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1
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Koizumi K, Shionoya K, Masuda S, Kubota J, Kimura K. Unique double guidewire technique using a guidewire perforating the diverticulum for a difficult biliary cannulation. Endoscopy 2023; 55:E734-E735. [PMID: 37236249 PMCID: PMC10219756 DOI: 10.1055/a-2086-2153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Kazuya Koizumi
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Kento Shionoya
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Sakue Masuda
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Jun Kubota
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Karen Kimura
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
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2
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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.
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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
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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.
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4
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Kawasaki Y, Hijioka S, Saito Y. Modified double-guidewire technique using a new double-lumen catheter and 0.018-inch guidewire for difficult biliary cannulation. Dig Endosc 2022; 34:e71-e72. [PMID: 35352854 DOI: 10.1111/den.14264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Yuki Kawasaki
- Department of 1Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan.,Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Susumu Hijioka
- Department of 1Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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Laquière A, Privat J, Jacques J, Legros R, Urena-Campos R, Belkhodja H, Subtil C, Kanafi L, Lecomte L, Boustière C, Katsogiannou M, Karsenti D. Early double-guidewire versus repeated single-guidewire technique to facilitate selective bile duct cannulation: a randomized controlled trial. Endoscopy 2022; 54:120-127. [PMID: 33860484 DOI: 10.1055/a-1395-7485] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND During endoscopic retrograde cholangiopancreatography (ERCP), access to the common bile duct (CBD) can be problematic after unintentional insertion of the guidewire into the pancreatic duct. We conducted a prospective, randomized study in order to compare biliary cannulation success rates of early double-guidewire (EDG) and repeated single-guidewire (RSG) techniques in patients with inadvertent passage of the guidewire into the pancreatic duct. METHODS Patients with a native papilla were randomly assigned to either the EDG or RSG groups after unintentional insertion of the guidewire into the pancreatic duct. The primary outcome was successful selective CBD cannulation within 10 minutes. The secondary outcomes were successful final selective bile duct cannulation, time to bile duct cannulation, and frequency of post-ERCP pancreatitis (PEP). RESULTS 142 patients were randomized and selective bile duct cannulation was achieved in 57/68 patients (84 %) in the EDG group and in 37/74 patients (50 %) in the RSG group within 10 minutes (relative risk 1.34; 95 % confidence interval 1.08-6.18; P < 0.001). The overall final selective bile duct cannulation rate was 99.3 %. The time to access the CBD was shorter using the EDG technique (6.0 vs. 10.4 minutes; P = 0.002). Mild PEP was not observed more frequently in the EDG group than in the RSG group. CONCLUSION The EDG technique significantly increased the success rate of biliary duct cannulation within 10 minutes compared with an RSG approach.
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Affiliation(s)
- Arthur Laquière
- Department of Gastroenterology, Saint Joseph Hospital, Marseille, France
| | - Jocelyn Privat
- Department of Gastroenterology, Jacques Lacarin Hospital, Vichy, France
| | - Jeremie Jacques
- Department of Endoscopy and Gastroenterology, Dupuytren Hospital, Limoges, France
| | - Romain Legros
- Department of Endoscopy and Gastroenterology, Dupuytren Hospital, Limoges, France
| | | | - Hichem Belkhodja
- Digestive Endoscopy Unit, University Hospital Lyon Sud, Lyon, France
| | - Clément Subtil
- Digestive Endoscopy Unit, University Hospital, Bordeaux, France
| | - Leïla Kanafi
- Department of Gastroenterology, Groupe Polyclinique Marzet-Navarre, Pau, France
| | - Laurence Lecomte
- Department of Gastroenterology, Saint Joseph Hospital, Marseille, France
| | | | - Maria Katsogiannou
- Department of Clinical Research, Saint Joseph Hospital, Marseille, France
| | - David Karsenti
- Digestive Endoscopy Unit, Pôle Digestif Paris Bercy, Clinique Paris-Bercy, Charenton-le-Pont, France
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6
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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: 1.0] [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.
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7
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Yane K, Sumiyoshi T, Kondo H. Successful pancreatic duct cannulation using double-guidewire technique. Dig Endosc 2021; 33:e81-e82. [PMID: 33713495 DOI: 10.1111/den.13955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/09/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Kei Yane
- Department of Gastroenterology, Tonan Hospital, Hokkaido, Japan
| | | | - Hitoshi Kondo
- Department of Gastroenterology, Tonan Hospital, Hokkaido, Japan
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8
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Shiomi H, Kutsumi H, Ryozawa S, Irisawa A, Kodama Y. Modified double-guidewire technique using a unique double-lumen sphincterotome for difficult biliary cannulation. VideoGIE 2021; 6:124-128. [PMID: 33738361 PMCID: PMC7947635 DOI: 10.1016/j.vgie.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Hideyuki Shiomi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiromu Kutsumi
- Center for Clinical Research and Advanced Medicine Establishment, Shiga University of Medical Science, Ōtsu, Shiga, Japan
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka-city, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Shintani S, Inatomi O, Takeda Y, Matsumoto H, Fujimoto T, Tsuji Y, Kutsumi H, Andoh A. Utility and safety of a new uneven double-lumen sphincterotome in cases of difficult biliary cannulation. BMC Gastroenterol 2021; 21:102. [PMID: 33663397 PMCID: PMC7934518 DOI: 10.1186/s12876-021-01689-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/24/2021] [Indexed: 11/30/2022] Open
Abstract
Background We investigated the utility and safety of a new uneven double-lumen sphincterotome in biliary cannulation in comparison with the conventional pancreatic guidewire (PGW) method.
Methods We retrospectively evaluated 119 patients who required PGW placement because of difficult biliary cannulation. Endoscopic retrograde cholangiopancreatography (ERCP) was performed using a conventional ERCP catheter or a new uneven double-lumen sphincterotome. The success rate of bile duct cannulation, the operation time of bile duct cannulation, and the incidence of post-ERCP pancreatitis (PEP) were evaluated. Results Forty-four patients were treated with a new double-lumen sphincterotome (the new sphincterotome group) and 75 patients underwent conventional PGW placement (the conventional group). The success rate of bile duct cannulation was 39/44 (88.6%) in the new sphincterotome group and 63/75 (84.0%) in the conventional group (not significant). The total biliary cannulation time (from the reach to the papilla to the finish of biliary cannulation) was 16.0 (6.5–78) min in the new sphincterotome group and 26.0 (5–80) min in the conventional group (P < 0.01). The time from PGW placement to bile duct cannulation was 3.5 (0.3–57) min in the magictome group and 12.0 (1–65) min in the conventional group (P < 0.01). Hyperamylasemia was observed in 13/44 (29.5%) and 17/75 (22.7%), respectively (not significant). Five of 44 (11.3%) of the new sphincterotome group and 14/75 (18.7%) of the conventional group were diagnosed with PEP (not significant). Conclusion A new double-lumen sphincterotome allows selective bile duct cannulation to be performed in a shorter time than the conventional PGW method.
