Biliary Cannulation Research Articles

Visibility of the biliary orifice after precut papillotomy: Comparison between white light imaging and texture and color enhancement imaging.

Precut papillotomy is performed in cases of difficult biliary cannulation, but identification of the biliary orifice is difficult. Texture and color enhancement imaging (TXI) can enhance the structure, color, and brightness. This study compared TXI and white light imaging (WLI) in visibility of biliary orifices. We retrospectively examined 20 patients who underwent bile duct cannulation using both WLI and TXI after precut papillotomy at our center between 2021 and 2022. On WLI and TXI images displayed in random order, bile duct orifice on precut-incision surface of each image was independently evaluated by eight evaluators. Single-indication accuracy rate of biliary orifices, visibility score rated on a 4-grade scale, and color difference between the biliary orifice and the surrounding tissue were examined. The single-indication accuracy rate was higher in TXI compared to WLI (50.6% vs. 35.6%, odds ratio 2.26 [95% CI: 1.32-3.89], p = .003). The time to indicate the biliary orifice was comparable between TXI and WLI (median, 9.7 s [range, 2.6-43] vs. 10.9 s [1.5-64], p = .086). Furthermore, the visibility score was higher in TXI than in WLI (median, 3 [interquartile range, 2-3] vs. 2 [2, 3], p < .001), and the color difference between the biliary orifice and surrounding tissue in TXI was more pronounced than in WLI (median, 22.9 [range, 9.39-55.2] vs. 18.0 [6.48-43.0]; p < .001). TXI enhanced the color difference and visibility of the biliary orifice after precut and improved single-indication accuracy rate, suggesting that it could be useful for biliary cannulation after precut papillotomy.

Needle-Knife Fistulotomy Versus Needle-Knife Papillotomy in Difficult Biliary Cannulation: A Systematic Review and Meta-Analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential endoscopic therapeutic modality for biliary and pancreatic diseases. Needle-knife fistulotomy (NKF) and papillotomy (NKP) are the two most commonly used rescue techniques for patients with difficult biliary cannulation. However, there remains a need for comparative studies on these approaches to inform clinical decision-making. This meta-analysis aimed to evaluate the efficacy and safety of NKF compared to NKP as a rescue technique in difficult biliary cannulation after failed conventional ERCP. We searched PubMed, Scopus, Embase, and Web of Science databases through November 2023 to include all studies that directly compared the outcomes of NKF with NKP in difficult biliary cannulation. Single-arm studies were excluded. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data related to clinical events were calculated using the Mantel-Haenszel method within a random-effect model. The primary outcome was the biliary cannulation success rate. Four studies with 823 patients (n = 376 NKF vs. n = 447 NKP) were included in our analysis. There was no significant difference between the two groups in biliary cannulation success rate (91.7% vs. 86.9%, respectively; OR = 1.54, 95% CI: 0.21 - 2.49, P = 0.14; I2 = 0%). However, the overall rate of adverse events was significantly lower in the NKF group than in the NKP group (OR = 0.46, 95% CI: 0.25 - 0.84, P = 0.01). Pancreatitis (OR = 0.23, 95% CI: 0.05 - 1.11, P = 0.07) and bleeding (OR = 1.43, 95% CI: 0.59 - 3.46, P = 0.42) were similar between the two groups. No significant differences in cholangitis, cholecystitis, perforation, or mortality were observed. Our meta-analysis indicates comparable success rates in comparing NKF and NKP techniques for difficult biliary cannulation after failed conventional ERCP cannulation. Notably, the NKF technique significantly reduces overall adverse events compared to NKP, suggesting that NKF may be preferable due to its favorable safety profile. Additional randomized controlled trials (RCTs) are warranted to evaluate the interval benefit of an NKF technique.

Successful Selective Biliary Cannulation Using Biopsy Forceps during Endoscopic Retrograde Cholangiopancreatography: A Case Report

Periampullary diverticulum is a risk factor for the occurrence and recurrence of gallstone diseases. It is controversial whether periampullary diverticulum affects the success rate of elective biliary cannulation. In some cases, periampullary diverticulum makes selective biliary cannulation difficult. We report a case in which selective biliary cannulation was possible using biopsy forceps in the presence of periampullary diverticulum.

