangitis. Difficult cannulation, EST-related complications, and precutting were associated with an unsuccessful procedure. In this series, outpatient EST with attempted stone retrieval was found to be as safe as performing the procedure in hospitalized patients.
Collapse
Affiliation(s)
- Júlio Carlos Pereira Lima
- Department of Gastroenterology, Hepatology and Endoscopy, Santa Casa Hospital, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Ivan David Arciniegas Sanmartin
- Department of Gastroenterology, Hepatology and Endoscopy, Santa Casa Hospital, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil,
| | - Bruna Latrônico Palma
- Department of Gastroenterology, Hepatology and Endoscopy, Santa Casa Hospital, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | | |
Collapse
|
17
|
Gkolfakis P, Arvanitakis M. Precut fistulotomy for choledocholithiasis: what about long-term efficacy? Endosc Int Open 2020; 8:E231-E233. [PMID: 32016158 PMCID: PMC6994268 DOI: 10.1055/a-0959-6105] [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] [Received: 06/01/2019] [Accepted: 06/05/2019] [Indexed: 10/25/2022] Open
Affiliation(s)
- Paraskevas Gkolfakis
- Department of Gastroenterology Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Marianna Arvanitakis
- Department of Gastroenterology Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium,Corresponding author Marianna Arvanitakis, MD PhD Department of Gastroenterology, Hepatopancreatology and Digestive OncologyErasme University HospitalUniversité Libre de BruxellesRoute de Lennik 8081070 BrusselsBelgium+3225554697
| |
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
Wen J, Li T, Lu Y, Bie LK, Gong B. Comparison of efficacy and safety of transpancreatic septotomy, needle-knife fistulotomy or both based on biliary cannulation unintentional pancreatic access and papillary morphology. Hepatobiliary Pancreat Dis Int 2019; 18:73-78. [PMID: 30518483 DOI: 10.1016/j.hbpd.2018.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 11/21/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Precut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography (ERCP). However, scarce data are available on different precut techniques for difficult biliary cannulation. This study aimed to evaluate the efficacy and safety of transpancreatic septotomy (TPS), needle-knife fistulotomy (NKF) or both based on the presence of unintentional pancreatic access and papillary morphology. METHODS Between March 2008 and December 2016, 157 consecutive patients undergoing precutting for an inaccessible bile duct during ERCP were identified. Precut techniques were chosen depending on repetitive inadvertent pancreatic cannulation and the papillary morphology. We retrospectively assessed the rates of cannulation success and procedure-related complications among three groups, namely TPS, NKF, and TPS followed by NKF. RESULTS The baseline characteristics of the three groups were comparable. The overall success rate of biliary cannulation reached 98.1%, including 111 of 113 (98.2%) with TPS, 35 of 36 (97.2%) with NKF and 8 of 8 (100%) with NKF following TPS, without significant difference among groups. The incidences of total complications and post-ERCP pancreatitis were 9.6% and 7.6%, respectively. There was a trend towards less frequent post-ERCP pancreatitis after NKF (0%) compared with 11 cases (9.7%) after TPS and one case (12.5%) after NKF following TPS, but not significantly different (P = 0.07). No severe adverse event occurred during this study period. CONCLUSIONS The choice of precut techniques by the presence of unintended pancreatic access and the papillary morphology brought about a high success rate without increasing risk in difficult biliary cannulation.
Collapse
Affiliation(s)
- Jun Wen
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Tao Li
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Yi Lu
- Digestive Endoscopy Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Li-Ke Bie
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Biao Gong
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China.
| |
Collapse
|
21
|
Berry R, Han JY, Tabibian JH. Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist. World J Gastrointest Endosc 2019; 11:5-21. [PMID: 30705728 PMCID: PMC6354112 DOI: 10.4253/wjge.v11.i1.5] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 12/18/2018] [Accepted: 01/03/2019] [Indexed: 02/06/2023] Open
Abstract
Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.
