The success rate of cannulation of needle-knife precut is superior to continuing wire-guided after difficult biliary cannulation with pancreatic stent placement

BACKGROUND

Difficult biliary cannulation and unintended pancreatic cannulation exist in biliary interventions during endoscopic retrograde cholangiopancreatography. Wire-guided cannulation over a pancreatic stent (PS-WGC) and needle-knife precut over a pancreatic stent (PS-NKP) may facilitate biliary cannulation. This study aimed to compare the outcomes of PS-NKP and PS-WGC following guidewire passage into the pancreatic duct.

METHODS

A total of 304 patients who inserted a pancreatic stent and continued cannulation using wire-guided (PS-WGC) or needle-knife precut (PS-NKP) from October 2018 to November 2021 in three centers were ultimately enrolled in this study. The success rate of cannulation and incidence of complications were compared between the two groups.

RESULTS

Results of the success rate of cannulation in the PS-NKP (n = 98) group were significantly higher compared with the PS-WGC (n = 206) group (96.9% vs. 89.8%; P < 0.05). The overall adverse events were 10.2% (31/304), and PS-NKP had lower (PEP) rates compared with the PS-WGC (3.1% vs. 10.7%, P < 0.05).

CONCLUSION

The PS-NKP group is superior to the PS-WGC group in terms of the effectiveness and safety of continued cannulation. Using needle-knife precut, especially early use, over the pancreatic stent to continue cannulation reduced PEP compared with PS-WGC.

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

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

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

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

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

Newly designed J-shaped tip guidewire: A preliminary feasibility study in wire-guided cannulation

AIM: To perform wire-guided cannulation using a newly designed J-shaped tip guidewire, and to verify feasibility and safety for use.

METHODS: The study was conducted on endoscopic retrograde cholangiopancreatography (ERCP) patients with naïve papilla undergoing diagnosis and treatment of biliary diseases between September 2011 and July 2012. We performed ERCP in a succession of 50 cases with a J-shaped tip guidewire. The first insertion attempt began with a trainee who had 5 min to complete cannulation, followed if necessary by the trainer for another 5 min. We assessed the primary success rate of selective biliary cannulation within 10 min and adverse events such as post-ERCP pancreatitis (PEP), bleeding or perforation.

RESULTS: The primary success rate was 90% (45/50) within 10 min, the initial success rate within 5 min by trainee staff was 76% (38/50). The rate of PEP was 6% (3/50), but all 3 cases were mild pancreatitis. All patients were managed successfully with conservative treatment. There was no bleeding or perforation.

CONCLUSION: A newly designed J-shaped tip guide-wire has the possibility to facilitate selective biliary cannulation for ERCP and appears to be safe.

Impact of changing our cannulation method on the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis after pancreatic guidewire placement

AIM: To clarify whether the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) after pancreatic guidewire placement (PGW) can be reduced by using a different cannulation method.

METHODS: Between April 2001 and October 2009, PGW was performed in 142 patients with native papilla to overcome difficult biliary cannulation. Our cannulation method for ERCP was changed from contrast injection (CI) using a single-lumen catheter (April 2001-May 2008) to wire-guided cannulation (WGC) using a double-lumen catheter (June 2008-October 2009). The CI protocol was also changed during the study period: in the first period it was used for routine pancreatography for detecting small pancreatic cancer (April 2001-November 2002), whereas in the second period it was not (December 2002-May 2008). In PGW with CI using a single-lumen catheter, the contrast medium in the catheter lumen was injected into the pancreatic duct. The success rate of biliary cannulation, the incidence of PEP according to the cannulation method, and the impact of CI using a single-lumen catheter on PEP in comparison with WGC using a double-lumen catheter were investigated.

RESULTS: CI with routine pancreatography, CI without routine pancreatography, and WGC were performed in 27 patients, 77 patients and 38 patients, respectively. Routine pancreatography did not contribute to the early diagnosis of pancreatic cancer in our study period. In CI without routine pancreatography and WGC, diagnostic pancreatography was performed in 17 patients and no patients, respectively. The success rate of biliary cannulation by PGW alone was 69%, and the final success rate was increased to 80.3% by the addition of consecutive maneuvers or a second ERCP. PEP occurred in 22 patients (15.5%), and the severity was mild in all cases. When analyzed according to cannulation method, the incidence of PEP was 37.0% (10/27) in the patients who underwent CI with routine pancreatography, 14.3% (11/77) in those who underwent CI without routine pancreatography, and 2.6% (1/38) in those who underwent WGC. In all patients who underwent CI using a single-lumen catheter, the incidence of PEP was 20% (21/104), which was significantly higher than that in WGC using a double-lumen catheter. In univariate and multivariate analysis, CI using a single-lumen catheter showed a high, statistically significant, odds ratio for PEP after PGW.

CONCLUSION: The practice of a cannulation method involving the use of a double-lumen catheter minimizes the CI dose administered to the pancreatic duct and reduces the incidence of PEP after PGW.