Prospective Study of Operator-Controlled Guidewire Cannulation of the Bile Duct

Abstract

Bile duct (BD) access during ERCP is usually achieved by contrast injection (CI) and/or assistant-directed guidewire cannulation (GWC). Short wire biliary catheters now allow the operator to control guidewire manipulations during ERCP. The aim of this prospective study was to evaluate the efficiency and safety of operator-controlled GWC when only BD cannulation is intended. Methods: BD cannulation was attempted in all cases using a hydrophilic tipped guidewire controlled by the endoscopist. Contrast was injected after GWC of the BD or when needed to help achieve BD cannulation. Access sphincterotomy (precut) was usually performed if repeated unintentional PD cannulations occurred. Data collected included ERCP indication, BD GWC success and need for CI, unintentional pancreatic duct (PD) GWC or CI, cannulation difficulty, and complications. Cannulation difficulty was graded as: easy (1-4 attempts & < 5 min), moderate (5-10 attempts & < 10 min), difficult, or precut. Results: From 996 ERCPs performed between 5/2004 and 11/2006, 398 patients without prior endotherapy underwent attempted operator-controlled GWC. GWC of only the BD was intended in 223 patients. Indications for ERCP were: abnormal liver tests (n = 135), abnormal intraoperative cholangiogram (n = 43), pain (n = 23), biliary pancreatitis (n = 12), or other (n = 10). Successful BD cannulation was achieved in 220 (99%) cases. GWC of the BD was achieved before any CI in 114 (51%). CI was needed in 48 and precut was performed in 58. Unintentional PD cannulation occurred in 110 (49%) cases with only GWC of the PD in 28 and PD GWC + PD CI in 82. BD cannulation difficulty and post-procedure complication data according to whether the PD was cannulated are found in Tables 1 & 2. One case of mild post-ERCP pancreatitis occurred after operator-controlled unintentional PD GWC without CI. Conclusions: 1) Operator-controlled GWC of the BD is most often easily obtained but unintentional PD cannulation still occurs about half the time. 2) Attempted GWC of the BD is associated with an acceptable risk for post-ERCP complications but is most safe when PD cannulation is completely avoided. Table 1Operator-controlled biliary GWC difficulty according to PD cannulation Cannulation difficulty Easy Moderate Difficult Precut Failed No PD cannulation (n = 113) 85 17 3 7 1 Unintentional PD (n = 110) 19 27 11 51 2 Total (n = 223) 104 44 14 58 3 Open table in a new tab Table 2Post-procedure complications Pancreatitis Perforation Other complications No PD cannulation (n = 113) 0 0 1 (pain) Unintentional PD (n = 110) 5 (4.5%) 1 (0.9%) 1 (bleed) Total ERCP (n = 996) 20 (2%) 7 (0.7%) 21 Open table in a new tab