3361 Guide-wire cannulation of vater's papilla for detecting the main biliary duct during ercp: a valid and effective method to avoid post-procedural pancreatitis.

Abstract

Background: Post-ERCP pancreatitis is a feared complication that every endoscopist would avoid and that in about 0.5% of cases can be fatal. Aim: To evaluate the incidence of post-ERCP pancreatic reaction or acute pancreatitis in patients undergone ERCP and/or endoscopic sphincterotomy (EST) in whom a guide-wire was used to cannulate the papilla of Vater and the main biliary duct, so that a contrast injection of the main pancreatic duct was not obtained. Methods: From 1997 to 1999, the same endoscopist performed 435 ERCP (302 EST): 285 for biliary tract lithiasis; 88 for hilar or main bile duct malignancy; 20 cases for idiopathic recurrent pancreatitis; 23 for suspected SOD dysfunction. In 4 cases, the papillary cannulation was obtained through a combined videolaparoscopic-endoscopic approach. Nineteen procedures (3.5%) failed for anatomical causes. The mean age of patients (201 men, 225 women) was 62.5 years (range, 36-92 years). Features consistent with pancreatitis were: serum amylase elevation more than five times the upper normal limit at 24 hours after the procedure, associated with persisting pancreatic-like abdominal pain and/or with leukocytosis. In all patients, the papilla was cannulated with a teflon tracer guide-wire through a 6F double channel sphincterotomy. Only after the cannulation of the main biliary duct with the guide-wire, the contrast medium was injected in the biliary tree. In all patients both proceduralrelated and patient-related risk factors were recorded. Results: No cases of acute pancreatitis were detected. In 38 patients serum amylase arose more than five time the upper normal limit within 12 hours after the procedure; 16 of these patients presented a non-specific abdominal disconfort (mean duration, 4 hours), which resolved spontaneously or after a single dose of analgesic drug. One patient had a severe papillary bleeding after EST, which had been carried out with combined ERCP-videolaparoscopic approach. This patients was effectively treated with RBC transfusion and was discharged ten days after the procedure. Conclusions: This report indicates that a guide-wire cannulation of the main biliary duct before the contrast medium injection is a safe and effective method to prevent post- ERCP pancreatitis and to obtain a safe EST, by avoiding the accidental contrast medium injection of the main pancreatic duct with its correlated chemical and pressure injuries.