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Wang S, Bai B, Liu S, Fang Y, Zhang C, Chen X, Huang Q, Wang J, Hong J, Li Y, Xu Z, Liu X, Bao J, Mei Q, Hong R. Transpancreatic Sphincterotomy After Double Guidewire Technique Was Noninferior to Primary Transpancreatic Sphincterotomy in Difficult Biliary Cannulation. Dig Dis Sci 2024; 69:2215-2222. [PMID: 38594433 DOI: 10.1007/s10620-024-08319-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/25/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND When unintentional pancreatic duct access occurs during difficult biliary cannulation, the double guidewire (DGW) or transpancreatic sphincterotomy (TPS) may be utilized. DGW can be easily switched to TPS due to the existing guidewire in the pancreatic duct. However, the efficacy of TPS after DGW, named sequential DGW-TPS technique, versus primary TPS has not been assessed. AIMS Our aim was to compare the benefits and adverse events of sequential DGW-TPS technique and primary TPS. METHODS We performed a comparative retrospective cohort study that enrolled a total of 117 patients with native papillae. The patients were divided into one of 2 groups according to the primary bile duct access technique (sequential DGW-TPS or primary TPS), both with pancreatic stenting. RESULTS Between November 2017 and May 2023, a total of 84 patients were grouped into sequential DGW-TPS and 33 into primary TPS. The overall post-ERCP pancreatitis (PEP) rate was 4.3% in the entire cohort, with no statistical differences were observed between the groups in terms of PEP rates (P = 0.927), PEP severity (P = 1.000), first biliary cannulation success (P = 0.621), overall cannulation success (P = 1.000), hyperamylasemia incidence (P = 0.241), elevated amylase levels (P = 0.881), and postoperative hospital stay (P = 0.185). Furthermore, these results remained consistent in multivariable regression analysis. CONCLUSIONS The sequential DGW-TPS technique showed a comparable safety and biliary cannulation success rate to primary TPS in difficult biliary cannulation. Given the potential long-term complications associated with TPS, DGW should be first if inadvertent pancreatic access occurs, with TPS serving as second only if DGW fails.
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Affiliation(s)
- Shaofei Wang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
- Department of Gastroenterology, Suzhou First People's Hospital, Suzhou, 234000, Anhui Province, China
| | - Bingqing Bai
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Sisi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Yuanyuan Fang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Chenyu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Xinwen Chen
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Qiming Huang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Jiren Wang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Jianglong Hong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Yang Li
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Zhangwei Xu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Xiaochang Liu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Junjun Bao
- Department of Endoscopy, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Qiao Mei
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Rutao Hong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China.
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Ryu J, Paik KH, Kwon CI, Koh DH, Song TJ, Jeong S, Park WS. The Safety and Efficacy of an Unflanged 4F Pancreatic Stent in Transpancreatic Precut Sphincterotomy for Patients with Difficult Biliary Cannulation: A Prospective Cohort Study. J Clin Med 2022; 11:jcm11195692. [PMID: 36233560 PMCID: PMC9573508 DOI: 10.3390/jcm11195692] [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: 08/08/2022] [Revised: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
Prophylactic pancreatic stenting effectively reduces the rate and severity of post-ERCP pancreatitis (PEP) in the precut technique; however, studies on the optimal type and duration of the stent are still lacking. This prospective study evaluated the incidence and severity of PEP and the rate of spontaneous stent dislodgement in patients undergoing transpancreatic precut sphincterotomy (TPS) accompanied by prophylactic pancreatic stenting with an unflanged plastic stent (4F × 5 cm) for difficult biliary cannulation. A total of 247 patients with naïve papilla were enrolled in this study, and data were collected prospectively. In the final analysis, 170 and 61 patients were included in the standard cannulation technique and TPS groups, respectively. The incidence of PEP in the standard cannulation technique and TPS groups was 3.5% and 1.6% (p = 0.679), respectively. The technical success rate of selective biliary cannulation in the TPS group was 91.8%. The spontaneous dislodgement rate of the prophylactic plastic stent was 98.4%. In conclusion, an unflanged pancreatic stent (4F × 5 cm) placement in TPS for patients with failed standard cannulation technique is a safe and effective measure due to low adverse events and few additional endoscopic procedures for removing the pancreatic duct (PD) stent.