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Affiliation(s)
- Shuhei Shintani
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
| | - Osamu Inatomi
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan.
| | - Yoshiya Takeda
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
| | - Hiroshi Matsumoto
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
| | - Takehide Fujimoto
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
| | - Yoshihisa Tsuji
- Department of General Medicine, Sapporo Medical University, Sapporo, Japan
| | - Hiromu Kutsumi
- Center for Clinical Research and Advanced Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Akira Andoh
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan
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11
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Dubravcsik Z, Hritz I, Szepes A, Madácsy L. Risk factors of post-ERCP pancreatitis in high-risk patients despite prevention with prophylactic pancreatic stents. Scand J Gastroenterol 2020; 55:95-99. [PMID: 31852319 DOI: 10.1080/00365521.2019.1701069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objectives: To analyze risk factors of post-ERCP pancreatitis (PEP) in high risk patients in whom prophylactic pancreatic stents (PPSs) were intended to use to prevent endoscopic retrograde cholangiography (ERCP)-related complications.Patients and methods: Three hundred and seventeen high-risk patients for developing PEP were considered for preventive pancreatic stent placement in our endoscopy unit over 5 years. 5 Fr, 3-5 cm long PPSs were used. All data were collected in a predefined database. Development of PEP despite PPS placement was analyzed.Results: PEP occurred in 29 of 288 successfully stented patients (10.07%; 24 mild, four moderate, one severe). PPS was protective against all risks factors except for sphincter of Oddi dysfunction (SOD). PPS related complication rate was 2.78% (n = 8). Unsuccessful stenting occurred in 29 patients (9.15%), PEP developed in 41.38% (n = 12; seven mild, four moderate, one severe). Those patients who had more patient related risk factors were more likely to develop PEP despite preventive measures with PPS. On the contrary, PPS placement was less successful in patients who had more procedure related risk factors.Conclusions: PPS is protective against all risks factors of PEP except for SOD in high-risk patients. More vulnerable patients who have more patient-related risk factors are more likely to develop PEP despite PPS is used, while more complex procedures predispose to unsuccessful PPS placement in patients with more procedure-related risk factors. PPS insertion in high-risk patients is effective and safe preventive method and the procedure related complication rate is reasonably low.
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Affiliation(s)
- Zsolt Dubravcsik
- Department of Gastroenterology, Bács-Kiskun Megyei Kórház, Kecskemét, Hungary
| | - István Hritz
- Department of Gastroenterology, Bács-Kiskun Megyei Kórház, Kecskemét, Hungary
| | - Attila Szepes
- Department of Gastroenterology, Bács-Kiskun Megyei Kórház, Kecskemét, Hungary
| | - László Madácsy
- Department of Gastroenterology, Bács-Kiskun Megyei Kórház, Kecskemét, Hungary
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12
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Abstract
Biliary cannulation represent a challenge for the endoscopists that approach to endoscopic retrograde cholangiopancreatography, with non-negligible rate of failure even in expert hands. In order to achieve the biliary tree, two main technique are nowadays mainly used, namely the contrast-assisted cannulation and the wire-guided cannulation (WGC) techniques. The WGC technique is widely used because it seems to be related to higher success rate of cannulation of the common bile duct and, at the same time, to lower rates of complications. Particularly, this approach is associated with lower risk of post endoscopic retrograde cholangiopancreatography pancreatitis, although the pathogenesis of this adverse event is still not completely understood. The outspread of this technique among endoscopists promoted the development of different methods of performing WGC-assisted endoscopic retrograde cholangiopancreatography, such as the touch technique, the no-touch technique and the double guide-wire cannulation. Furthermore, the variety of guide wires and accessories, with their different characteristics, contribute to make the scenario extremely heterogeneous. To date, the published studies did not highlight which is the best strategy that maximizes the rate of success and minimizes the percentage of complications, even because the experience of the operator represents an important variable that conditions the outcomes. The aim of this review is to define state of the art in WGC technique, in order to better understand the possible advantages in using this approach and to bring to light the possible area that may be object of further studies.
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Pécsi D, Farkas N, Hegyi P, Varjú P, Szakács Z, Fábián A, Varga G, Rakonczay Z, Bálint ER, Erőss B, Czimmer J, Szepes Z, Vincze Á. 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: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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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Affiliation(s)
- Dániel Pécsi
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
| | - Nelli Farkas
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
- Institute of Bioanalysis, Medical School, University of Pécs, Pecs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
- Momentum Research Group, Hungarian Academy of Sciences, University of Szeged, Szeged, Hungary
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Péter Varjú
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
| | - Anna Fábián
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Gábor Varga
- Department of Oral Biology, Faculty of Dentistry, Semmelweis University, Budapest, Hungary
| | - Zoltán Rakonczay
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Emese Réka Bálint
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
| | - József Czimmer
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Ifjúság u. 13, Pecs, Hungary
| | - Zoltán Szepes
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Áron Vincze
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Ifjúság u. 13, Pecs, Hungary.
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14
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Hakuta R, Hamada T, Nakai Y, Isayama H, Kogure H, Takahara N, Mizuno S, Yagioka H, Togawa O, Matsubara S, Ito Y, Yamamoto N, Tada M, Koike K. Early pancreatic stent placement in wire-guided biliary cannulation: A multicenter retrospective study. J Gastroenterol Hepatol 2019; 34:1116-1122. [PMID: 30152138 DOI: 10.1111/jgh.14453] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/09/2018] [Accepted: 08/19/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIM Guidewire insertion to a pancreatic duct under wire-guided cannulation (WGC) during endoscopic retrograde cholangiopancreatography (ERCP) is associated with a high incidence of post-ERCP pancreatitis (PEP). Pancreatic stent placement followed by WGC (PS-WGC) is considered for these cases to reduce PEP. This study was aimed to examine the effectiveness of PS-WGC compared with repeated WGC. METHODS The consecutive data of patients without history of ERCP who underwent ERCP for biliary intervention were retrospectively collected from five centers. Patients without guidewire insertion to the pancreatic duct were excluded. Pancreatic stent was immediately placed after guidewire insertion to the pancreatic duct in the PS-WGC group. The association between the method of biliary cannulation (PS-WGC or repeated WGC) and PEP was analyzed using multivariable logistic regression model. RESULTS A total of 590 patients (183 in the PS-WGC and 407 in the repeated WGC group) were included. PS-WGC decreased PEP (8.7% vs 19%, P = 0.001) and improved its severity (moderate and severe PEP; 2.2% vs 6.4%, P = 0.04) compared with repeated WGC. PS-WGC was associated with reduction of PEP in the multivariable model (Odds ratio 0.31, P < 0.001). The rates of difficult cannulation and overall successful biliary cannulation were not different between the two groups (66% vs 70%, P = 0.39 and 98% vs 96%, P = 0.21 in the PS-WGC and repeated WGC group, respectively). CONCLUSIONS Pancreatic stent placement followed by WGC reduced PEP in patients with guidewire insertion to the pancreatic duct during WGC for native papilla compared with repeated WGC.
