Difficult Biliary Cannulation: Use of Physician Controlled Wire-Guided Cannulation Over a Pancreatic Duct Stent to Reduce the Rate of Precut Sphincterotomy

Abstract

Background: Successful cannulation of the common bile duct (CBD) remains the benchmark for endoscopic retrograde cholangiopancreatography (ERCP). Difficult cannulation, particularly with the use of precut sphincterotomy, has been shown to be a risk factor for post-ERCP pancreatitis. While use of a pancreatic duct (PD) stent to facilitate biliary cannulation has been described, the majority of patients required precut sphincterotomy to achieve CBD cannulation. We report the performance characteristics of this technique in conjunction with physician controlled wire-guided biliary cannulation to minimize the need for precut. Methods: We performed a retrospective, cohort analysis of ERCPs performed by two experienced endoscopists at independent medical centers. Both endoscopists routinely use a PD stent to facilitate biliary cannulation prior to resorting to a precut sphincterotomy and to reduce the risk of post ERCP pancreatitis. All patients with native papillae undergoing ERCP between January, 2006 and April, 2008 were included. Routine cannulation and failure to cannulate either the PD or CBD were excluded. In cases of difficult biliary access where the PD is cannulated, a soft, 5Fr pancreatic stent is left in the PD without performing a pancreatic sphincterotomy. Following this, physician controlled wire-guided biliary cannulation is attempted using the PD stent to direct the sphincterotome into the biliary orifice. If cannulation is unsuccessful after several minutes, a precut sphincterotomy is performed over the PD stent or the procedure is terminated. We reviewed medical records to determine rates of PD stent placement to facilitate biliary cannulation as well as rate of precut sphincterotomy. Outcomes included biliary cannulation rate, frequency of precut sphincterotomy, and incidence of procedure-related complications. Results: 2,345 ERCPs were identified, 1,544 with native papillae. Among these, CBD and PD cannulation failed in 16 (1.0%), while 76 (4.9%) patients received a PD stent to facilitate biliary cannulation. Successful cannulation was achieved in 71 of 76 (93.4%) patients, 60 (78.9%) of whom did not require precut sphincterotomy. Complications included mild post-ERCP pancreatitis in 4 (5.3%) and aspiration in 1 (1.3%). Precut sphincterotomy was complicated by hemorrhage controlled during the procedure in 2 of 16 (12.5%). Conclusions: Physician controlled wire-guided cannulation over a PD stent facilitates biliary cannulation and significantly reduces the rate of precut sphincterotomy. Future studies should compare the use of a PD stent with other noninvasive techniques to promote safe and effective biliary cannulation.