Transpancreatic Sphincterotomy After Double Guidewire Technique Was Noninferior to Primary Transpancreatic Sphincterotomy in Difficult Biliary Cannulation.

When unintentional pancreatic duct access occurs during difficult biliary cannulation, the double guidewire (DGW) or transpancreatic sphincterotomy (TPS) may be utilized. DGW can be easily switched to TPS due to the existing guidewire in the pancreatic duct. However, the efficacy of TPS after DGW, named sequential DGW-TPS technique, versus primary TPS has not been assessed. Our aim was to compare the benefits and adverse events of sequential DGW-TPS technique and primary TPS. We performed a comparative retrospective cohort study that enrolled a total of 117 patients with native papillae. The patients were divided into one of 2 groups according to the primary bile duct access technique (sequential DGW-TPS or primary TPS), both with pancreatic stenting. Between November 2017 and May 2023, a total of 84 patients were grouped into sequential DGW-TPS and 33 into primary TPS. The overall post-ERCP pancreatitis (PEP) rate was 4.3% in the entire cohort, with no statistical differences were observed between the groups in terms of PEP rates (P = 0.927), PEP severity (P = 1.000), first biliary cannulation success (P = 0.621), overall cannulation success (P = 1.000), hyperamylasemia incidence (P = 0.241), elevated amylase levels (P = 0.881), and postoperative hospital stay (P = 0.185). Furthermore, these results remained consistent in multivariable regression analysis. The sequential DGW-TPS technique showed a comparable safety and biliary cannulation success rate to primary TPS in difficult biliary cannulation. Given the potential long-term complications associated with TPS, DGW should be first if inadvertent pancreatic access occurs, with TPS serving as second only if DGW fails.

Efficacy of texture and color enhancement imaging for short-type single-balloon enteroscopy-assisted biliary cannulation in patients with Roux-en-Y gastrectomy: Multicenter study (with video).

Texture and color enhancement imaging (TXI) reportedly improves the identification of the papilla of Vater for selective biliary cannulation compared with white light imaging (WLI). This multicenter study evaluated the efficacy of short-type single-balloon enteroscopy (SBE)-assisted biliary cannulation using a new-generation image-enhanced endoscopy processing system equipped with TXI in patients who underwent Roux-en-Y gastrectomy. Patients with Roux-en-Y gastrectomy with a native papilla, and underwent short SBE-assisted biliary cannulation during endoscopic retrograde cholangiopancreatography-related procedures between January 2019 and April 2023 were retrospectively reviewed. Outcomes of biliary cannulation using TXI and WLI were compared. The primary outcome was time to successful biliary cannulation. Thirty-three patients underwent biliary cannulation with TXI and 98 underwent WLI. The biliary cannulation success rates and median time to successful biliary cannulation with TXI and WLI were 93.9% (95% confidence interval [CI] 79.8-99.3%) and 83.7% (95% CI 74.8-90.4%), respectively (P = 0.14), and 10 min (interquartile range [IQR] 2.5-23.5) and 18 min (IQR 9.75-24), respectively (P = 0.04). Biliary cannulation with TXI required a shorter cannulation time than that required withWLI. Adverse event rates with TXI and WLI did not differsignificantly (P = 0.58). Multivariate linear regression analysis showed that the use of TXI and short length of oral protrusion were associated with a shorter successful biliary cannulation time. Short SBE-assisted biliary cannulation was effective and safe on TXI in patients who underwent Roux-en-Y gastrectomy, and achieved shorter successful biliary cannulation time.

Precut over a pancreatic stent using the marking method to aid biliary cannulation in a patient with Roux-en-Y reconstruction.

Precut over a pancreatic stent using the marking method to aid biliary cannulation in a patient with Roux-en-Y reconstruction.

Prognostic Factors for Severe-to-Fatal Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Multicenter Prospective Cohort Study.