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Affiliation(s)
- Jieun Ryu
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon 34943, Korea
| | - Kyu-Hyun Paik
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon 34943, Korea
| | - Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam 13497, Korea
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
| | - Dong Hee Koh
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea
| | - Tae Jun Song
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Division of Gastroenterology, Department of Internal Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Seok Jeong
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon 22332, Korea
| | - Won Suk Park
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon 34943, Korea
- Research Group for Endoscopic Instruments and Stents, Korean Society of Gastrointestinal Endoscopy, Seoul 03741, Korea
- Correspondence: ; Tel.: +82-42-220-9339
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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.
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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
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Sakr C, Harb M, Makhoul E. The role of double-guidewire technique in preventing postendoscopic retrograde cholangiopancreatography pancreatitis. Arab J Gastroenterol 2021; 22:133-136. [PMID: 34120852 DOI: 10.1016/j.ajg.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND STUDY AIMS Postendoscopic retrograde cholangiopancreatography (ERCP) complications increase with repeated cannulation attempts. We evaluated several advanced biliary cannulation techniques, which have been used when the standard approach fails, to increase the success rate and decrease post-ERCP complications. We aimed to evaluate the use of double-wire technique in terms of success rates and effects on post-ERCP pancreatitis (PEP) and to assess the value of pancreatic duct stenting following needle-knife sphincterotomy in difficult biliary cannulation. PATIENTS AND METHODS A single-center, retrospective, randomized study was conducted on patients who underwent ERCP in Notre Dame De Secours University Hospital at Byblos, Lebanon, after obtaining the hospital's ethics committee approval. Patients were divided into three groups. The first group consisted of patients who had an ERCP and was divided into two subgroups, namely, one usingdouble-guidewire technique (DGT) only and another using an extra technique of precut with double-guidewire and pancreatic plastic stent placement. The second group of patients who had only ERCP was the control group. Finally, the third group endured the precut technique alone. RESULTS We could not prove any significant association between the intervention and the occurrence of pancreatitis when comparing double-wire technique plus ERCP to ERCP alone. When DGT with a pancreatic plastic stent was used, the incidence of PEP was significantly lower than that in other techniques. CONCLUSION DGT has a neutral effect on the reduction of PEP compared with the classic ERCP, but the technique can decrease the time of examination and increase success in difficult cases. ERCP using the double-guidewire with placement of a pancreatic plastic stent can contribute to decreasing PEP.
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Affiliation(s)
- Charlyne Sakr
- Hepato Biliary and Pancreas Division, Notre dame des secours University Hospital and the School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Byblos, Lebanon
| | - Marc Harb
- Hepato Biliary and Pancreas Division, Notre dame des secours University Hospital and the School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Byblos, Lebanon
| | - Elias Makhoul
- Hepato Biliary and Pancreas Division, Notre dame des secours University Hospital and the School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Byblos, Lebanon.
