Biliary Cannulation Research Articles

Difficult biliary cannulation in patients with distal malignant biliary obstruction: An underestimated problem?

Failed biliary cannulation still poses a major challenge in patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP). To date, there is a lack of data on rates of Difficult Biliary Cannulation (DBC) in patients with distal malignant biliary obstruction (DMBO). This was a retrospective study (09/2015 to 02/2019) of consecutive patients with DMBO that underwent ERCP in four Italian centers. The primary outcome was to evaluate the rate of DBC. Secondary outcomes were: cannulation failure, rate of adverse events (AEs), the predictive factors for DBC as well as for AEs. A total of 622 patients with DMBO, were included in the study, with 351(56,4%) matching the definition of DBC. One-hundred and two ERCP-related AEs occurred in 97 of 622 patients (15,6%). Subjects with DBC showed a higher risk for AEs (p=0.02). The lack of pancreatitis prophylaxis (p=0.03), diagnosis of cholangiocarcinoma (p=0.02), the use of papillotomy (OR=1.98; 95%CI=1.14-3.45) and the combination of two or more techniques for cannulation (OR=2.88; 95%CI=1.04-7.97) were associated with the occurrence of AEs. According to the results of this study, patients with DMBO carries a higher rate of DBC thus requiring alternative techniques for biliary drainage. Furthermore, DBC carries a high risk for AEs. Further prospective multicentric studies are needed to confirm these data in this specific subgroup of patients.

Clinical safety and outcomes of glucagon use during endoscopic retrograde cholangiopancreatography (ERCP).

Background and study aims Injectable glucagon enables easier biliary cannulation by inhibiting gastrointestinal motility and decreasing the frequency and amplitude of phasic activity of the sphincter of Oddi during endoscopic retrograde cholangiopancreatography (ERCP). Data about the safety profile of glucagon use and patient clinical outcomes are scarce. Patients and methods We used a federated cloud-based network research database, TriNetX, comprising 92 US healthcare organizations to find adult patients undergoing ERCP with glucagon use (Group A) vs. without using glucagon (Group B) from August 1, 2010, to August 1, 2021. The primary outcomes were rates of gastrointestinal bleeding, gastrointestinal perforation, post-ERCP pancreatitis, inpatient hospitalizations, and 30-day overall mortality measured after 1:1 propensity matching of the groups based on the baseline demographics and comorbidities. Results There were 9,008 patients in Group A compared to 256,597 in Group B. After matching, Group A patients had lower rates of gastrointestinal bleeding (risk ratio [RR], 0.68; CI, 0.52–0.86), post-ERCP pancreatitis (RR, 0.64; CI, 0.58–71), inpatient hospitalization (RR 0.34; CI:0.32 to 0.36) and overall mortality (RR, 0.81; CI, 0.66–0.99). The rates of gastrointestinal perforation (RR, 0.64; CI: 0.34 to 1.19), hyperkalemia (RR, 0.83; CI, 0.64–1.09) and hyperglycemia (RR, 0.65; CI, 0.41–1.03) did not differ between the two groups. Discussion Glucagon use during ERCP was associated with low rates of gastrointestinal bleeding, post-ERCP pancreatitis, inpatient hospitalization, and overall mortality. Moreover, the rates of hyperkalemia and hyperglycemia did not differ between the two groups even after matching for diabetes, indomethacin use, obesity, and chronic kidney disease.

Does ERCP position matter? A randomized controlled trial comparing efficacy and complications of left lateral versus prone position (POSITION study).

