Cannulation Difficulty Research Articles

Endoscopic Pancreatic Duct Stents Reduce the Incidence of Post–Endoscopic Retrograde Cholangiopancreatography Pancreatitis in High-Risk Patients

Pancreatitis is the most common and potentially serious complication of post-endoscopic retrograde cholangiopancreatography (ERCP). Post-ERCP pancreatitis (PEP) is caused mostly by postprocedural papillary edema and retention of pancreatic juice. We conducted a randomized controlled trial to determine whether placement of a temporary-type, pancreatic duct stent prevents PEP and to identify risk factors for PEP. We analyzed data from 426 consecutive patients who underwent ERCP-related procedures at 37 endoscopic units. The patients were assigned randomly to groups that received stents (S group, n = 213) or did not (nS group, n = 213). The stent used was temporary, 5F in diameter, 3 cm long, and straight with an unflanged inner end. The overall frequency of PEP was 11.3%. The frequencies of PEP in the S and nS groups were 7.9% and 15.2%, respectively; the lower incidence of PEP in the S group was statistically significant based on the full analysis set (P = .021), although there was no statistically significant differences in an intention-to-treat analysis (P = .076). There were significant differences in PEP incidence between groups in multivariate analysis for the following risk factors: pancreatography first, nonplacement of a pancreatic duct stent after ERCP, procedure time of 30 minutes or more, sampling of pancreatic tissue by any method, intraductal ultrasonography, and difficulty of cannulation (≥15 min). Patients with more than 3 risk factors had a significantly greater incidence of pancreatitis. Placement of a pancreatic duct stent reduces the incidence of PEP. Several risk factors are associated with PEP.

The use of a guide catheter extension system as an aid during transradial percutaneous coronary intervention of coronary artery bypass grafts

Prior coronary artery bypass graft (CABG) surgery is one of the main predictors of failure of transradial PCI. Frequently this is due to difficulty in graft cannulation and/or poor backup support. In addition to Proxis's™ embolic protection role, the Proxis™, Heartrail™, and GuideLiner™ guide catheter extension devices have all been shown to facilitate coronary intervention by increasing backup support and aiding stent delivery. We describe our institution's experiences using these devices to aid transradial graft intervention. Between October 2007 and March 2010, the utility and safety of these devices were assessed in consecutive transradial graft intervention procedures. Proxis™ cases used for proximal protection alone were excluded. Deep intubation was defined as an intubation depth of ≥2 cm. Guide catheter extensions were used in 33 of 41 transradial graft interventions identified. Proxis™ was used for proximal protection alone in 3 cases, leaving 30 cases as the study group (Heartrail™ n = 18, GuideLiner™ n = 3, Proxis™ n = 9). In all study cases procedural success with final TIMI-3 flow was achieved. Guide catheter extensions were used to aid during graft cannulation (n = 11), to improve backup support via deep intubation (n = 26) and as an adjunctive aspiration device (n = 11). Filter-based distal embolic protection devices were used in 11/21 Heartrail™ and GuideLiner™ cases. Deep intubation depths ranged from 30 to 138 mm (mean 61 mm) with no complications related to deep intubation seen. The use of guide catheter extension systems facilitated transradial graft intervention via several mechanisms including aid to graft cannulation, increasing backup support, and as an adjunctive aspiration device.

Mo1445 Double Guidewire Technique Versus Transpancreatic Precut Sphincterotomy in Difficult Biliary Cannulation; Randomized Prospective Study

Successful cannulation of the common bile duct (CBD) is an important benchmark of ERCP. Difficulty in CBD cannulation is one of the main risk factors for post-ERCP pancreatitis. Recently, double guidewire technique (DGT) or transpancreatic precut sphincterotomy (TPS) have been considered a promising alternative approach in difficult cannulation situations. The aim of this study was to compare the outcomes between DGT and TPS in the patients with difficult CBD cannulation.