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Affiliation(s)
- Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Yagioka
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Osamu Togawa
- Department of Gastroenterology, Kanto Central Hospital, Tokyo, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Natsuyo Yamamoto
- Department of Gastroenterology, Toshiba General Hospital, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Prophylactic efficacy of a novel method against postendoscopic papillary balloon dilation pancreatitis. Eur J Gastroenterol Hepatol 2019; 31:577-585. [PMID: 30664021 DOI: 10.1097/meg.0000000000001355] [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: 12/10/2022]
Abstract
OBJECTIVE This study aimed to investigate whether a novel method including prophylactic pancreatic stent (PS) placement prevents postendoscopic papillary balloon dilation pancreatitis. PATIENTS AND METHODS This study enrolled 200 consecutive patients with bile duct stones measuring up to 8 mm in diameter and retrospectively recruited 113 patients undergoing ordinary endoscopic papillary balloon dilation (EPBD) without PS placement from our previous study. In the novel method, EPBD and PS placement was attempted with a guidewire left in the main pancreatic duct for patients in whom stable guidewire placement in the main pancreatic duct was possible. EST was performed for patients in whom stable guidewire placement was impossible. The incidence rate of pancreatitis was compared between the novel method and ordinary EPBD, and risk factors for pancreatitis were analyzed. RESULTS Of 194 patients undergoing the novel method, EPBD and EST were performed in 180 and 14 patients, respectively. Following EPBD, PS placement was successful in 177/180 (98.3%) of patients. Pancreatitis occurred in 7/194 (3.6%) of patients after the novel method and 9/113 (8.0%) of patients after ordinary EPBD. There was a trend toward lower incidence rate of pancreatitis in the novel method. Stent dislodgement by the first postoperative morning and no previous endoscopic nasobiliary drainage (ENBD) were identified as risk factors for pancreatitis after EPBD with PS placement. No previous ENBD was also identified as a risk factor for pancreatitis after ordinary EPBD. CONCLUSION Our novel method is likely to be superior to ordinary EPBD in preventing pancreatitis. Previous ENBD may prevent post-EPBD pancreatitis regardless of PS placement.
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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: 16] [Impact Index Per Article: 2.7] [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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Kahaleh M, Artifon ELA, Perez-Miranda M, Gaidhane M, Rondon C, Freeman M, Attam R, Itoi T, Giovannini M. EUS-guided drainage: Summary of therapeutic EUS consortium meeting. Endosc Ultrasound 2019; 8:151-160. [PMID: 31134899 PMCID: PMC6590008 DOI: 10.4103/eus.eus_26_19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
EUS-guided drainage is a safe and efficacious endoscopic technique for biliary, pancreatic, and gallbladder decompression. Recent literature has described many successful procedural techniques and devices to achieve EUS-guided drainage. This consortium gathering advanced endoscopists with expertise in both ultrasonography and therapeutic endoscopy, discuss the introduction to learning several EUS-guided drainage approaches, devices, and technology involved, possible obstacles to certain procedural and all potential complications.
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Affiliation(s)
- Michel Kahaleh
- Division of Gastroenterology, Robert Wood Johnson Medical School, Rutgers University, New Jersey,, USA
| | - Everson L A Artifon
- Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Manuel Perez-Miranda
- Department of Medicine, Endoscopy Unit, University Hospital Rio Hortega, Valladolid, Spain
| | - Monica Gaidhane
- Division of Gastroenterology, Robert Wood Johnson Medical School, Rutgers University, New Jersey,, USA
| | - Carlos Rondon
- Division of Gastroenterology, Robert Wood Johnson Medical School, Rutgers University, New Jersey,, USA
| | - Martin Freeman
- Department of Gastroenterology, University of Minnesota Medical School, Mineapolis, MN, USA
| | - Rajeev Attam
- Department of Gastroenterology, University of Minnesota Medical School, Mineapolis, MN, USA
| | - Takao Itoi
- Department of Gastroenterology and Hematology, Tokyo Medical University, Tokyo, Japan
| | - Marc Giovannini
- Department of Gastroenterology, Paoli-Calmettes Institute, Marseille, France
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Tarnasky PR, Kedia P. Endoscopic retrograde cholangiopancreatography complications: Techniques to reduce risk and management strategies. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii170004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paul R. Tarnasky
- Methodist Dallas Medical Center, Methodist Digestive Institute, Dallas, TX, USA
| | - Prashant Kedia
- Methodist Dallas Medical Center, Methodist Digestive Institute, Dallas, TX, USA
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Laquiere A, Desilets E, Belle A, Castellani P, Grandval P, Laugier R, Penaranda G, Lecomte L, Boustiere C. Double guidewire endoscopic technique, a major evolution in endoscopic retrograde cholangiopancreatography: Results of a retrospective study with historical controls comparing two therapeutic sequential strategies. Dig Endosc 2017; 29:182-189. [PMID: 27638137 DOI: 10.1111/den.12740] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/14/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Endoscopic access to the common bile duct (CBD) remains difficult in 10% of cases, requiring alternative techniques .CBD access was difficult after either five unsuccessful attempts, five unintentional insertions into the pancreatic duct or >10-min-long unsuccessful attempts. This retrospective study with historical controls aimed to evaluate the benefit of the double guidewire (DGW) technique after failure of standard CBD cannulation. METHODS From January 2012 to December 2014, all patients requiring therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with difficult access to CBD were included in a Studied group. This group was compared to a historical ERCP control group from January 2009 to December 2011. In the Studied group, a sequential strategy including DGW technique was done when the guidewire was unintentionally passed into the pancreatic duct. In the control group, only pre-cut technique was used. RESULTS Among the 538 patients with naive papilla eligible for ERCP, 73 had difficult CBD access. Successful CBD access rate was higher in the Studied group: 91% (50/55) versus 67% (12/18) P = 0.0215. Complication rates were similar in both groups: 28% versus 20%, P = 0.5207. LOS was shorter in the Studied group (9.2 ± 8.5 vs 14.4 ± 7.4 days, P = 0.0028). Post-ERCP cholangitis were lower in the Studied group: 2% (1/55) versus 22% (4/18), P = 0.0118. CONCLUSION After standard cannulation failure, DGW technique increased successful CBD access rate and decreased LOS without increasing complications.
