Safety and Efficacy of the Double Guidewire Technique for Difficult Biliary Cannulation in Endoscopic Retrograde Cholangiopancreatography

Abstract

Introduction: In 6-10% of endoscopic retrograde cholangiopancreatographies (ERCPs), biliary cannulation (BC) is unsuccessful. In these cases with difficult BC, other cannulation techniques, such as the double guidewire technique (DGT), may be required. In the DGT, a guidewire is placed deep into the pancreatic duct, then alongside this guidewire a sphincterotome loaded with another guidewire is used for BC. 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. Methods: A total of 652 ERCP were studied at three centers in Guayaquil, Ecuador from October 2013 to May 2017. In total, 143 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 143 patients with unsuccessful SGT, biliary cannulation being successful in 72 %( 103 patients). Of the 11 patients who underwent precut sphincterotomy, biliary cannulation was achieved in 52%. 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). Conclusion: The DGT can be used as an alternative to other cannulation techniques in difficult BC with similar success rates. However, the higher risk of PEP with the DGT may prohibit its widespread use. Further studies on whether this higher risk is due to the technique itself or other factors such as a pancreatic duct stent are required.