Collapse
Affiliation(s)
- Rani Berry
- Department of Internal Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA 90095, United States
| | - James Y Han
- Department of Internal Medicine, University of California, Irvine, CA 92868, United States
| | - James H Tabibian
- Geffen School of Medicine at UCLA, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
| |
Collapse
|
22
|
Köksal AŞ, Eminler AT, Parlak E. Biliary endoscopic sphincterotomy: Techniques and complications. World J Clin Cases 2018; 6:1073-1086. [PMID: 30613665 PMCID: PMC6306628 DOI: 10.12998/wjcc.v6.i16.1073] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 10/20/2018] [Accepted: 11/26/2018] [Indexed: 02/05/2023] Open
Abstract
Biliary endoscopic sphincterotomy (EST) refers to the cutting of the biliary sphincter and intraduodenal segment of the common bile duct following selective cannulation, using a high frequency current applied with a special knife, sphincterotome, inserted into the papilla. EST is either used solely for the treatment of diseases of the papilla of Vater, such as sphincter of Oddi dysfunction or to facilitate subsequent therapeutic biliary interventions, such as stone extraction, stenting, etc. It is a prerequisite for biliary interventions, thus every practitioner who performs endoscopic retrograde cholangiopancreatography needs to know different techniques and the clinical and anatomic parameters related to the efficacy and safety of the procedure. In this manuscript, we will review the indications, contraindications and techniques of biliary EST and the management of its complications.
Collapse
Affiliation(s)
- Aydın Şeref Köksal
- Department of Gastroenterology, Sakarya University, School of Medicine, Sakarya 54290, Turkey
| | - Ahmet Tarik Eminler
- Department of Gastroenterology, Sakarya University, School of Medicine, Sakarya 54290, Turkey
| | - Erkan Parlak
- Department of Gastroenterology, Hacettepe University, School of Medicine, Ankara 41000, Turkey
| |
Collapse
|
23
|
Tang Z, Yang Y, Yang Z, Meng W, Li X. Early precut sphincterotomy does not increase the risk of adverse events for patients with difficult biliary access: A systematic review of randomized clinical trials with meta-analysis and trial sequential analysis. Medicine (Baltimore) 2018; 97:e12213. [PMID: 30200135 PMCID: PMC6133433 DOI: 10.1097/md.0000000000012213] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The present study was conducted to investigate whether early precut sphincterotomy (EPS) itself increases the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), bleeding, and perforation, or improves the overall success rates of biliary cannulation. METHODS Four electronical databases were searched systematically for randomized controlled trials (RCTs) reporting the incidence of adverse events for difficult biliary access (DBA) between EPS groups and persistent cannulation attempts (PCA). The primary endpoint was the incidence of PEP. Secondary outcomes were the incidence of bleeding and perforation, and the overall success rates of biliary cannulation. The Mantel-Haenszel method was used to pool data on the outcomes into random-effect models. Heterogeneity, sensitivity, and stratified analyses were performed with Review Manager 5.3. Furthermore, we performed trial sequential analysis (TSA) to evaluate the reliability of the primary endpoint and secondary outcomes. RESULTS Seven RCTs (999 patients with DBA of 10450, 9.5%) were included. The incidence of PEP was significantly lower in EPS groups than PCA (risk ratio [RR] = 0.57, 95% confidence interval [CI] 0.36, 0.92, P = .02). Furthermore, TSA (TSA-adjusted 95% CI 0.30-0.82, P = .0061) and subgroup analysis stratified by the fellow involvement in initial cannulation before randomization, technique of precut, and the definition of DBA confirmed this finding. Success rates of overall cannulation (RR = 1.00, P = .94), bleeding (RR = 1.22, P = .58), and perforation (RR = 1.59, P = .32) were similar in both groups; however, the results of TSA could not confirm these findings. CONCLUSION Both the quality and the quantity of evidence supporting, compared with PCA, EPS itself do not increase the risk of PEP for DBA patients. Moreover, subgroup analysis demonstrated that EPS can significantly decrease the risk of PEP when it is performed by qualified staff endoscopists with using needle-knife fistulutomy earlier for patients with DBA.