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Affiliation(s)
- Arthur Laquiere
- Hepato-Gastroenterology Department, Saint Joseph Hospital, Marseille, France
| | - Etienne Desilets
- Hepato-Gastroenterology Department, Saint Joseph Hospital, Marseille, France
| | - Arthur Belle
- Hepato-Gastroenterology Department, Saint Joseph Hospital, Marseille, France
| | - Paul Castellani
- Hepato-Gastroenterology Department, Saint Joseph Hospital, Marseille, France
| | | | - René Laugier
- Gastroenterology Department, La Timone Hospital, Marseille, France
| | | | - Laurence Lecomte
- Hepato-Gastroenterology Department, Saint Joseph Hospital, Marseille, France
| | - Christian Boustiere
- Hepato-Gastroenterology Department, Saint Joseph Hospital, Marseille, France
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Mukai S, Itoi T. Selective biliary cannulation techniques for endoscopic retrograde cholangiopancreatography procedures and prevention of post- endoscopic retrograde cholangiopancreatography pancreatitis. Expert Rev Gastroenterol Hepatol 2016; 10:709-22. [PMID: 26782710 DOI: 10.1586/17474124.2016.1143774] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Numerous endoscopic retrograde cholangiopancreatography (ERCP) techniques have been reported to achieve selective biliary cannulation success. For standard biliary cannulation procedures, the wire-guided cannulation technique has been reported to reduce the rate of post-ERCP pancreatitis (PEP) and increase the biliary cannulation success rate, although conflicting reports exist. The pancreatic or double-guidewire technique and several precut techniques have been reported as useful techniques in difficult biliary cannulation cases. Although ERCP is a useful endoscopic procedure, the risk of adverse events, particularly post-ERCP pancreatitis, is inevitable. Previous studies and analyses have revealed the risk factors for PEP. The efficacy of prophylactic pancreatic duct stent placement and the administration of rectal nonsteroidal anti-inflammatory drugs for preventing PEP has also been reported. Herein, we reviewed reports in the literature regarding the current status of selective biliary cannulation techniques and PEP prevention.
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Affiliation(s)
- Shuntaro Mukai
- a Department of Gastroenterology and Hepatology , Tokyo Medical University , Tokyo , Japan
| | - Takao Itoi
- a Department of Gastroenterology and Hepatology , Tokyo Medical University , Tokyo , Japan
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21
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Tse F, Yuan Y, Bukhari M, Leontiadis GI, Moayyedi P, Barkun A, Cochrane Upper GI and Pancreatic Diseases Group. 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: 1.1] [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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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: 13] [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.
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Affiliation(s)
- Long Huang
- Department of No. 1 Surgery, The First Hospital Affiliated to Anhui Chinese Medical University, Hefei, China
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Kim CW, Chang JH, Kim TH, Han SW. Sequential double-guidewire technique and transpancreatic precut sphincterotomy for difficult biliary cannulation. Saudi J Gastroenterol 2015; 21:18-24. [PMID: 25672234 PMCID: PMC4355857 DOI: 10.4103/1319-3767.151212] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS The double-guidewire technique (DGT) and transpancreatic precut sphincterotomy (TPS) are introduced as alternative biliary cannulation techniques for difficult biliary cannulation. This study aimed to evaluate the sequential use of DGT and TPS compared with a needle-knife precut papillotomy (NK). PATIENTS AND METHODS Six hundred and thirty-five consecutive patients with naοve papilla and who underwent endoscopic retrograde cholangiopancreatography (ERCP) for biliary cannulation from March 2010 to April 2014 in a single institute were analyzed. When standard techniques were unsuccessful, DGT or NK was performed. TPS was sequentially performed if DGT failed. RESULTS DGT and NK were attempted in 65 and 58 patients, respectively. A sequential DGT-TPS was performed in 38 patients after a failed DGT. Biliary cannulations were successful in 42%, 74%, and 66% of the DGT, sequential DGT-TPS, and NK patients, respectively (P = 0.002). The cannulation rate was higher in the DGT ± TPS patients (85%) than in the NK patients (P = 0.014). Post-ERCP pancreatitis (PEP) developed in 26% of the successful DGT patients, 37% of the sequential DGT-TPS patients, and 10% of the NK patients (P = 0.008). Of the sequential DGT-TPS patients, the incidence of PEP was significantly reduced in patients with a pancreatic duct (PD) stent compared with patients without a PD stent (24% vs. 62%, P = 0.023). CONCLUSIONS Sequential DGT-TPS is a useful alternative method compared with NK for patients in whom biliary cannulation is difficult. In the sequential DGT-TPS patients, the incidence of PEP was significantly reduced with the use of a PD stent.
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Affiliation(s)
- Chang W. Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae H. Chang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea,Address for correspondence: Dr. Jae Hyuck Chang, Division of Gastroenterology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo daero, Seocho gu, Seoul 137-701, Korea. E-mail:
| | - Tae H. Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sok W. Han
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Ito K, Horaguchi J, Fujita N, Noda Y, Kobayashi G, Koshita S, Kanno Y, Ogawa T, Masu K, Hashimoto S. Clinical usefulness of double-guidewire technique for difficult biliary cannulation in endoscopic retrograde cholangiopancreatography. Dig Endosc 2014; 26:442-9. [PMID: 23937334 DOI: 10.1111/den.12158] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 07/12/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM Although biliary cannulation with pancreatic guidewire placement (P-GW) is useful for difficult cases in endoscopic retrograde cholangiopancreatography (ERCP), the clinical significance of wire-guided cannulation with P-GW (double-guidewire technique: DGT) has not been clarified. The aim of the present study was to evaluate the usefulness of DGT for difficult biliary cannulation after unsuccessful biliary cannulation using a cannula/sphincterotome under guidance of injected contrast with P-GW (single-guidewire technique: SGT). METHODS One-hundred and forty-six patients with difficult biliary cannulation who underwent SGT were included in this retrospective study. DGT was carried out if SGT was unsuccessful. Pancreatic duct (PD) stenting was attempted to prevent post-ERCP pancreatitis (PEP) in all patients. The success rate of cannulation and the risk factors for PEP were investigated. RESULTS Biliary cannulation with SGT was achieved in 70%. DGT was carried out in 25 patients with unsuccessful SGT, biliary cannulation being successful in 72%. Of the 13 patients who underwent precut sphincterotomy, biliary cannulation was achieved in 46%. The incidence of PEP in patients who had undergone SGT, DGT, and precut sphincterotomy was 8% (12: mild, 8; moderate, 3; severe, 1), 4% (mild, 1), and 0%, respectively. PD stenting was successfully carried out in 86%. Multivariate analysis revealed unsuccessful PD stenting to be the only risk factor for PEP (OR 8.3, 95% CI 2.3-30). CONCLUSIONS DGT may replace SGT or become the salvage procedure in cases of unsuccessful SGT as a result of its high success rate with an acceptable incidence of PEP. Failed pancreatic duct stenting in these techniques was frequently associated with PEP.