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is traditionally performed with patients in the prone position (PP). However, this poses a potentially increased risk of anesthetic complications. An alternative is the left lateral (LL) decubitus position, which is commonly used for endoscopic procedures. Our aim was to compare cannulation rate, time, and outcomes in ERCP performed in LL versus PP. Patients and methods We conducted a non-inferiority, prospective, randomized control trial with 1:1 randomization to either LL or PP position. Patients > 18 years of age with native papillae requiring a therapeutic ERCP were recruited between March 2017 and November 2018 in a single tertiary center. Results A total of 253 patients were randomized; 132 to LL (52.2 %) and 121 to PP (47.8 %). Cannulation rates were 97.0 % in LL vs 99.2 % in PP (difference –2.2 % (one-sided 95 % CI: –5 % to 0.6 %). Median time to biliary cannulation was 03:50 minutes in LL vs 02:57 minutes in PP ( P = 0.62). Pancreatitis rates were 2.3 % in LL vs 5.8 % in PP ( P = 0.20). There were significantly lower radiation doses used in PP (0.23 mGy/m 2 in LL vs 0.16 mGy/m 2 in PP, P = 0.008) without a difference in fluoroscopy times. Conclusions Our analysis comparing LL to PP during ERCP shows comparable procedural and anesthetic outcomes, with significantly lower radiation exposure when performed in PP. We conclude that ERCP undertaken in the LL position is not inferior to PP, except for higher radiation exposure, and should be considered as a safe alternate position for patients undergoing ERCP.

Modified double-guidewire technique using a new double-lumen catheter and 0.018-inch guidewire for difficult biliary cannulation.

Watch a video of this article.

Guidewire-assisted cannulation of the common bile duct for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

Cannulation techniques have been recognized as being important in causing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, considerable controversy exists about the usefulness of the guidewire-assisted cannulation technique for the prevention of PEP. To assess the effectiveness and safety of the guidewire-assisted cannulation technique compared to the conventional contrast-assisted cannulation technique for the prevention of PEP in people undergoing diagnostic or therapeutic ERCP for biliary or pancreatic diseases. For the previous version of this review, we searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL and major conference proceedings, up to February 2012, with no language restrictions. An updated search was performed on 26 February 2021 for the current version of this review. Two clinical trial registries, clinicaltrials.govand WHO ICTRP, were also searched in this update. Randomized controlled trials (RCTs) comparing the guidewire-assisted cannulation technique versus the contrast-assisted cannulation technique in people undergoing ERCP. Two review authors conducted study selection, data extraction, and methodological quality assessment independently. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi² test (P < 0.10) and I² statistic (> 50%). To explore sources of heterogeneity, we conducted a priori subgroup analyses according to trial design, publication type, risk of bias, use of precut sphincterotomy, inadvertent guidewire insertion or contrast injection of the pancreatic duct (PD), use of a PD stent, cannulation device, and trainee involvement in cannulation. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed-effect versus random-effects) and per-protocol analysis. 15 RCTs comprising 4426 participants were included. There was moderate heterogeneity among trials for the outcome of PEP (P = 0.08, I² = 36%). Meta-analyses suggest that the guidewire-assisted cannulation technique probably reduces the risk of PEP compared to the contrast-assisted cannulation technique (RR 0.51, 95% CI 0.36 to 0.72, 15 studies, moderate-certainty evidence). In addition, the guidewire-assisted cannulation technique may result in an increase in primary cannulation success (RR 1.06, 95% CI 1.01 to 1.12, 13 studies, low-certainty evidence), and probably reduces the need for precut sphincterotomy (RR 0.79, 95% CI 0.64 to 0.96, 10 studies, moderate-certainty evidence). Compared to the contrast-assisted cannulation technique, the guidewire-assisted cannulation technique may result in little to no difference in the risk of post-sphincterotomy bleeding (RR 0.87, 95% CI 0.49 to 1.54, 7 studies, low-certainty evidence) and perforation (RR 0.93, 95% CI 0.11 to 8.23, 8 studies, very low-certainty evidence). Procedure-related mortality was reported by eight studies, and there were no cases of deaths in both arms (moderate-certainty evidence).Subgroup analyses suggest that the heterogeneity for the outcome of PEP could be explained by differences in trial design. The results were robust in sensitivity analyses. There is moderate-certainty evidence that the guidewire-assisted cannulation technique probably reduces the risk of PEP compared to the contrast-assisted cannulation technique. There is low-certainty evidence that the guidewire-assisted cannulation technique may result in an increase in primary cannulation success. There is low- and very low-certainty evidence that the guidewire-assisted cannulation technique may result in little to no difference in the risk of bleeding and perforation. No procedure-related deaths were reported. Therefore, the guidewire-assisted cannulation technique appears to be superior to the contrast-assisted cannulation technique considering the certainty of evidence and the balance of benefits and harms. However, the routine use of guidewires in biliary cannulation will be dependent on local expertise, availability, and cost. Future research should assess the effectiveness and safety of the guidewire-assisted cannulation technique in the context of other pharmacologic or non-pharmacologic interventions for the prevention of PEP.