Collapse
Affiliation(s)
- Zengwei Tang
- The First Clinical Medical School of Lanzhou University
| | - Yuan Yang
- The First Clinical Medical School of Lanzhou University
| | - Zhangfu Yang
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital,Fudan University, and Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Shanghai
| | - Wenbo Meng
- The First Clinical Medical School of Lanzhou University
- Department of Special Minimally Invasive Surgery, The first Hospital of Lanzhou University, Lanzhou
| | - Xun Li
- The First Clinical Medical School of Lanzhou University
- The second department of General Surgery, The first Hospital of Lanzhou University, Lanzhou, China
| |
Collapse
|
24
|
Takano Y, Nagahama M, Niiya F, Kobayashi T, Yamamura E, Maruoka N. Optimal timing for precutting in cases with difficult biliary cannulation. Endosc Int Open 2018; 6:E1015-E1019. [PMID: 30105288 PMCID: PMC6086685 DOI: 10.1055/a-0599-6260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 02/20/2018] [Indexed: 12/20/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Yuichi Takano
- Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan,Corresponding author Yuichi Takano 1-30 Fujigaoka, Aoba-kuYokohama-shiKanagawa 227-8501Japan+81-45-9731019
| | - Masatsugu Nagahama
- Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Fumitaka Niiya
- Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Takahiro Kobayashi
- Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Eiichi Yamamura
- Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Naotaka Maruoka
- Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| |
Collapse
|
25
|
de la Morena Madrigal EJ, Rodríguez García MªI, Galera Ródenas AB, Pérez Arellano E. Biliary cannulation effectiveness and pancreatitis risk using two early precut techniques. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 110:74-81. [PMID: 29271219 DOI: 10.17235/reed.2017.5175/2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Precut techniques allow for successful biliary cannulation rates approaching 100% but there may be an associated increase in the risk of complications. Recently, early needle-knife precut has been shown to be a safe procedure and is now used as a pancreatitis prevention resource for difficult cannulation cases. The goal of the present study was to assess cannulation and pancreatitis rates using two early precut techniques. PATIENTS AND METHODS This was a retrospective study of endoscopic retrograde cholangio-pancreatography (ERCP) procedures performed from 2013 to 2016. The efficacy and safety of simple cannulation, needle-knife precut and transpancreatic precut were assessed. RESULTS Simple cannulation was achieved in 369 (73.4%) of 503 evaluable ERCP procedures. Needle-knife precut was successful in 51 (96.2%) of 53 attempts and transpancreatic precut was successful in 75 (96.2%) of 78 attempts. The overall cannulation rate was 98.4%. There were eleven (2.4%) pancreatitis events, six (1.8%) with simple cannulation (two severe, one fatal), five (6.3%) with transpancreatic precut (two severe) and zero events with the needle-knife precut procedure. Among the patients undergoing the precut procedure, seven experienced perforations (two severe) and there were seven bleeding events. The overall complication rate was 14.4%. CONCLUSIONS The complementary use of either precut technique provides a satisfactory biliary cannulation rate. However, the rates of pancreatitis and other severe complications are higher for transpancreatic versus needle-knife precut, therefore the indications for both techniques should be modified.
Collapse
|
26
|
Wu DX, Chen YD, Liu P. Advances in management of difficult biliary access. Shijie Huaren Xiaohua Zazhi 2017; 25:3149-3154. [DOI: 10.11569/wcjd.v25.i35.3149] [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] [Indexed: 02/06/2023] Open
Abstract
Since the first report of endoscopic retrograde cholangio-pancreatography (ERCP) in 1986 for the diagnosis of biliary-pancreatic disease, ERCP has become an important means for the diagnosis and treatment of biliary-pancreatic disease. At present, although the success rate of endoscopic selective biliary cannulation is more than 90%, there are still 5%-10% of cases with failed cannulation, for which assistive technology is needed as a supplementary to achieve successful cannulation. Repeated attempts correlate with a higher success rate of cannulation, but also extend the operating time and increase the incidence of complications. In recent years, the concept of difficult biliary cannulation has been put forward and gradually accepted by endoscopic physicians. In the cases of difficult biliary cannulation, endoscopic physicians can adjust the cannulation strategy in time to improve the success rate and reduce the complication rate. This paper summarizes the literature published recently to make a systematic review of the advances in the management of difficult biliary cannulation.