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Affiliation(s)
- Kei Ito
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
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Lee TH, Hwang SO, Choi HJ, Jung Y, Cha SW, Chung IK, Moon JH, Cho YD, Park SH, Kim SJ. Sequential algorithm analysis to facilitate selective biliary access for difficult biliary cannulation in ERCP: a prospective clinical study. BMC Gastroenterol 2014; 14:30. [PMID: 24529239 PMCID: PMC3929560 DOI: 10.1186/1471-230x-14-30] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 02/10/2014] [Indexed: 01/17/2023] Open
Abstract
Background Numerous clinical trials to improve the success rate of biliary access in difficult biliary cannulation (DBC) during ERCP have been reported. However, standard guidelines or sequential protocol analysis according to different methods are limited in place. We planned to investigate a sequential protocol to facilitate selective biliary access for DBC during ERCP. Methods This prospective clinical study enrolled 711 patients with naïve papillae at a tertiary referral center. If wire-guided cannulation was deemed to have failed due to the DBC criteria, then according to the cannulation algorithm early precut fistulotomy (EPF; cannulation time > 5 min, papillary contacts > 5 times, or hook-nose-shaped papilla), double-guidewire cannulation (DGC; unintentional pancreatic duct cannulation ≥ 3 times), and precut after placement of a pancreatic stent (PPS; if DGC was difficult or failed) were performed sequentially. The main outcome measurements were the technical success, procedure outcomes, and complications. Results Initially, a total of 140 (19.7%) patients with DBC underwent EPF (n = 71) and DGC (n = 69). Then, in DGC group 36 patients switched to PPS due to difficulty criteria. The successful biliary cannulation rate was 97.1% (136/140; 94.4% [67/71] with EPF, 47.8% [33/69] with DGC, and 100% [36/36] with PPS; P < 0.001). The mean successful cannulation time (standard deviation) was 559.4 (412.8) seconds in EPF, 314.8 (65.2) seconds in DGC, and 706.0 (469.4) seconds in PPS (P < 0.05). The DGC group had a relatively low successful cannulation rate (47.8%) but had a shorter cannulation time compared to the other groups due to early switching to the PPS method in difficult or failed DGC. Post-ERCP pancreatitis developed in 14 (10%) patients (9 mild, 1 moderate), which did not differ significantly among the groups (P = 0.870) or compared with the conventional group (P = 0.125). Conclusions Based on the sequential protocol analysis, EPF, DGC, and PPS may be safe and feasible for DBC. The use of EPF in selected DBC criteria, DGC in unintentional pancreatic duct cannulations, and PPS in failed or difficult DGC may facilitate successful biliary cannulation.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan Hospital, 23-20 Bongmyung-dong, Cheonan, South Korea.
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Multidimensional assessment of spirituality/religion in patients with HIV: conceptual framework and empirical refinement. Surg Endosc 2013; 25:1599-602. [PMID: 21136166 DOI: 10.1007/s00464-010-1458-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Accepted: 09/28/2010] [Indexed: 12/17/2022]
Abstract
A decade ago, an expert panel developed a framework for measuring spirituality/religion in health research (Brief Multidimensional Measure of Religiousness/Spirituality), but empirical testing of this framework has been limited. The purpose of this study was to determine whether responses to items across multiple measures assessing spirituality/religion by 450 patients with HIV replicate this model. We hypothesized a six-factor model underlying a collective of 56 items, but results of confirmatory factor analyses suggested eight dimensions: Meaning/Peace, Tangible Connection to the Divine, Positive Religious Coping, Love/Appreciation, Negative Religious Coping, Positive Congregational Support, Negative Congregational Support, and Cultural Practices. This study corroborates parts of the factor structure underlying the Brief Multidimensional Measure of Religiousness/Spirituality and some recent refinements of the original framework.
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Tanaka R, Itoi T, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T, Tsuji S, Ishii K, Ikeuchi N, Umeda J, Tonozuka R, Honjo M, Mukai S, Moriyasu F. Is the double-guidewire technique superior to the pancreatic duct guidewire technique in cases of pancreatic duct opacification? J Gastroenterol Hepatol 2013; 28:1787-93. [PMID: 23800118 DOI: 10.1111/jgh.12303] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Pancreatic duct guidewire placement (P-GW) techniques include both the injection cannulation technique with a contrast medium and wire-guided cannulation without contrast injection for selective biliary cannulation; the latter is the so-called "double-guidewire technique" (D-GW). The aim of this study was to compare the outcomes between P-GW and D-GW for biliary cannulation. METHODS The procedures for biliary cannulation with a naïve papilla were performed in a total of 363 cases. We divided the patients chronologically, according to the time period during which the procedures were performed, into two groups: group A, P-GW performed from March 2008 to June 2009; and group B, D-GW performed from July 2009 to December 2010. The success rates and complication rates were evaluated in each group. RESULTS Biliary cannulation was successful in 31 (81.6%) patients in the P-GW group and 34 patients (82.9%) in the D-GW group. The onsets of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) occurred in the P-GW and D-GW groups were four (10.5%) and three (7.3%) patients, respectively, and all were mild cases (P = 0.616). The frequency of hyperamylasemia and the serum amylase level tended to be lower in the D-GW group than in the P-GW group (P = 0.213). There was a statistically significant difference on the onsets of PEP in the GW and non-GW groups (P = 0.04, 8.9% and 1.1%, respectively). CONCLUSIONS Both the D-GW and P-GW techniques were equally effective for difficult biliary cannulation. Furthermore, the complication rates, including PEP, were similar in both techniques. A prospective randomized trial is warranted.
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Affiliation(s)
- Reina Tanaka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Abstract
Endoscopic retrograde cholangiopancreatography allows intervention for a variety of diseases of the biliary tract. Cannulation of the bile duct is the prerequisite step for biliary intervention. Although obtaining biliary access is straightforward in many cases, it can occasionally be challenging. Multiple devices, all with additional wire-guided techniques, have been developed to aid cannulation. More advanced techniques have also been developed to aid biliary access if it is unsuccessful with standard devices. Multimodality techniques can be used if other approaches fail. This article provides an evidence-based discussion of these approaches, and provides insight into their appropriate application.
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Affiliation(s)
- Yan G Bakman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, USA
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Yoo YW, Cha SW, Lee WC, Kim SH, Kim A, Cho YD. Double guidewire technique vs transpancreatic precut sphincterotomy in difficult biliary cannulation. World J Gastroenterol 2013; 19:108-14. [PMID: 23326171 PMCID: PMC3542752 DOI: 10.3748/wjg.v19.i1.108] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 11/14/2012] [Accepted: 11/24/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the outcomes between double-guidewire technique (DGT) and transpancreatic precut sphincterotomy (TPS) in patients with difficult biliary cannulation.