Predictive factors of needle-knife pre-cut papillotomy failure in patients with difficult biliary cannulation

Predictors of needle-knife pre-cut papillotomy (NKP) failure for patients with difficult biliary cannulation has not been reported. Between 2004 and 2016, 390 patients with difficult biliary cannulation undergoing NKP were included in this single-center study. Following NKP, deep biliary cannulation failed in 95 patients (24.4%, NKP-failure group) and succeeded in 295 patients (75.6%, NKP-success group). Patient and technique factors were used to identify the predictors of initial NKP failure. Compared with the NKP-success group, periampullary diverticulum (28.4% vs. 18%, p = 0.028), surgically altered anatomy (13.7% vs. 7.1%, p = 0.049), number of cases performed by less experienced endoscopists, and bleeding during NKP (38.9% vs. 3.4%, p < 0.001), were significantly more frequent in the NKP-failure group. On multivariate analysis, surgically altered anatomy (OR 2.374, p = 0.045), endoscopists’ experience (OR 3.593, p = 0.001), and bleeding during NKP (OR 21.18, p < 0.001) were significantly associated with initial failure of NKP. In conclusion, NKP is a highly technique-sensitive procedure, as endoscopists’ experience, bleeding during NKP, and surgically altered anatomy were predictors of initial NKP failure.

FACTORS ASSOCIATED WITH DIFFICULT BILIARY CANNULATION IN A TRAINING CENTER FOR ENDOSCOPIC INTERVENTION OF THE BILIARY TRACT.

This paper aims to determine factors associated with difficult biliary cannulation (DBC) that are identifiable before procedures. This is a nested case-control study within a historical cohort in adult patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) from 2015-2019 in the Hospital Universitario San Ignacio, Colombia. This study assessed the associations among variables that could be identified before or at the beginning of procedures and the probability of DBC. These associations were evaluated through a bivariate and multivariate analysis. The study used criteria for DBC defined by the European Society of Gastrointestinal Endoscopy. A total of 498 ERCP performed in 376 patients were analyzed. Of all procedures, 144 (29%) fulfilled criteria for DBC. The multivariate analysis showed an association between DBC and the acute care hospital setting (OR:2.92; CI95% 1.70-5.01; P<0.001), redundant papilla (OR:7.26; CI95% 3.38-15.61; P<0.001), or peridiverticular papilla (OR:2.45; CI95% 1.38-4.36; P=0.002). No association was found between DBC and endoscopist's experience, bilirubin levels, or dilation of the biliary tract. The DBC is a frequent event. Alterations in the papilla and ERCP performed in the acute care hospital setting are the principal factors associated with DBC. This information might be useful to predict DBC and establish healthcare and administrative strategies to reduce its implications.

Second endoscopic retrograde cholangiopancreatography after failure of initial biliary cannulation: A single institution retrospective experience.

Endoscopic retrograde cholangiopancreatography (ERCP) is not always successful when difficult biliary cannulation occurs. A second ERCP seems to be a worthwhile option following initial failure cannulation; however, relevant data are limited. Thus, the aim of the present study was to determine the outcomes of repeating ERCP in patients in whom the first biliary cannulation with or without precut sphincterotomy failed. It retrospectively analyzed 4,136 patients who underwent an initial biliary access between June 2016 and September 2020. Data from our databases were analyzed. Efficacy was based on the cannulation rate of the second ERCP and safety was assessed in terms of adverse events. Of 94 patients, 56 (59.6%) underwent a second ERCP and the success rate in biliary cannulation was 83.9% (47 of 56). The median operative time in the second ERCP was shorter than that in the initial procedure (47 vs. 65 min, P<0.001). A total of 5 patients (8.9%) suffered from mild ERCP-associated complications following the second ERCP. Compared with patients that did not undergo a second ERCP, patients that underwent a second ERCP had a lower 30-day mortality rate (13.2 vs. 1.8%, P=0.038). In addition, by univariate and multivariate analysis, it was observed that normal preoperative serum bilirubin levels and an interval time of <3 days were correlated with the cannulation failure of a second ERCP (OR=9.211, P=0.019, OR=6.765, P=0.041, respectively). A second ERCP following failure of an initial biliary cannulation appears to be safe and effective. For most clinically stable patients with an unsuccessful initial ERCP, a second ERCP after 2-4 days may be an optimal strategy. Preoperative normal serum bilirubin levels may be a risk factor that can be used for predicting cannulation failure of a second ERCP procedure.