Collapse
Affiliation(s)
- Dong-Xia Wu
- Department of Gastroenterology, the First Affiliated Hospital of Hunan Normal University, Changsha 410000, Hunan Province, China
| | - Ya-Dong Chen
- Department of Gastroenterology, the First Affiliated Hospital of Hunan Normal University, Changsha 410000, Hunan Province, China
| | - Peng Liu
- Department of Gastroenterology, the First Affiliated Hospital of Hunan Normal University, Changsha 410000, Hunan Province, China
| |
Collapse
|
27
|
Li JW, Ang TL, Kam JW, Kwek ABE, Teo EK. The learning curve for needle knife precut sphincterotomy revisited. United European Gastroenterol J 2017; 5:1116-1122. [PMID: 29238590 DOI: 10.1177/2050640617701808] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/26/2017] [Indexed: 12/22/2022] Open
Abstract
Background There is no consensus on what constitutes adequate training for needle knife precut sphincterotomy. Objective The purpose of this study was to determine the number of procedures required before effective and safe precut sphincterotomy can be achieved. Methods This retrospective study examined the cumulative experience of a single endoscopist from January 2006-December 2015. Precut sphincterotomy success and complication rates were analyzed as a function of number of procedures performed. Acceptable success and complication rates were defined as 85% and 10% respectively. A one-sided binomial test was used to test success and complication rates of every 25 precut sphincterotomies performed. Results The index endoscopic retrograde cholangiopancreatography was successful in 141/158 (89.2%) patients who underwent precut sphincterotomy. This increased to 148/158 (93.7%) when endoscopic retrograde cholangiopancreatography was repeated on another day. Six precut sphincterotomies were required to achieve an 85% success probability. This was maintained consistently above 85% after 13 precuts, and was significantly higher (91.2%; p = 0.029) than 85% at the 125th precut. Bleeding and pancreatitis developed in 2/158 (1.3%) and 5/158 (3.2%). Probability of either complications remained below 5% after 50 precuts. No perforation occurred. Conclusion At least 13 precut sphincterotomies were required to achieve a sustained success rate greater than 85%. The probability of bleeding or pancreatitis was less than 5% after 50 precut sphincterotomies.
Collapse
Affiliation(s)
- James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jia Wen Kam
- Clinical Trials and Research Unit, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| |
Collapse
|
28
|
Liao WC, Angsuwatcharakon P, Isayama H, Dhir V, Devereaux B, Khor CJL, Ponnudurai R, Lakhtakia S, Lee DK, Ratanachu-Ek T, Yasuda I, Dy FT, Ho SH, Makmun D, Liang HL, Draganov PV, Rerknimitr R, Wang HP. International consensus recommendations for difficult biliary access. Gastrointest Endosc 2017; 85:295-304. [PMID: 27720741 DOI: 10.1016/j.gie.2016.09.037] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/28/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Wei-Chih Liao
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Phonthep Angsuwatcharakon
- Department of Anatomy and Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Vinay Dhir
- Baldota Institute of Digestive Sciences, Global Hopsitals, Parel, Mumbai, India
| | - Benedict Devereaux
- University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Christopher J L Khor
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Ryan Ponnudurai
- Division of Gastroenterology, Prince Court Medical Centre, Kuala Lumpur, Malaysia
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Dong-Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Thawee Ratanachu-Ek
- Department of Surgery, Rajavithi Hospital, Rangsit Medical College, Bangkok, Thailand
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | | | - Shiaw-Hooi Ho
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Dadang Makmun
- Department of Internal Medicine, Faculty of Medicine Universitas Indonesia/Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Huei-Lung Liang
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Peter V Draganov
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|
29
|
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.