METHODS: This was a prospective, randomized study conducted in single tertiary referral hospital in Korea. Between January 2005 and September 2010. A total of 71 patients, who bile duct cannulation was not possible and selective pancreatic duct cannulation was achieved, were randomized into DGT (n = 34) and TPS (n = 37) groups. DGT or TPS was done for selective biliary cannulation. We measured the technical success rates of biliary cannulation, median cannulation time, and procedure related complications.
RESULTS: The distribution of patients after randomization was balanced, and both groups were comparable in baseline characteristics, except the higher percentage of endoscopic nasobiliary drainage in the DGT group (55.9% vs 13.5%, P < 0.001). Successful cannulation rate and mean cannulation times in DGT and TPS groups were 91.2% vs 91.9% and 14.1 ± 13.2 min vs 15.4 ± 17.9 min, P = 0.732, respectively. There was no significant difference between the two groups. The overall incidence of post- endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis was 38.2% vs 10.8%, P < 0.011 in the DGT group and the TPS group; post-procedure pancreatitis was significantly higher in the DGT group. But the overall incidence of post-ERCP hyperamylasemia was no significant difference between the two groups; DGT group vs TPS group: 14.7% vs 16.2%, P < 1.0.
CONCLUSION: When free bile duct cannulation was difficult and selective pancreatic duct cannulation was achieved, DGT and TPS facilitated biliary cannulation and showed similar success rates. However, post-procedure pancreatitis was significantly higher in the DGT group.
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Feasibility of the novel 3-step protocol for biliary cannulation--a prospective analysis. Surg Laparosc Endosc Percutan Tech 2012; 22:161-4. [PMID: 22487632 DOI: 10.1097/sle.0b013e318247bb84] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Traditionally, a 2-step protocol has been used for deep biliary cannulation. The purpose of the present prospective study was to find out the feasibility and safety of the novel sequential 3-step protocol (traditional cannula with guidewire, double-guidewire, and needle-knife techniques) for deep biliary cannulation. All consecutive patients admitted for endoscopic retrograde cholangiopancreatography (ERCP) to a single, very experienced ERCP endoscopist during the year 2009 with intended biliary cannulation and with unhindered access to a native papilla (n=105) were included in the present study. The overall success rate for deep biliary cannulation was 99% (104/105). Cannulation with cannula and guidewire was attempted in all patients and proved successful in 80% (84/105) of the attempts, the double-guidewire technique was applied in 19% (20/105) and was successful in 65% (13/20) of the cases, and the needle-knife technique was applied in 7% (7/105) with success in all cases. The median cannulation time was 1 minute (range, 0 to 27 min). The rate of post-ERCP pancreatitis was 3% (3/105) and post-ERCP cholangitis 2% (2/105). We conclude that in experienced hands, the novel sequential 3-step protocol for biliary cannulation tested herein proved to be an effective cannulation protocol with the overall success rate of 99%. The complication rate of these ERCP procedures (5%) was within acceptable limits.
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Difficult biliary cannulation during ERCP: how to facilitate biliary access and minimize the risk of post-ERCP pancreatitis. Dig Liver Dis 2011; 43:596-603. [PMID: 21377432 DOI: 10.1016/j.dld.2011.01.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 01/25/2011] [Indexed: 12/11/2022]
Abstract
Endoscopic retrograde cholangio-pancreatography (ERCP) is one of the most technically challenging procedures in therapeutic endoscopy; difficulties in biliary cannulation and post-ERCP pancreatitis are still significant problems. Deep cannulation of Vater's papilla may fail in up to 5% of cases; selective biliary cannulation reportedly fails in 15-35% of cases, even in experienced hands; repeated and prolonged attempts at cannulation increase the risk of post-procedure pancreatitis. Therefore, cannulation technique plays a pivotal role in successful cannulation and occurrence of post-procedure pancreatitis. This review presents and discusses the techniques that can be used for achieving biliary cannulation after an initial failure and for minimizing the risk of pancreatitis, including guide wire assisted technique, needle knife precutting, trans-pancreatic sphincterotomy, and pancreatic stenting.
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Xinopoulos D, Bassioukas SP, Kypreos D, Korkolis D, Scorilas A, Mavridis K, Dimitroulopoulos D, Paraskevas E. Pancreatic duct guidewire placement for biliary cannulation in a single-session therapeutic ERCP. World J Gastroenterol 2011; 17:1989-95. [PMID: 21528077 PMCID: PMC3082752 DOI: 10.3748/wjg.v17.i15.1989] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 12/23/2010] [Accepted: 12/30/2010] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the technical success and clinical complication rate of a cannulated pancreatic duct with guidewire for biliary access.
METHODS: During a five-year study period, a total of 2843 patients were included in this retrospective analysis. Initial biliary cannulation method consisted of single-guidewire technique (SGT) for up to 5 attempts, followed by double-guidewire technique (DGT) when repeated unintentional pancreatic duct cannulation had taken place. Pre-cut papillotomy technique was reserved for when DGT had failed or no pancreatic duct cannulation had been previously achieved. Main outcome measurements were defined as biliary cannulation success and post-endoscopic retrograde cholangiopancreatography (ERCP) complication rate.
RESULTS: SGT (92.3% success rate) was characterized by statistically significant enhanced patient outcome compared to either the DGT (43.8%, P < 0.001), pre-cut failed DGT (73%, P < 0.001) or pre-cut as first step method (80.6%, P = 0.002). Pre-cut as first step method offered a statistically significantly more favorable outcome compared to the DGT (P < 0.001). The incidence of post-ERCP pancreatitis did not differ in a statistically significant manner between either method (SGT: 5.3%, DGT: 6.1%, Pre-cut failed DGT: 7.9%, Pre-cut as first step: 7.5%) or with patients’ gender.
CONCLUSION: Although DGT success rate proved not to be superior to SGT or pre-cut papillotomy, it is considered highly satisfactory in terms of safety in order to avoid the risk of a pre-cut when biliary therapy is necessary in difficult-to-cannulate cases.
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure routinely performed by endoscopists. ERCP cannulation requires the insertion of a subcentimeter catheter through a tiny orifice at a distance of almost a meter from the operator. Only after successful cannulation of the bile duct can the real "business" of ERCP be performed (eg, sphincterotomy, stone extraction, stent placement). Selective bile duct cannulation is all the more exacting due to the occasional anatomic challenge (eg, postsurgical anatomy, duodenal stricture) or wayward catheter. Serious morbid complications can and do occur, even in the hands of the most gifted and facile endoscopists. Although there are some "tricks" to facilitate successful cannulation of the bile duct, experience "trumps" all tricks. Of greatest importance when faced with a difficult cannulation is the recognition of one's personal limitations.