The prognostic factors associated with severe-to-fatal post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remain unclear despite the extensive number of studies on PEP. In total, 3739 ERCP patients with biliary disease with an intact papilla and indicated for ERCP were prospectively enrolled at 36 centers from April 2017 to March 2018. Those with acute pancreatitis diagnosed before ERCP, altered gastrointestinal anatomy, and an American Society of Anesthesiologists (ASA) physical status > 4 were excluded. Univariate and multivariate logistic regression analyses were performed on patient-related factors, operator-related factors, procedure-related factors, and preventive measures to identify potential prognostic factors for severe-to-fatal PEP. Multivariate analyses revealed pancreatic guidewire-assisted biliary cannulation (OR 13.59, 95% CI 4.21-43.83, p < 0.001), post-ERCP non-steroidal anti-inflammatory drug (NSAID) administration (OR 11.54, 95% CI 3.83-34.81, p < 0.001), and previous pancreatitis (OR 6.94, 95% CI 1.45-33.33, p = 0.015) as significant risk factors for severe-to-fatal PEP. Preventive measures included endoscopic biliary sphincterotomy (EST; OR 0.29, 95% CI, 0.11-0.79, p = 0.015) and prophylactic pancreatic stents (PPSs; OR 0.11, 95% CI, 0.01-0.87, p = 0.036). In biliary ERCP, pancreatic guidewire-assisted biliary cannulation, NSAID administration after ERCP, and previous pancreatitis were risk factors for severe-to-fatal PEP, whereas EST and PPS were significant preventive measures for severe-to-fatal PEP.

Impact of duodenal papilla anatomy on needle knife papillotomy safety and efficacy in patients with difficult biliary canulation

Background and aimsNeedle-knife papillotomy (NKP) is widely performed when biliary cannulation is difficult during endoscopic retrograde cholangiopancreatography (ERCP). However, its safety and efficacy in different types of duodenal papilla are not clear.Patients and methodsThis retrospective study analyzed 217 patients with difficult biliary cannulation who underwent NKP during ERCP procedures from June 2013 to May 2022 in our institution. Patients were classified according to Haraldsson classification type of duodenal papilla: type 1, regular; type 2, small; type 3, protruding or pendulous; and type 4, creased or ridged. Outcome measures were successful biliary cannulation and incidence of adverse events.ResultsHaraldsson classification was type 1 in 115 patients, type 2 in 29, type 3 in 52, and type 4 in 21. Biliary cannulation was successful in 166 patients (76.5%) Success rates according to Haraldsson type were as follows: type 1, 74.8%; type 2, 82.8%; type 3, 80.8%; and type 4, 66.7%. The rates did not significantly differ among the types (p = 0.48). Overall incidence of adverse events was 9.22%. Incidence of adverse events did not significantly differ among the types (p = 0.69).ConclusionsNKP was useful to achieve successful cannulation in patients with difficult biliary cannulation. The rate of successful cannulation and incidence of adverse events were similar among the different types of duodenal papilla.

Needle puncture fistulotomy: a new technique for needle-knife fistulotomy as a primary biliary access method for biliary cannulation.

Needle puncture fistulotomy: a new technique for needle-knife fistulotomy as a primary biliary access method for biliary cannulation.

A modified dual-knife fistulotomy for achieving challenging biliary cannulation in type 3 papilla

Video 1A modified dual-knife fistulotomy for achieving challenging biliary cannulation in type 3 papilla.

EUS-directed transgastric ERCP with EUS-guided rendezvous for difficult biliary cannulation in a patient with Roux-en-Y gastric bypass

Video 1Xxx.

Non-tip and rotatable sphincterotome for biliary cannulation in patients with Roux-en-Y gastrectomy.

Non-tip and rotatable sphincterotome for biliary cannulation in patients with Roux-en-Y gastrectomy.

Analysis of the Effectiveness of Second Attempt Endoscopic Retrograde Cholangiopancreatography (ERCP) 24 Hours (Second Day) After Primary Failure.