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Wang X, Ren G, Xi Y, Luo H, Liang S, Wang B, Tao Q, Luo B, Qin Q, Farrell JJ, Guo X, Wu K, Pan Y. Learning curve of double-guidewire technique by trainees during hands-on endoscopic retrograde cholangiopancreatography training. J Gastroenterol Hepatol 2020; 35:2176-2183. [PMID: 32473040 DOI: 10.1111/jgh.15120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/22/2020] [Accepted: 05/25/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Double-guidewire technique (DWT) has been successfully performed by experts in difficult biliary cannulation as an advanced technique. This study aimed to define the learning curve and safety of DWT by trainees during hands-on endoscopic retrograde cholangiopancreatography (ERCP) training. METHODS Patients were eligible for inclusion in the study if the biliary cannulation was difficult and the pancreatic duct was inadvertently cannulated. DWT was performed by two trainees randomly under trainers' guidance. The primary outcome was the success rate of DWT biliary cannulation of trainees. Cumulative sum analysis was used to generate visual learning curves. RESULTS A total of 60 patients with difficult cannulation were enrolled. The main indications for ERCP were common bile duct stones (65%) and biliary stricture (31.7%). The learning curve analysis showed that to achieve a 70% rate of successful DWT, 12 procedures were needed for trainee A and 15 for trainee B. Higher targeted success rate of DWT could be achieved if the number of DWT procedures increased. Compared with the early stage of learning DWT (case 1 to 15 for each trainee), trainees had significantly higher DWT success rate in the late stage (36.7% [11/30] vs 80% [24/30], P = 0.001). The final success rate of cannulation was 98.3% (59/60). The overall rate of post-ERCP pancreatitis and adverse events was 6.7% (4/60) and 8.3% (5/60), respectively. CONCLUSIONS Double-guidewire technique was safely performed by two novel trainees during hands-on ERCP training. Fifteen procedures may be enough for trainees to achieve the competency of performing DWT. (Clinicaltrials.gov number: NCT03707613).
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Affiliation(s)
- Xiangping Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Gui Ren
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yibin Xi
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Hui Luo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Shuhui Liang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Biaoluo Wang
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qin Tao
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bing Luo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qian Qin
- Department of General Surgery, First Affiliated Hospital of Xian Jiaotong University, Xi'an, China
| | - James J Farrell
- Department of Digestive Disease and Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Xuegang Guo
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kaichun Wu
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yanglin Pan
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Eminler AT, Parlak E, Koksal AS, Toka B, Uslan MI. Wire-guided cannulation over a pancreatic stent method increases the need for needle-knife precutting ın patients with difficult biliary cannulations. Gastrointest Endosc 2019; 89:301-308. [PMID: 30148994 DOI: 10.1016/j.gie.2018.08.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Cannulation of the major papilla can be problematic, and selective biliary cannulation may fail in up to 18% of cases. Various techniques, such as double-guidewire technique (DGWT), wire-guided cannulation over a pancreatic stent (WGC-PS), the precut endoscopic sphincterotomy (needle-knife precutting technique (NKP), and transpancreatic septostomy have been used to improve the success rate of biliary cannulation. We conducted a prospective, randomized study in order to compare the biliary cannulation success rates of DGWT and WGC-PS techniques in patients with inadvertent passage of guidewire to the pancreatic duct. METHODS A total of 100 patients were included in the study and randomized to DGWT (n = 50) or WGC-PS (n = 50) groups. The primary outcome was successful selective cannulation, defined as deep cannulation with selective injection of radiographic contrast material into the common bile duct within 5 minutes by DGW or WGC-PS techniques without performing precut sphincterotomy. RESULTS Successful selective cannulation was achieved in 45 patients in the DGWT group (90%) and in 27 patients in the WGC-PS group (54%) (P < .001). Five patients (10%) in the DGWT group and 23 (46%) in the WGC-PS group required NKP for biliary access (P < .001). The overall cannulation rate was 98% for DGWT and 98% for WGC-PS (P = 1.00). CONCLUSIONS In patients with unintentional passage of a guidewire into the pancreatic duct during biliary cannulation attempts, the WGC-PS technique significantly increased the need for NKP compared with DGWT.
