Gastrointestinal: Knuckle guidewire insertion: Safe techniques of guidewire insertion into the pancreatobiliary tract using a novel 0.025-inch guidewire.

Abstract

The guidewire is one of the most essential devices during endoscopic retrograde cholangiopancreatography (ERCP). From the perspective of safety management, preventing penetration of the pancreatic or bile duct by the guidewire is important. Recently, a novel guidewire has been available in Japan (MICHISUJI, KANEKA Medical, Osaka, Japan). The characteristics of this guidewire are (i) top side is extremely flexible and (ii) high torque transmission due to excellent surface hydrophilicity. This high flexibility plays an especially important role in safe guidewire technique, which we call ‘knuckle guidewire insertion' (Fig. 1a). In this paper, knuckle guidewire technique for the pancreatic and bile ducts in the ERCP procedure is described. The presented case was one of suspected autoimmune pancreatitis. Because of the negative results on EUS-guided fine needle aspiration, ERCP was attempted to obtain pancreatic and cholangiography imaging. First, the ERCP catheter was inserted into the pancreatic duct orifice, and the contrast medium was injected. The novel guidewire was gently inserted into the pancreatic duct. To prevent penetration, guidewire deflection was first made at the pancreatic head duct (Fig. 1b), and the guidewire was gently pushed. After this procedure, a knuckle shape was successfully made (Fig. 1c), and it was also successfully advanced into the pancreatic tail using knuckle guidewire technique (Fig. 1d). Next, biliary cannulation was attempted using wire-guided cannulation. Because of extreme flexibility and high torque transmission, wire-guided cannulation with knuckle guidewire technique could be easily performed. In addition, a knuckle shape was made automatically (Figs 1e,f). Pancreatic and cholangiographic imaging was successfully obtained without any adverse events. A knuckle shape can prevent pancreatic and bile duct penetration, and it is easily made if this novel guidewire is used. In conclusion, knuckle guidewire technique using a novel guidewire may be useful to prevent penetration of the pancreatic and bile ducts. After pancreatic duct cannulation, the novel guidewire is inserted into the pancreatic duct. To use knuckle guidewire technique, the guidewire is deflected in the pancreatic duct. The guidewire is successfully advanced into the duct of the pancreatic tail. Next, wire-guided biliary cannulation is attempted. During this procedure, the knuckle shape is automatically made. Video S1. Supporting Information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.