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive intervention that has established itself as the gold standard therapeutic option for various pancreaticobiliary conditions. Deep cannulation of the common bile duct (CBD) is essential in ERCP. However, cannulation is not possible in approximately 20% of the cases with the usual techniqueseven when performed by highly trained professionals or at major healthcare institutions. In case of failure on the first attempt, alternative choices include redoing the procedure (on the secondattempt) or moving on to more proficient endoscopic methods such as endoscopic ultrasound (EUS) or radiology-aided techniques (rendezvous procedures), totally percutaneous approaches, or surgical treatments. To analyze the effectiveness of the second attempt ERCP24 hours (second day) after primary failure. This analytical study was conducted to check the outcomes of second attempt ERCP in patients with prior failed cannulation, from June 20, 2023, to November 20,2023, at the Department of Gastroenterology, Lady Reading Hospital, Peshawar. Patients of either sex, aged >16 years with failed biliary cannulation, and who were otherwise clinically stable were included in the study. Patients with surgically modified anatomy, an unidentified main duodenal papilla, or a history of sphincterotomy at another setup were excluded. Outcomes were assessed in terms of gaining deep biliary access (cannulation) using a therapeutic duodenoscope and endoscopy system supported by a fluoroscope while using a wire-guided sphincterotome. Factors linked to second ERCP cannulation success or failure were analyzed using SPSS version 24. Ninety-four patients were enrolled including 61 (64.9%) males and 33 (35.10%) females. The mean age of the participants was 39.01±14.831 years. The most common indication for the intervention was CBDstones, which were present in 70 (74.5%) patients. Successful cannulation on the second attempt was achieved in 72 (76.6%) patients. Experienced endoscopists achieved a greater proportion of successful cannulation (86.8%) compared to 33.3% by endoscopists with lower experience (p-value: <0.001). Logistic regression analysis was conducted to predict the outcomes (cannulation), which revealed an odds ratio for endoscopist experience of 33.604 (95% confidence interval: 6.948-162.52). A second ERCP attempt24 hours after the primary failed attempt appears to be the best course of action for the majority of clinically stable patients.

The Bethesda ERCP Skills Assessment Tool (BESAT) can reliably differentiate endoscopists of different experience levels.

Background and study aims The Bethesda ERCP Skill Assessment Tool (BESAT) is a video-based assessment tool of technical endoscopic retrograde cholangiopancreatography (ERCP) skill with previously established validity evidence. We aimed to assess the discriminative validity of the BESAT in differentiating ERCP skill levels. Methods Twelve experienced ERCP practitioners from tertiary academic centers were asked to blindly rate 43 ERCP videos using the BESAT. ERCP videos consisted of native biliary cannulation and sphincterotomy and were recorded from 10 unique endoscopists of various ERCP experience (from advanced endoscopy fellow to > 10 years of ERCP experience). Inter-rater reliability, discriminative validity, and internal structure validity were subsequently assessed. Results The BESAT was found to reliably differentiate between endoscopists of varying levels of ERCP experience with experienced ERCPists scoring higher than novice ERCPists in 11 of 13 (85%) instrument items. Inter-rater reliability for BESAT items ranged from good to excellent (intraclass correlation range: 0.86 to 0.93). Internal structure validity was assessed with item-total correlations ranging from 0.53 to 0.83. Conclusions Study findings demonstrate that the BESAT, a video-based ERCP skill assessment tool, has high inter-rater reliability and has discriminative validity in differentiating novice from expert ERCP skill. Further investigations are needed to determine the role of video-based assessment in improving trainee learning curves and patient outcomes.

Successful cholangioscopy-guided cannulation using a novel slim cholangioscope.

Selective biliary cannulation is a difficult step in endoscopic retrograde cholangiopancreatography. In this case video, Tanisaka and colleagues report a successful cholangioscopy-guided cannulation achieved using a novel slim cholangioscope with a 2.3-mm scope tip. Cholangioscopy-guided cannulation using this cholangioscope could be a good option in cases of difficult biliary cannulation.

Double-guidewire technique for selective biliary cannulation does not increase the rate of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with naïve papilla.