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Affiliation(s)
- Ahmet Tarık Eminler
- Sakarya University Faculty of Medicine Department of Gastroenterology, Sakarya, Turkey
| | - Erkan Parlak
- Hacettepe University Faculty of Medicine Department of Gastroenterology, Ankara, Turkey
| | - Aydın Seref Koksal
- Sakarya University Faculty of Medicine Department of Gastroenterology, Sakarya, Turkey
| | - Bilal Toka
- Sakarya University Faculty of Medicine Department of Gastroenterology, Sakarya, Turkey
| | - Mustafa Ihsan Uslan
- Sakarya University Faculty of Medicine Department of Gastroenterology, Sakarya, Turkey
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Transpancreatic Sphincterotomy Is Effective and Safe in Expert Hands on the Short Term. Dig Dis Sci 2019; 64:2429-2444. [PMID: 31055720 PMCID: PMC6704096 DOI: 10.1007/s10620-019-05640-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 04/23/2019] [Indexed: 12/13/2022]
Abstract
In cases of difficult biliary cannulation, transpancreatic sphincterotomy (TPS) can be an alternative approach of biliary access. However, its success and safety profile have not been studied in detail. A systematic review and meta-analysis were performed to study the overall cannulation success and adverse events of TPS. These outcomes were also compared to other advanced cannulation methods. A systematic literature search was conducted to find all relevant articles containing data on TPS. Successful biliary cannulation and complications rates [post-ERCP pancreatitis (PEP), bleeding, and perforation rates] were compared in the pooled analyses of prospective comparative studies. The overall outcomes were calculated involving all studies on TPS. TPS was superior compared to needle-knife precut papillotomy (NKPP) and the double-guidewire method (DGW) regarding cannulation success (odds ratio [OR] 2.32; 95% confidence interval [CI] 1.37-3.93; and OR 2.72; 95% CI 1.30-5.69, respectively). The rate of PEP did not differ between TPS and NKPP or DGW; however, TPS (only retrospective studies were available for comparison) proved to be worse than needle-knife fistulotomy in this regard (OR 4.62; 95% CI 1.36-15.72). Bleeding and perforation rates were similar among these advanced techniques. There were no data about long-term consequences of TPS. The biliary cannulation rate of TPS is higher than that of the other advanced cannulation techniques, while the safety profile is similar to those. However, no long-term follow-up studies are available on the later consequences of TPS; therefore, such studies are strongly needed for its full evaluation.
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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.
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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
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Lee TH, Park SH. Optimal Use of Wire-Assisted Techniques and Precut Sphincterotomy. Clin Endosc 2016; 49:467-474. [PMID: 27642848 PMCID: PMC5066416 DOI: 10.5946/ce.2016.103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/19/2016] [Accepted: 08/19/2016] [Indexed: 12/12/2022] Open
Abstract
Various endoscopic techniques have been developed to overcome the difficulties in biliary or pancreatic access during endoscopic retrograde cholangiopancreatography, according to the preference of the endoscopist or the aim of the procedures. In terms of endoscopic methods, guidewire-assisted cannulation is a commonly used and well-known initial cannulation technique, or an alternative in cases of difficult cannulation. In addition, precut sphincterotomy encompasses a range of available rescue techniques, including conventional precut, precut fistulotomy, transpancreatic septotomy, and precut after insertion of pancreatic stent or pancreatic duct guidewire-guided septal precut. We present a literature review of guidewire-assisted cannulation as a primary endoscopic method and the precut technique for the facilitation of selective biliary access.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital, Soon Chun Hyang University College of Medicine, Cheonan, Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital, Soon Chun Hyang University College of Medicine, Cheonan, Korea
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Tse F, Yuan Y, Bukhari M, Leontiadis GI, Moayyedi P, Barkun A. Pancreatic duct guidewire placement for biliary cannulation for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Cochrane Database Syst Rev 2016; 2016:CD010571. [PMID: 27182692 PMCID: PMC10440590 DOI: 10.1002/14651858.cd010571.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Difficult cannulation is a risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). It has been postulated that the pancreatic duct guidewire (PGW) technique may improve biliary cannulation success and reduce the risk of PEP in people with difficult cannulation. OBJECTIVES To systematically review evidence from randomised controlled trials (RCTs) assessing the effectiveness and safety of the PGW technique compared to persistent conventional cannulation (CC) (contrast- or guidewire-assisted cannulation) or other advanced techniques in people with difficult biliary cannulation for the prevention of PEP. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL databases, major conference proceedings, and for ongoing trials on the ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) up to March 2016, using the Cochrane Upper Gastrointestinal and Pancreatic Diseases model with no language restrictions. SELECTION CRITERIA RCTs comparing the PGW technique versus persistent CC or other advanced techniques in people undergoing ERCP with difficult biliary cannulation. DATA COLLECTION AND ANALYSIS Two review authors independently conducted study selection, data extraction, and methodological quality assessment. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi(2) test (P < 0.15) and I(2) test (> 25%). To explore sources of heterogeneity, we conducted a priori subgroup analyses according to trial design, use of pancreatic duct (PD) stent, involvement of trainees in cannulation, publication type, and risk of bias. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed-effect versus random-effects). MAIN RESULTS We included seven RCTs comprising 577 participants. There was no significant heterogeneity among trials for the outcome of PEP (P = 0.32; I(2) = 15%). The PGW technique significantly increased PEP compared to other endoscopic techniques (RR 1.98, 95% CI 1.14 to 3.42; low-quality evidence). The number needed to treat for an additional harmful outcome was 13 (95% CI 5 to 89). Among the three studies that compared the PGW technique with persistent CC, the incidence of PEP was 13.5% for the PGW technique and 8.7% for persistent CC (RR 1.58, 95% CI 0.83 to 3.01; low-quality evidence). Among the two studies that compared the PGW technique with precut sphincterotomy, the incidence of PEP was 29.8% in the PGW group versus 10.3% in the precut group (RR 2.92, 95% CI 1.24 to 6.88; low-quality evidence). Among the two studies that compared the PGW technique with PD stent placement, the incidence of PEP was 11.7% for the PGW technique and 5.0% for PD stent placement (RR 1.75, 95% CI 0.08 to 37.50; very low-quality evidence). There was no significant difference in common bile duct (CBD) cannulation success with the randomised technique (RR 1.04, 95% CI 0.87 to 1.24; low-quality evidence) or overall CBD cannulation success (RR 1.04, 95% CI 0.91 to 1.18; low-quality evidence) between the PGW technique and other endoscopic techniques. There was also no statistically significant difference in the risk of other ERCP-related complications (bleeding, perforation, cholangitis, and mortality). The results were robust in sensitivity analyses. The overall quality of evidence for the outcome of PEP was low or very low because of study limitations and imprecision. AUTHORS' CONCLUSIONS In people with difficult CBD cannulation, sole use of the PGW technique appears to be associated with an increased risk of PEP. Prophylactic PD stenting after use of the PGW technique may reduce the risk of PEP. However, the PGW technique is not superior to persistent attempts with CC, precut sphincterotomy, or PD stent in achieving CBD cannulation. The influence of co-intervention in the form of rectal peri-procedural nonsteroidal anti-inflammatory drug administration is unclear.
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Affiliation(s)
- Frances Tse
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1200 Main Street West2F53HamiltonONCanadaL8N 3Z5
| | - Yuhong Yuan
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1200 Main Street West2F53HamiltonONCanadaL8N 3Z5
| | - Majidah Bukhari
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1200 Main Street West2F53HamiltonONCanadaL8N 3Z5
| | - Grigorios I Leontiadis
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1200 Main Street West2F53HamiltonONCanadaL8N 3Z5
| | - Paul Moayyedi
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1200 Main Street West2F53HamiltonONCanadaL8N 3Z5
| | - Alan Barkun
- The Montreal General HospitalClinical Epidemiology1650 Cedar Ave Rm D7‐148MontrealQCCanadaH3G 1A4
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Kawakami H, Kubota Y, Kawahata S, Kubo K, Kawakubo K, Kuwatani M, Sakamoto N. Transpapillary selective bile duct cannulation technique: Review of Japanese randomized controlled trials since 2010 and an overview of clinical results in precut sphincterotomy since 2004. Dig Endosc 2016; 28 Suppl 1:77-95. [PMID: 26825609 DOI: 10.1111/den.12621] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/21/2016] [Accepted: 01/24/2016] [Indexed: 12/20/2022]
Abstract
In 1970, a Japanese group reported the first use of endoscopic retrograde cholangiopancreatography (ERCP), which is now carried out worldwide. Selective bile duct cannulation is a mandatory technique for diagnostic and therapeutic ERCP. Development of the endoscope and other devices has contributed to the extended use of ERCP, which has become a basic procedure to diagnose and treat pancreaticobiliary diseases. Various techniques related to selective bile duct cannulation have been widely applied. Although the classical contrast medium injection cannulation technique remains valuable, use of wire-guided cannulation has expanded since the early 2000s, and the technique is now widely carried out in the USA and Europe. Endoscopists must pay particular attention to a patient's condition and make an attendant choice about the most effective technique for selective bile duct cannulation. Some techniques have the potential to shorten procedure time and reduce the incidence of adverse events, particularly post-ERCP pancreatitis. However, a great deal of experience is required and endoscopists must be skilled in a variety of techniques. Although the development of the transpapillary biliary cannulation approach is remarkable, it is important to note that, to date, there have been no reports of transpapillary cannulation preventing post-ERCP pancreatitis. In the present article, selective bile duct cannulation techniques in the context of recent Japanese randomized controlled trials and cases of precut sphincterotomy are reviewed and discussed.