Underwater Cannulation for Intradiverticular Papilla: A New Technique of Biliary Cannulation.

Underwater Cannulation for Intradiverticular Papilla: A New Technique of Biliary Cannulation.

Combined rectal indomethacin and intravenous saline hydration in post-ERCP pancreatitis prophylaxis

Background and study aimAcute pancreatitis (AP) is a potentially life-threatening complication of endoscopic retrograde cholangiopancreatography (ERCP). There is a lack of effective measures to prevent post-ERCP pancreatitis (PEP), except NSAIDs. Aggressive hydration for AP can be considered, given the frequency of hemoconcentration, hypovolemia, and hypoperfusion in pancreatitis. We aimed to clarify the clinical utility of combined indomethacin and saline hydration for preventing PEP. Patients and methodIn this cross-sectional study, 120 patients undergoing ERCP for the first time at the Gastrointestinal Endoscopy Unit and Liver Unit Kasralainy (GIELUKA) were enrolled and then randomly allocated into two groups: indomethacin and indomethacin-hydration groups. Intravenous (IV) saline was given to the latter at a rate of 10 ml/kg/h after the ERCP for 2 h. ResultsThe age of the studied patients was 43.8 ± 14.9 years, with 55% of them being female. The patient-related risk factors for PEP were older age (p = 0.039), higher pre-ERCP urea level (p = 0.032), and less choledocholithiasis (p = 0.028). The patients with PEP had a higher frequency of biliary cannulation attempts (p = 0.004) and accidental pancreatic duct cannulation (p = 0.003), required a longer cannulation time (p = 0.021), had undergone precut knife and transpancreatic sphincterotomy at a higher rate (p = 0.032; and p = 0.001, respectively), and had a significantly longer procedure time (p = 0.006).PEP occurred in only five patients in the indomethacin group, while it did not occur in the indomethacin-hydration group (8% vs. 0%, p = 0.022). Serum amylase and lipase elevation 2 h after ERCP were predictors of PEP. However, serum amylase only was significantly lower 2 h post-ERCP in the indomethacin-hydration group than in the indomethacin group (p = 0.045). Moreover, abdominal pain and vomiting on the first day of ERCP were good predictors of PEP. ConclusionAggressive IV saline hydration with rectal indomethacin can more effectively prevent PEP than indomethacin alone.

Multicenter prospective cohort study of adverse events associated with biliary endoscopic retrograde cholangiopancreatography: Incidence of adverse events and preventive measures for post-endoscopic retrograde cholangiopancreatography pancreatitis.