This study aimed to compare the safety of the double-guidewire technique (DGT) with that of the conventional single-guidewire technique (SGT) in real-world situations. A total of 240 patients with naïve papilla who underwent endoscopic retrograde cholangiopancreatography (ERCP) at Daegu Catholic University Medical Center between January 2021 and December 2021 were included. The primary outcome was the rate of post-ERCP pancreatitis (PEP) in the SGT and DGT groups. A total of 163 patients (67.9%) belonged to the SGT group, and 77 (32.1%) belonged to the DGT group. The rates of successful biliary cannulation were 95.7% and 83.1% in the SGT and DGT groups, respectively (p=0.002). In the study group, PEP occurred in 14 patients (5.8%). The PEP rates were not significantly different between the SGT and DGT groups (4.3% vs. 9.1%, p=0.150). In the multivariate analysis, the age of <50 years (odds ratio [OR], 9.305; 95% confidence interval [CI], 1.367-63.358; p=0.023) and hyperlipidemia (OR, 7.384; 95% CI, 1.103-49.424; p=0.039) were significant risk factors for PEP in the DGT group. DGT did not increase the PEP rate in patients with naïve papilla. In addition, the age of <50years and hyperlipidemia were significant risk factors for PEP in the DGT group.

A new pancreatic guidewire–assisted biliary cannulation technique using double soft-tipped guidewire: wire bridge cannulation

A new pancreatic guidewire–assisted biliary cannulation technique using double soft-tipped guidewire: wire bridge cannulation

Endoscopic drainage of malignant distal biliary obstruction. Will ERCP no longer be necessary?

We read with interest the Editorial by Vila et al. on the paradigm shift for endoscopic biliary drainage of malignant distal biliary obstruction (MDBO) which places Endoscopic Ultrasound (EUS) drainage as the first option instead of traditional ERCP drainage. The modern biliary endoscopist must have the duodenoscope in one hand and the therapeutic echoendoscope in the other. ERCP training alone is no longer appropriate because the goal is to drain the obstruction during a single session. That is why in more and more centers the patient signs a single consent for endoscopic biliary drainage, whether by ERCP, EUS or combined. Should EUS drainage be used first for MDBO without attempting ERCP? A possible protocol for endoscopic drainage of MDBO could be to start with the duodenoscope for ERCP. If the papilla of Vater is accessible, try cannulation considering the ESGE criteria for a difficult cannulation: more than 5 contacts with the papilla; more than 5 minutes spent attempting to cannulate following visualization of the papilla; more than one unintended pancreatic duct cannulation or opacification. If biliary cannulation is not achieved, immediately switch to EUS drainage during the same session. Occasionally, the double guidewire technique or even transpancreatic biliary sphincterotomy could be used, but not needle-knife precut.

Weekend endoscopic retrograde cholangiopancreatography has similar outcomes as weekday procedures-a propensity score match analysis of the Hungarian ERCP Registry.

Endoscopic retrograde cholangiopancreatography (ERCP) is essential for the minimally invasive management of biliary and pancreatic disorders. Under certain indications, performing ERCP without delay during the weekend can be important for improving outcomes. To compare the outcomes of ERCP performed on weekends and holidays with those of regular weekday ERCPs. Propensity score match analysis of the data from the Hungarian ERCP Registry. A total of 116 ERCPs were performed during weekends or holidays, and 3144 during weekday working hours. The analyses were performed on 1:2 propensity-matched groups (116 weekend and 232 weekday cases). Weekend ERCPs were mostly performed for acute cholangitis and acute biliary pancreatitis (70% of cases), whereas in the weekday group, only 32% of cases were performed for these indications. No significant difference was found between weekday and weekend ERCPs in terms of the rates of successful (91.38% vs 93.1%, p = 0.565) and difficult (33.62% vs 36.64%, p = 0.511) biliary cannulations. We found no significant differences in the number of adverse events (bleeding, post-ERCP pancreatitis, and 30-day mortality) in ERCPs performed during weekends or weekdays. Moreover, no significant differences in the aforementioned outcomes were detected between the propensity-matched groups. In this propensity-matched study, no significant differences were found in the outcomes of weekend and weekday ERCPs.

Transpancreatic sphincterotomy with double guidewire and pancreatic prothesis after involuntary passage of the guidewire to the pancreas in attempts at biliary cannulation.

In this work we review the approach to difficult cannulation situations during ERCP. Among the known options to solve this problem, we suggest a technical variant that we believe can be useful to successfully complete ERCP with complication rates similar to a conventional ERCP, at least in our experience. To do this, we reviewed 1488 ERCPs and the 23 cases in which we applied this technical variant with its results and complications.