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Affiliation(s)
- Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Yoshimasa Kubota
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Shuhei Kawahata
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Kimitoshi Kubo
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masaki Kuwatani
- Division of Endoscopy, Hokkaido University Hospital, Sapporo, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan.,Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Zou XP, Leung JW, Li YH, Yao YL, Pei QS, Wu YL, He QB, Cao J, Ding XW. Comparison of sequential pancreatic duct guidewire placement technique and needle knife precut sphincterotomy for difficult biliary cannulation. J Dig Dis 2015; 16:741-6. [PMID: 26562073 DOI: 10.1111/1751-2980.12300] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/28/2015] [Accepted: 11/08/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Pancreatic duct guidewire placement (PDGP) includes double guidewire technique (DGT) and transpancreatic sphincterotomy (TPS). DGT can be switched to TPS with ease due to the existing guidewire in the pancreatic duct. In this study, we aimed to combine DGT and TPS as a single technique, named sequential PDGP, and to compare its performance with needle knife precut sphincterotomy (NKPS) in treating difficult biliary cannulation (BC). METHODS A total of 83 patients with difficult BC were enrolled in this study. Of these, 63 underwent sequential PDGP and 20 underwent NKPS. Cannulation success rate, cannulation time and endoscopic retrograde cholangiopancreatography (ERCP)-related complications were prospectively recorded and compared between the two groups. RESULTS Successful BC was achieved in 88.9% (56/63) of the patients in the sequential PDGP group compared with 70.0% (14/20) in the NKPS group (P = 0.095). Cannulation time was 7.49 ± 5.03 min in the sequential PDGP group and 10.60 ± 7.24 min in the NKPS group (P = 0.086). Post-ERCP pancreatitis occurred in 12.7% of patients in the sequential PDGP group and 10.0% in the NKPS group (P = 1.000). There was no significant difference in the rates of other complications (bleeding, perforation and cholangitis) between the two groups. CONCLUSIONS Sequential PDGP is a safe and effective alternative method to NKPS in cases of difficult BC. In those with failed standard cannulation, sequential PDGP can be considered when the guidewire is inadvertently inserted into the pancreatic duct or can be placed in the pancreatic duct without difficulty.
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Affiliation(s)
- Xiao Ping Zou
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province
| | - Joseph W Leung
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province, China.,Division of Gastroenterology, Sacramento VA Medical Center, Mather, CA, USA
| | - Yun Hong Li
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province
| | - Yu Ling Yao
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province
| | - Qing Shan Pei
- Division of Gastroenterology, UC Davis Medical Center, Sacramento, CA, USA
| | - Yu Lin Wu
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province
| | - Qi Bin He
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province
| | - Jun Cao
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province
| | - Xi Wei Ding
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province
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Affiliation(s)
- Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan. E-mail:
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan. E-mail:
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan. E-mail:
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