Collapse
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
| |
Collapse
|
30
|
Prachayakul V, Aswakul P. Endoscopic ultrasound-guided interventions in special situations. World J Gastrointest Endosc 2016; 8:104-112. [PMID: 26839650 PMCID: PMC4724027 DOI: 10.4253/wjge.v8.i2.104] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 09/07/2015] [Accepted: 12/02/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic ultrasound (EUS) was introduced in 1982 and has since become a popular advanced procedure for diagnosis and therapeutic intervention. Initially, EUS was most commonly used for the diagnosis of pancreatobiliary diseases and tissue acquisition. EUS was first used for guided cholangiography in 1996, followed by EUS-guided biliary drainage in 2001. Advancements in equipment and endoscopic accessories have led to an expansion of EUS-guided procedures, which now include EUS-guided drainage of intra-abdominal abscesses or collections, intra-vascular treatment of refractory variceal and nonvariceal bleeding, transmural pancreatic drainage, common bile duct stone clearance, enteral feeding tube placement and entero-enteric anastomosis. Patients with surgically altered upper gastrointestinal anatomies have greatly benefited from EUS also. This systematic review describes and discusses EUS procedures performed in uncommon diseases and conditions, as well as applications on more vulnerable patients such as young children and pregnant women. In these cases, routine approaches do not always apply, and thus may require the use of innovative and unconventional techniques. Increased knowledge of such special applications will help increase the success rates of these procedures and provide a foundation for additional advances and utilizations of the technique.
Collapse
|
31
|
A Novel Round Insulated Tip Papillotome as an Alternative to the Classic Needle-Knife for Precut Sphincterotomy in Endoscopic Retrograde Cholangiopancreatography. Gastroenterol Res Pract 2015; 2015:972041. [PMID: 26347424 PMCID: PMC4546750 DOI: 10.1155/2015/972041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 06/28/2015] [Indexed: 01/17/2023] Open
Abstract
Objective. The purpose of this study was to investigate the efficacy and safety of a new round insulated tip papillotome (r-ITP) as compared to that of the classic needle-knife sphincterotome (NKS) in difficult-to-cannulate endoscopic retrograde cholangiopancreatography (ERCP) patients. Materials and Methods. Patients with no exclusion criteria and an intact papilla referred for ERCP were invited to participate in the study. “Difficult-to-cannulate” patients, defined as failure to achieve deep biliary cannulation within five minutes from the first touch of papilla, with no more than ten attempts permitted, were randomly assigned for precut sphincterotomy using either the classic NKS or r-ITP. Results. Seventy and 69 patients were randomly assigned to the NKS and r-ITP groups, respectively. The groups were comparable regarding age, sex, indications, and associated conditions. There was no statistically significant difference in terms of successful cannulation or post-ERCP complications between the two groups. Only five patients (3.6%) developed mild to moderate post-ERCP pancreatitis and two had mild bleeding. No perforations or deaths were encountered. Conclusions. Although the round insulated tip papillotome was not shown to be superior to the classic NKS concerning efficacy and safety when used by an experienced endoscopist, it remains a simple, safe, and efficacious alternative.
Collapse
|
32
|
Kim SJ, Kang DH, Kim HW, Choi CW, Park SB, Song BJ, Hong YM. Needle-knife fistulotomy vs double-guidewire technique in patients with repetitive unintentional pancreatic cannulations. World J Gastroenterol 2015; 21:5918-5925. [PMID: 26019456 PMCID: PMC4438026 DOI: 10.3748/wjg.v21.i19.5918] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 01/30/2015] [Accepted: 03/19/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the success rates and adverse events of early needle-knife fistulotomy (NKF) and double-guidewire technique (DGT) in patients with repetitive unintentional pancreatic cannulations.
METHODS: From a total of 1650 patients admitted for diagnostic or therapeutic endoscopic retrograde cholangiopancreatography (ERCP) at a single tertiary care hospital (Pusan National University Yangsan Hospital, Yangsan, South Korea) between January 2009 and December 2012, 134 (8.1%) patients with unsuccessful biliary cannulation after 5 min trial of conventional methods, together with 5 or more repetitive unintentional pancreatic cannulations, were enrolled in the study. Early NKF and DGT groups were assigned 67 patients each. In the DGT group, NKF was performed for an additional 7 min if successful cannulation was not achieved.