ObjectivesThe reported incidence of adverse events (AEs) in endoscopic retrograde cholangiopancreatography (ERCP) varies between 2.5% and 14%. The aim of this study was to evaluate the incidence and severity of AEs in biliary ERCP and to specify the risk factors and preventive measures for post‐ERCP pancreatitis (PEP).MethodsPatients with biliary disease with intact papilla were prospectively enrolled at 36 hospitals between April 2017 and March 2018. The primary outcomes were the incidence and severity of AEs.ResultsA total of 16,032 ERCP procedures were performed at the 36 hospitals during the study period and 3739 patients were enrolled. The overall incidence of AEs was 10.1% and ERCP‐related mortality was 0.08%. PEP developed in 258 cases (6.9%), bleeding in 33 (0.9%), instrumental AEs in 17 (0.5%), infections in 37 (1.0%), cardiovascular AEs in eight (0.2%), pulmonary AEs in eight (0.2%), drug reaction AE in one (0.03%), pain in 15 (0.4%), and other AEs in 15 (0.4%). Multivariable analysis showed significant risk factors for PEP were: female of younger age, pancreatic guidewire‐assisted biliary cannulation, temporary guidewire insertion into the pancreatic duct, total procedure time >60 min, and post‐ERCP administration of non‐steroidal anti‐inflammatory drugs. Effective preventive measures were prophylactic pancreatic stenting (PPS) and epinephrine spraying onto the papilla.ConclusionsIn patients with intact papilla who underwent biliary ERCP, the incidence of AEs was 10.1% and the mortality was 0.08%. PPS and epinephrine spraying may prevent PEP.RegistrationThis study was registered in the University Hospital Medical Information Network (UMIN000024820).

Development and Utilization of Sphincterotome for Successful Biliary Cannulation and Safe Endoscopic Sphincterotomy

Development and Utilization of Sphincterotome for Successful Biliary Cannulation and Safe Endoscopic Sphincterotomy

Safety, Risk Stratification and Cost of ERCP in Patients with Cirrhosis

Introduction: Procedure related complications and cost of therapeutic ERCP in patients with cirrhosis were compared to patients without cirrhosis. Disease severity scores were used to stratify procedure risks. Patients and Methods: Outcome and complications of therapeutic ERCP were prospectively studied in patients with cirrhosis and compared to patients without cirrhosis undergoing ERCP. Patients with cirrhosis were evaluated using liver scores. Results: The study included 150 patients with cirrhosis (60% males, mean age 60+/-12.4 years), and 150 patients without cirrhosis (56% males, mean age 52.4+/-20.3 years). Biliary cannulation was successful in 98% and 98.3% of patients with and without cirrhosis. Clinical pancreatitis, perforation, bleeding and cardiopulmonary complications were not different in patients with and without cirrhosis (8% vs 9.3, 0% vs 2%, 3.3% vs 4%, and 4% vs 2% respectively), while cholangitis occurred more frequently in patients with cirrhosis (13.3% vs 1.3% respectively). Hospital stay was longer and mortality and costs were significantly higher among patients with cirrhosis. Patients with Child C cirrhosis developed more complications and had higher mortality. A MELD score cut off of ≥11.5 separated all mortalities. Conclusions: Patients with cirrhosis experienced more complications and costs, and patients with cirrhosis who developed moderate to severe complications were more likely to die.

A fatal case intra-abdominal hemorrhage following self-removal of a percutaneous transhepatic gallbladder drainage tube

A 92-year-old woman with gallstone pancreatitis and acute cholangitis was admitted to our hospital where endoscopic retrograde cholangiopancreatography was performed for emergency biliary drainage. Biliary cannulation was unsuccessful. Consequently, percutaneous transhepatic gallbladder drainage (PTGBD) was performed, and her symptoms improved. The PTGBD tube was removed by the patient on the third day of admission resulting in cardiopulmonary arrest two hours later. Cardiopulmonary resuscitation restored spontaneous circulation. Contrast computed tomography revealed intra-abdominal hemorrhage from the right hepatic artery by the removed part of the PTGBD tube. The patient died despite hemostasis by transcatheter artery embolization. PTGBD is generally effective and safe;however, it can cause fatal hemorrhage, especially if PTGBD tubes are removed by the patient. Thus, self-removal should be strictly prevented.

How to perform EUS-guided biliary drainage.