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Affiliation(s)
- Sean P Lynch
- Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157, USA
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Dye-free wire-guided cannulation of the biliary tree during ERCP is associated with high success and low complication rates: outcomes in a single operator experience of 822 cases. J Clin Gastroenterol 2010; 44:e57-62. [PMID: 19636260 DOI: 10.1097/mcg.0b013e3181aacbd1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Deep biliary cannulation (DBC) is a prerequisite to most endoscopic retrograde cholangiopancreatographies (ERCPs). Numerous techniques have been described to maximize success and minimize ERCP-related complications, most notably post-ERCP pancreatitis. Dye-free cannulation by using guidewires with hydrophilic tips has been proposed as a technique with a high rate of success and a low rate of complications. We report the outcomes 822 consecutive ERCP procedures by using dye-free guidewire cannulation techniques. OBJECTIVE To evaluate the success rate for DBC and rates of complications by using dye-free guidewire cannulation techniques. DESIGN Retrospective. Consecutive ERCP procedures with intent to achieve DBC exclusively by using dye-free guidewire technique were included. Complication data on post-ERCP pancreatitis, bleeding, perforation, and cholangitis were extracted. SETTING University. PATIENTS Patients undergoing biliary ERCP. INTERVENTIONS ERCP. MAIN OUTCOME MEASUREMENTS Success, complication rates. RESULTS Eight hundred and twenty-two ERCPs were performed on 744 patients. Five hundred and fifty-nine (68%) procedures were performed on inpatients, 263 (32%) on outpatients. DBC was successful in 801 of 822 (97%) ERCPs. In 795 of 801 (99%) ERCPs with successful DBC procedures, DBC was achieved in a dye-free fashion. Eleven patients (1.3%) developed post-ERCP pancreatitis-all cases were mild. Guidewire perforations occurred 11 times (1.3%), none required surgery. Ten of 11 patients with known or suspected (91%) guidewire perforation achieved successful DBC on repeat ERCP by the same endoscopist by using dye-free techniques. LIMITATIONS Retrospective. CONCLUSIONS In this large retrospective case series, a high success rate of DBC was achieved by using dye-free guidewire techniques. This technique has associated lower rates of complications in comparison to those reported earlier.
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Double-guidewire technique for difficult bile duct cannulation: a multicenter randomized, controlled trial. Gastrointest Endosc 2009; 70:700-9. [PMID: 19560764 DOI: 10.1016/j.gie.2009.03.031] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Accepted: 03/11/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND ERCP can be associated with serious complications. Difficulty in common bile duct (CBD) cannulation is one of the main risk factors for post-ERCP pancreatitis. The double-guidewire technique (DGT) has been considered a promising alternative approach in difficult cannulation situations. OBJECTIVE To compare the performance of DGT with the standard cannulation technique (SCT) in patients in whom CBD cannulation is difficult to perform. DESIGN Multicenter randomized, controlled trial. SETTING Six tertiary referral centers. PATIENTS A total of 188 patients with difficult CBD cannulation defined by completion of 5 unsuccessful cannulation attempts were enrolled. INTERVENTIONS Ninety-seven patients were assigned to the DGT group and 91 to the SCT group. Both techniques were compared for an extra 10 cannulation attempts. MAIN OUTCOME MEASUREMENTS CBD cannulation rate, number of attempts required to cannulate, and ERCP-related complications. RESULTS Successful CBD cannulation was achieved in 46 of 97 (47%) patients in the DGT group compared with 51 of 91 (56%) in the SCT group (OR 0.85; 95% CI, 0.64-1.12). The median number of attempts required for each group was 9 and 7, respectively (P = .128). The incidence of post-ERCP pancreatitis was 17% in the DGT group and 8% in the SCT group (OR 2.13; 95% CI, 0.89-5.05). LIMITATIONS Reduced number of enrolled subjects and a lack of detailed information regarding the number and extent of pancreatic duct contrast injections. CONCLUSIONS In patients with difficult CBD cannulation, DGT was not superior to SCT in achieving CBD cannulation. DGT might be associated with a higher risk of post-ERCP pancreatitis.
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Abstract
Guidewires are routinely used at the time of endoscopic retrograde cholangiopancreatography (ERCP) to gain and maintain access to the desired duct and aid in the advancement of various devices. Limitations of the traditional long-wire systems have led to the introduction of three proprietary short-wire systems. These systems differ in many respects but share two main principles: They lock a shorter wire in position to allow advancement or removal of various devices without displacement of the wire and they all allow for physician control of the wire. In this comprehensive review, we describe the key features of the three currently available short-wire systems: RX, Fusion and V systems. We also focus on the potential benefits and drawbacks that accompany the short-wire concept as a whole and each specific system in particular. Although the available data are limited, it appears that the use of the short-wire systems lead to reduced procedure, fluoroscopy and device exchange times, decreased sedation requirements, improved wire stability and increased endoscopist control of the wire. Furthermore, the physician-controlled wire-guided cannulation has the potential to decrease ampullary trauma and the rate of post-ERCP pancreatitis. The short guidewire systems appear to be an improvement over the traditional long-wire systems but further studies directly comparing the two approaches are needed.
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Madácsy L, Kurucsai G, Fejes R, Székely A, Székely I. Prophylactic pancreas stenting followed by needle-knife fistulotomy in patients with sphincter of Oddi dysfunction and difficult cannulation: new method to prevent post-ERCP pancreatitis. Dig Endosc 2009; 21:8-13. [PMID: 19691794 DOI: 10.1111/j.1443-1661.2008.00819.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The aim of the present study was to reduce post-endoscopic retrograde cholangiopancreatography (ERCP) complications with a combination of early needle-knife access fistulotomy and prophylactic pancreatic stenting in selected high-risk sphincter of Oddi dysfunction (SOD) patients with difficult cannulation. METHODS Prophylactic pancreatic stent insertion was attempted in 22 consecutive patients with definite SOD and difficult cannulation. After 10 min of failed selective common bile duct cannulation, but repeated (>5x) pancreatic duct contrast filling, a prophylactic small calibre (3-5 Fr) pancreatic stent was inserted, followed by fistulotomy with a standard needle-knife, then a standard complete biliary sphincterotomy followed. The success and complication rates were compared retrospectively with a cohort of 35 patients, in which we persisted with the application of standard methods of cannulation without pre-cutting methods. RESULTS Prophylactic pancreatic stenting followed by needle-knife fistulotomy was successfully carried out in all 22 consecutive patients, and selective biliary cannulation and complete endoscopic sphincterotomy were achieved in all but two cases. In this group, not a single case of post-ERCP pancreatitis was observed, in contrast with a control group of three mild, 10 moderate and two severe post-ERCP pancreatitis cases. The frequency of post-ERCP pancreatitis was significantly different: 0% versus 43%, as were the post-procedure (24 h mean) amylase levels: 206 U/L versus 1959 U/L, respectively. CONCLUSIONS In selected, high-risk, SOD patients, early, prophylactic pancreas stent insertion followed by needle-knife fistulotomy seems a safe and effective procedure with no or only minimal risk of post-ERCP pancreatitis. However, prospective, randomized studies are awaited to lend to support to our approach.