RESULTS: The success rates with early NKF and the DGT were 79.1% (53/67) and 44.8% (30/67) (P < 0.001), respectively. The incidence of post-ERCP pancreatitis (PEP) was lower in the early NKF group than in the DGT group [4.5% (3/67) vs 14.9% (10/67), P = 0.041]. The mean cannulation times in the early NKF and DGT groups after assignment were 257 s and 312 s (P = 0.013), respectively.
CONCLUSION: Our data suggest that early NKF should be considered as the first approach to selective biliary cannulation in patients with repetitive unintentional pancreatic cannulations.
Collapse
|
33
|
Huang L, Yu QS, Zhang Q, Liu JD, Wang Z. Comparison between double-guidewire technique and transpancreatic sphincterotomy technique for difficult biliary cannulation. Dig Endosc 2015; 27:381-7. [PMID: 25284147 DOI: 10.1111/den.12387] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 09/22/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM The aim of the present study was to compare the effectiveness and complications of the double-guidewire technique (DWT) with the transpancreatic sphincterotomy (TPS) technique. METHODS From January 2013 to December 2014, 366 consecutive endoscopic retrograde cholangiopancreatography (ERCP) procedures were carried out. Of 366 procedures, 354 procedures were carried out in patients with native major papilla biliary cannulation. A total of 279 consecutive therapeutic ERCP were included in the study and data of included patients were collected retrospectively. One hundred and thirty-seven procedures (49.1%) were done with DWT and 142 procedures (50.9%) were done with TPS for patients with difficult cannulation. The results and complications of ERCP were compared. RESULTS Success rate of first-attempt cannulation was 62.0% in the DWT group and 81.0% in the TPS group (P = 0.00). Final rate of successful cannulation of the two biliary cannulation techniques was 86.9% and 90.8%, respectively (P = 0.09). Cannulation time in the DWT group was 7.8 ± 1.7 min compared with 3.7 ± 2.3 min in the TPS group (P = 0.00). Overall incidence of post-ERCP pancreatitis (PEP), hemorrhage, perforation and cholangitis was 1.8%, 1.1%, 0.4% and 1.1%, respectively. Adverse event rate was 2.19% in the DWT group and 7.04% in the TPS group (P = 0.04). CONCLUSIONS DWT and TPS procedures were safe and effective. Overall cannulation rate was similar between the groups. Although DWT had a longer cannulation time, it could be considered the preferred technique in patients with failed standard cannulation for lower adverse event rate.
Collapse
Affiliation(s)
- Long Huang
- Department of No. 1 Surgery, The First Hospital Affiliated to Anhui Chinese Medical University, Hefei, China
| | | | | | | | | |
Collapse
|
34
|
Hauser G, Milosevic M, Stimac D, Zerem E, Jovanović P, Blazevic I. Preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: What can be done? World J Gastroenterol 2015; 21:1069-1080. [PMID: 25632179 PMCID: PMC4306150 DOI: 10.3748/wjg.v21.i4.1069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 09/05/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
|
35
|
Rustagi T, Jamidar PA. Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events: post-ERCP pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:107-21. [PMID: 25442962 DOI: 10.1016/j.giec.2014.09.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), and not uncommonly is the reason behind ERCP-related lawsuits. Patients at high risk for PEP include young women with abdominal pain, normal liver tests, and unremarkable imaging. Procedure-related factors include traumatic and persistent cannulation attempts, multiple injections of the pancreatic duct, pancreatic sphincterotomy, and, possibly, use of precut sphincterotomy. Aggressive hydration, use of rectal indomethacin, and prophylactic pancreatic stenting can diminish the risk (and likely severity) of PEP. Though hugely beneficial, these measures do not supersede careful patient selection and technique.
Collapse
Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA.
| |
Collapse
|