EUS-guided biliary drainage (EUS-BD) has recently gained widespread acceptance as a minimally invasive alternative method for biliary drainage. Even in experienced endoscopy centers, ERCP may fail due to inaccessibility of the papillary region, altered anatomy (particularly postsurgical alterations), papillary obstruction, or neoplastic gastric outlet obstruction. Biliary cannulation fails at first attempt in 5%-10% of cases even in the absence of these factors. In such cases, alternative options for biliary drainage must be provided since biliary obstruction is responsible for poor quality of life and even reduced survival, particularly due to septic cholangitis. The standard of care in many centers remains percutaneous transhepatic biliary drainage (PTBD). However, despite the high technical success rate with experienced operators, the percutaneous approach is more invasive and associated with poor quality of life. PTBD may result in long-term external catheters for biliary drainage and carry the risk of serious adverse events (SAEs) in up to 10% of patients, including bile leaks, hemorrhage, and sepsis. PTBD following a failed ERCP also requires scheduling a second procedure, resulting in prolonged hospital stay and additional costs. EUS-BD may overcome many of these limitations and offer some distinct advantages in accessing the biliary tree. Current data suggest that EUS-BD is safe and effective when performed by experts, although SAEs have been also reported. Despite the high number of clinical reports and case series, high-quality comparative studies are still lacking. The purpose of this article is to report on the current status of this procedure and to discuss the tools and techniques for EUS-BD in different clinical scenarios.

Safety and efficacy of different techniques in difficult biliary cannulation at endoscopic retrograde cholangiopancreatography

ABSTRACT Background Adverse events (AEs) are commonly seen at endoscopic retrograde cholangiopancreatography (ERCP) during difficult biliary cannulation (DBC). Therefore, attaining the right technique is essential to have improved outcomes. Methods Patients who had DBC over a 3-year period were assessed for outcomes. The protocol included double guidewire (DGW) technique, wire-guided cannulation (WGC) after pancreatic stent, precut sphincterotomy/fistulotomy, and EUS-guided rendezvous (RV). The success of various techniques and AE was studied. Results As per available case analysis, a total of 3680 patient details were assessed out of which DBC was noted in 471 (12.8%) patients with a mean (SD) age of 51.5 (17.4) years; majority being 330 (70.1%) males. Most patients underwent precut sphincterotomy 230 (48.8%); however, it was not successful in the first attempt in 10 (2.1%) patients with the success rate of 220 (95.6%). The success rate of DGW cannulation was 120 (95.2%), WGC after pancreatic stent was 64 (94.1%), EUS-RV was 34 (97.1%), and wire-guided repeat ERCP after 48 h was 10 (98.3%). AEs were noted in 52 (11.1%) patients. After precut, 32 (13.9%) patients developed AE out of which post-ERCP pancreatitis was noted in 20 (8.7%). Twenty-three patients had failed biliary access after all methods and 20 (86.9%) of those received successful percutaneous transhepatic biliary drainage. Conclusion Repeat ERCP after 48 h and EUS-RV appear prudent for DBC. Precut remains one of the preferred choices for most endoscopists when there is no entrance to PD. Further utilizing an algorithmic approach can contribute to higher success rates without compromising safety.

Prevention of post-ERCP pancreatitis using pancreatic duct stenting in difficult cannulation patients with calcular biliary bbstruction

Background: Post-ERCP pancreatitis (PEP) has been the most frequent complication of Endoscopic Retrograde Cholangiopancreatography (ERCP). It has been documented to happen after 5–30% of ERCP procedures. PEP is new or exacerbated abdominal pain associated with a serum lipase or amylase concentration which is more than three times the upper limit of normal at 24 hours post-ERCP, requiring at least two days of prolongation of the planned admission. Following pancreatic sphincterotomy, pancreatic stenting is commonly used with the objective of decreasing both early restenosis and post-ERCP pancreatitis. Aim of the work: Evaluation of the pancreatic stenting technique as a preventive measure against post ERCP pancreatitis in calcular obstructive jaundice patients with difficult cannulation. Patients and methods: Forty Egyptian patients with calcular biliary obstruction with a difficult biliary cannulation who are at risk of developing PEP enrolled in a prospective randomized controlled comparative study. Group A: 20 patients with manipulation of pancreatic duct by guidewire without pancreatic stent insertion; Group B: 20 patients with manipulation of pancreatic duct by guidewire with pancreatic stent insertion.Results: The pancreatic duct stenting technique had reduced the risk of PEP significantly in calcular biliary obstruction patients with difficult CBD cannulation to 20?% (in group B) compared with 60?% in (group A).Conclusion: Prophylactic pancreatic stenting technique is a simple and easy procedure that showed to be efficient in decreasing cases of post ERCP pancreatitis in difficult cannulation patients. The endoscopists should be trained to practice the procedure safely.