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Affiliation(s)
- László Madácsy
- First Department of Internal Medicine, Fejér Megyei Szent György Hospital, Székesfehérvár, Hungary.
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Hou SL, Gao YP, Qiao N, Qiao ZY, Kang JS, Zhang LC. Role of guide-wire in lowering complications of endoscopic retragrade cholangiopancreatgraphy. Shijie Huaren Xiaohua Zazhi 2008; 16:3347-3350. [DOI: 10.11569/wcjd.v16.i29.3347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the significance of guide-wire in reducing complications of endoscopic retragrade cholangiopancreatography (ERCP).
METHODS: Eight hundred and fifty one cases undergoing guide-wire procedure were taken as the guide-wire group while 327 cases without guide-wire procedure were taken as conventional treatment group. Incidence rates of complications between the two groups were analyzed.
RESULTS: Incidence of pancreatitis, cholangitis, stone incarceration and total complication rate were significantly lower in the guide-wire group than in the conventional treatment group (2.47% vs 4.90%, 1.41% vs 3.67%, 0% vs 0.61%, 4.70% vs10.40%, all P < 0.05). The bleeding rate and perforation of duodenum were also lower in the guide-wire group but no statistical significance was observed.
CONCLUSION: Guide-wire flexibly reduces incidence rate of complications and the effect is prominent.
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The double-wire technique as an aid to selective cannulation of the common bile duct during pediatric endoscopic retrograde cholangiopancreatography. J Pediatr Gastroenterol Nutr 2007; 45:438-42. [PMID: 18030210 DOI: 10.1097/mpg.0b013e318054e1f4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Selective cannulation of the common bile duct (CBD) during endoscopic retrograde cholangiopancreatography (ERCP) can be difficult. Several techniques have been described to assist endoscopists in obtaining access when initial cannulation fails. The objective of this report is to describe our initial experience with the "double-wire technique" in the pediatric population. PATIENTS AND METHODS Sixty ERCPs were performed in children with ages ranging from 8 months to 18 years and the technique was used in 8 cases. After wire-guided access to the pancreatic duct is obtained, the wire is left in place within the pancreatic duct to aid subsequent selective cannulation of the CBD. RESULTS In 2 of these cases, transient increase in pancreatic enzymes was observed after ERCP. Nevertheless, in this small series of patients it was found to be an effective and useful tool in cases in which repeated attempts have yielded only pancreatic duct cannulation. CONCLUSIONS This technique is a useful aid for the endoscopist attempting to selectively cannulate the CBD in difficult cases. Further study will be needed to establish the safety of this technique in the pediatric population.
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Abstract
Az enteralis táplálás indikációs köre egyre tágul, és az ily módon növekvő beteganyag ellátása egyre inkább a mindennapos gyakorlat részévé válik. Az enteralis táplálás előnyösebb az intravénásnál, ezen belül is a jejunális táplálás a legelfogadottabb, de ehhez nasojejunalis szondalevezetés szükséges. Ez lehetséges vakon, képerősítő, endoszkóp vagy ultrahang segítségével. A szerzők saját gyakorlatuk alapján a röntgenkép-erősítős technikát ismertetik, ez nem igényel speciális jártasságot, és bármely fekvőbeteg-intézményben elvégezhető. Gyors, olcsó, és kis megterhelést jelent a betegnek, nincs szükség képzett endoszkópos szakemberre, premedikációra. Hátránya, hogy kizárólag éber, kielégítő spontán légzésű, kooperáló betegnél alkalmazható, valamint röntgensugár-terheléssel jár. A szerzők az elmúlt 3 év alatt 34 esetben alkalmazták a módszert akut pancreatitises betegeiknél, súlyos szövődmények nélkül. A költséghatékonysági elveket is figyelembe véve, a fekvőbeteg-ellátás minden szintjén biztonságos módszerként ajánlják ezt az eljárást.
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Affiliation(s)
- Zoltán Szántó
- Jász-Nagykun-Szolnok Megyei Hetényi Géza Kórház-Rendelointézet Altalános Er- és Mellkassebészeti Osztály Szolnok.
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Artifon ELA, Sakai P, Ishioka S, Hondo FY, Raju GS. Suprapapillary puncture of the common bile duct for selective biliary access: a novel technique (with videos). Gastrointest Endosc 2007; 65:124-31. [PMID: 17185091 DOI: 10.1016/j.gie.2006.06.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Accepted: 06/12/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Selective cannulation of the bile duct while avoiding the potential mechanisms that initiate the cascade of pancreatic injury may prevent or minimize post-ERCP pancreatitis. This could be accomplished by suprapapillary needle puncture of the bile duct with a specially designed needle. OBJECTIVES The aim of this study is to describe a new technique to perform selective biliary cannulation by using a novel needle-puncture device and its outcome in 28 patients with suspected biliary pathology. DESIGN This is a single-center, prospective pilot study of suprapapillary puncture of bile duct for both diagnosis and therapy of biliary pathology. SUBJECTS Thirty patients were enrolled: 28 patients underwent suprapapillary puncture to gain biliary access, and 2 patients with a large periampullary diverticulum were excluded. INTERVENTIONS After successful biliary cannulation by using a suprapapillary puncture technique and balloon dilation of the tract if necessary, stone removal, plastic stent insertion, and metal stent insertion were attempted. MAIN OUTCOME MEASUREMENTS Successful biliary cannulation, time for cannulation, outcome of therapy (clearing the stones or providing stent drainage with stent insertion), and complications were recorded. At 60 days, the suprapapillary puncture was evaluated to check the status of drainage. RESULTS Suprapapillary puncture was successful in 25 of the 28 patients, and, in 1 patient, it was successful after a week. It was useful in demonstrating a normal bile duct in 9 of 11 patients with suspected biliary pathology. Subsequent therapy was successful in the management of 11 patients with stones, benign biliary pathology in 2 patients, and malignant biliary pathology in 3 of 4 patients. None of the patients developed post-ERCP pancreatitis. Complications included small perforations that resolved with conservative management (n = 2), minor bleeding (n = 2), and submucosal injection (n = 1). At 60 days, all the puncture sites healed in patients who did not undergo dilation, while those with dilation of the tract had a patent orifice, with excellent flow of bile. CONCLUSIONS Suprapapillary puncture for biliary cannulation is a useful technique for selective cannulation of the bile duct and avoids injury to the pancreas but with higher complication rates. Further studies will be needed to define its safety and its relative benefits compared with conventional access methods.
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Affiliation(s)
- Everson L A Artifon
- Department of Gastroenterology, University of São Paulo Medical School, São Paulo, Brazil.
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Affiliation(s)
- Martin L Freeman
- Division of Gastroenterology, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN 55415, USA
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