Transillumination by light‐emitting diode facilitates peripheral venous cannulations in infants and small children

Transillumination facilitates the visualization of peripheral veins in infants and children. The clinical usefulness of light-emitting diode (LED)-powered devices has not been thoroughly studied. We randomly assigned 136 infants and children weighing <15 kg, undergoing general anesthesia, to red LED-powered transillumination (TM group, n=67) vs. the usual method (UM group, n=69) of peripheral venous cannulations. Venous puncture was performed following anesthesia induction with sevoflurane and nitrous oxide. The primary and secondary study endpoints were the rate of successful cannulations at initial attempt, and the duration of insertion attempts, respectively. The median score of the estimated cannulation difficulty before attempted puncture was similar in both groups. The success rates at first attempt were 75% and 61% (NS) and mean+/-SD times to successful venous access were 47+/-34 and 68+/-66 s (NS) in the TM and UM groups, respectively. The cannulation procedures were completed significantly earlier in the TM group than in the UM group (hazard ratio, 1.59; 95% confidence interval, 1.03-2.47; P=0.03). In the subgroup of infants and children <2 years old, venous cannulation was successful at first attempt in 73% and 49% in the TM group (n=44) and in the UM group (n=47), respectively (P=0.03). LED-powered transillumination devices facilitated peripheral venous cannulations in small infants and children.

S1446: Predicting Difficult Bile Duct Cannulation: Accuracy of Endoscopic Visualization of the Papilla to Predict Cannulation Difficulty

S1446: Predicting Difficult Bile Duct Cannulation: Accuracy of Endoscopic Visualization of the Papilla to Predict Cannulation Difficulty

Is External Jugular Venous Pressure a Good Predictor of Volume Status in Kidney Graft Recipients?

To ensure appropriate function of the transplanted organ, it is necessary to adequately maintain vascular volume during the kidney transplantation procedure. For this purpose, central venous pressure (CVP) is monitored through a catheter inserted into the superior vena cava (SVC). Central venous cannulation is associated with a risk of serious complications. An objective of this study was to investigate whether there was a correlation between pressures measured in the SVC and in the external jugular vein (EJV). We studied 33 chronically dialyzed patients who had a short catheter placed in the EJV because of difficulties in peripheral vein cannulation in the limbs. In each case, general anesthesia was induced and a central catheter inserted into the SVC. Every 10 minutes venous pressure measurements were obtained simultaneously at both sites. A significant ( P < .001) correlation was observed between external jugular vein pressure (EJVP) and CVP. CVP could be described as a function of EJVP by the equation CVP = {0.90299 × EJVP} − 0.8361. The results of this study indicated that monitoring the EJVP allows equally efficient evaluation of vascular volume as the CVP. In our opinion, EJVP is sufficient to evaluate vascular volume during kidney transplantation in patients with difficult vascular access.

Female Infertility: A Systematic Approach to Radiologic Imaging and Diagnosis

Imaging plays a key role in the diagnostic evaluation of women for infertility. The pelvic causes of female infertility are varied and range from tubal and peritubal abnormalities to uterine, cervical, and ovarian disorders. In most cases, the imaging work-up begins with hysterosalpingography to evaluate fallopian tube patency. Uterine filling defects and contour abnormalities may be discovered at hysterosalpingography but typically require further characterization with hysterographic or pelvic ultrasonography (US) or pelvic magnetic resonance (MR) imaging. Hysterographic US helps differentiate among uterine synechiae, endometrial polyps, and submucosal leiomyomas. Pelvic US and MR imaging help further differentiate among uterine leiomyomas, adenomyosis, and the various müllerian duct anomalies, with MR imaging being the most sensitive modality for detecting endometriosis. The presence of cervical disease may be inferred initially on the basis of difficulty or failure of cervical cannulation at hysterosalpingography. Ovarian abnormalities are usually detected at US. The appropriate selection of imaging modalities and accurate characterization of the various pelvic causes of infertility are essential because the imaging findings help direct subsequent patient care.

Thebesian valve: the guard dog of the coronary sinus?