The feasibility of cap‐assisted routine adult colonoscope for therapeutic endoscopic retrograde cholangiopancreatography in patients with Roux‐en‐Y reconstruction after total gastrectomy

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y reconstruction after total gastrectomy is difficult to be performed using routine tools. The aim of this study was to evaluate the feasibility and safety of cap-assisted routine adult colonoscope (CARAC) for ERCP in these patients. Sixteen consecutive patients with indications of ERCP who had previously undergone total gastrectomy with Roux-en-Y reconstruction at two tertiary care endoscopy centers were identified. All ERCP procedures were carried out by using CARAC. The success rate of reaching the papilla, biliary cannulation and procedure-related adverse events were analyzed. The papilla was successful reached in 11 (68.8%) of the 16 cases, and biliary cannulation was subsequently reached in eight (72.7%) of the 11 cases. The procedures succeeded in three patients by using a percutaneous-endoscopic rendezvous procedure after failed cannulation. Overall clinical success was achieved in 11 (68.8%) of 16 patients. Procedure-related mild acute pancreatitis was observed in 25.0% (4/16) of the cases and mild cholangitis in 18.8% (3/16). No serious adverse events were reported. CARAC for therapeutic ERCP is safe and effective in treating patients with Roux-en-Y reconstruction after total gastrectomy.

An unusual cause of failed selective biliary cannulation

A 40-year-old man underwent ERCP because of a 4-mm bile duct (BD) calculus. The longitudinal fold in the second part of the duodenum was seen oriented in the 11 to 5 o’clock axis. Initial attempts at selective biliary cannulation accessed the pancreatic duct (PD). Precut papillotomy using a needle-knife exposed a clear opening toward 11 o’clock (A, thick arrow), which surprisingly accessed the PD. A faintly visible opening toward 3 o’clock (A, slim arrow) led to the BD (B). The stone was extracted after sphincterotomy at this opening (C).

OUR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATICOGRAPHY EXPERIENCES: SINGLE CENTER, 688 PATIENTS

Abstract Introduction and Aim: Successful ERCP requires deep cannulation of the common bile duct and/or the main pancreatic duct through the major duodenal papilla (papilla of Vater). Complications have been reported in cases of selective biliary cannulation, but this diminishes in experienced hands. The aim of this topic is to evaluate the practices and results in our clinic on how to achieve successful cannulation and sphincterotomy at minimum risk for the patient. Methods: The results of 688 patients who underwent ERCP in the endoscopy unit of our clinic over a 6-year period (2015-2021) are evaluated. Demographic findings, co-morbidities, duration of the procedure, presence of periampullary diverticulum, difficult cannulation rate, stent use, complication rate and successful cannulation rates of the patients were evaluated. Results: 58.5% of the patients were female. Heart diseases were found in 44.6% of the patients, kidney diseases in 11.5%, lung diseases in 14.9%, central nervous system diseases in 7.8% and malignancy in 2.1%. The common bile duct diameter is 12.98 ± 3.44 mm, and the mean stone size is 8.70 ± 4.50 mm. Periampullary diverticulum was present in 110 (15.9%) of the patients, and stony gall bladder was present in 48.0% of the patients. Selective cannulation was performed in 77.9% and pre-cut sphincterotomy was performed in 18.2%. Periampullary malignancy was detected in 12.1% of patients, and stent was applied to 22.1% of patients. Failed in 3.1% of patients. Emergency laparotomy was performed in 4 patients (0.6%). Bleeding was found in 58 patients (8.5%), perforation in five patients (0.8%), pancreatitis in 25 patients (4.0%), and mortality in six patients (1.0%). Conclusions: Although endoscopic retrograde cholangiopancreatography is an effective diagnostic and therapeutic tool, it can lead to serious complications. ERCP indication should be put correctly, procedures should be done by experienced people. In experienced hands, the success rate is high even with anatomical variations and difficult stones.