When the Silesian physician Adam Christian Thebesius described the valve guarding the ostium of the coronary sinus, he could hardly imagine that this structure would attract attention of many researchers and clinicians more than 300 years later.1 However, the advent of novel therapeutic techniques such as catheter ablation of cardiac arrhythmias, cardiac resynchronization therapy, and most recently percutaneous mitral repair have turned interest to this structure as an integral part of anatomy of the coronary sinus. The Thebesian valve is a caudal remnant of the embryonic sinoatrial valves. Whether it has any role in normal physiology is not known and some believe that it may prevent the regurgitation of blood into the sinus during the contraction of the atrium. However, experience from clinical practice suggests that the valve may pose difficulties in cannulation of the coronary sinus. Therefore, studies on anatomy of the Thebesian valve have potential practical implications. The paper by Mak et al. ,2 published in the current issue of the journal, provides another piece of knowledge in a mosaic. In a series of 75 autopsied human hearts (54 with organic heart disease), these authors confirmed a wide variety of Thebesian valve patterns. The valve was present in 73% of examined hearts. Most of these valves were membranous in composition (46%), followed by fibrous (24%), fibromuscular (11%), and muscular composition (18%). Fenestrations were noted in 26% of valves. Importantly, 16% of hearts showed a valve that … *Corresponding author. Tel: +420 261 365 009, Fax: +420 2 4172 82 25, Email: joka{at}medicon.cz

Technical Enhancements to Breast Ductal Lavage

Ductal lavage is a technique that samples the contents of breast ducts for research into the biology of breast cancer. Enthusiasm for this method has declined because of technical challenges associated with the procedure. These include: difficulty in duct cannulation, high levels of subject discomfort, and an inability to confirm perforation. As part of a larger institutional review board (IRB)-approved study, consenting healthy women underwent ductal lavage of 3-4 ducts in one breast. Intranipple lidocaine was administered before duct cannulation. Ductoscopy was performed prior to catheterization and high-definition ultrasound was used for imaging during the lavage procedure. Pain scores were recorded at 24 hours and 2 weeks. Subjects were asked to return in 6 months for a repeat of the procedure. Ductoscopy was performed prior to lavage under real-time ultrasound 308 times in 107 subjects. There were 280 confirmed ducts (90.9%) and 21 perforations (6.8%), while seven (2.3%) were indeterminate. Subjects reported minimal discomfort, and 91% reported a 0 (0-10 range) pain score 2 weeks after the procedure. The retention rate was 90% at 6 months. The injection of lidocaine directly into the nipple greatly increases the feasibility of duct cannulation and improves subject comfort. Confirmation of duct cannulation and lavage can be documented with ductoscopy and ultrasound imaging. These procedures can be added to ductal lavage to facilitate its use as a research tool.

Influence of juxtapapillary diverticula on the success or difficulty of cannulation and complication rate

Periampullary diverticula (PAD) are found in 9% to 32% of patients who undergo an ERCP. Published studies confer conflicting results regarding the true impact of PAD on the technical success and complications of ERCP. The aim of the study was to investigate and compare success rate, difficulty at cannulation, and complications between patients with and without PAD, as well as to identify independent factors that influence the difficulty at cannulation. A prospective study. Tzaneio General Hospital. A total of 601 consecutive patients who underwent an ERCP were divided into 2 groups according to the presence (group A, 117 patients) or absence (group B, 484 patients) of PAD. Patients with undetectable papilla were excluded from the study cohort. The incidence of undetectable papilla was 8.3% in patients with duodenal diverticula and 0.9% in patients without duodenal diverticula (P = .000). Successful cannulation was achieved in up to 94.9% and 94.8% in groups A and B, respectively. The effort and difficulty at attempting this goal was different between the groups (43.5% vs 59.1%, P = .003), because patients without PAD were subjected to more vigorous attempts or even the pre-cut technique to attain a cholangiogram. There was no significant difference between the groups in the complication rate either in total or in any particular patient. Multivariate logistic regression analysis showed 3 of the variables, namely choledocholithiasis, abnormal papilla, and the presence of diverticula, remained significant, and all of them presented with odds ratios indicating an easier cannulation attempt. A nonrandomized study. The finding of a periampullary diverticulum during an ERCP should not be considered an obstacle to a successful cannulation and, furthermore, may be an indicator of an easier cannulation attempt, provided that the papilla can be found with confidence. Concerns about increased complications are not substantiated in this study.

Optimising laparoscopic cholangiography time using a simple cannulation technique

Opponents of the routine use of intraoperative cholangiography (IOC) express concern over its technical difficulty and the length of time it takes. To evaluate the impact of our cystic duct cannulation (CDC) technique, as implemented by one consultant and his trainees, on the IOC time. IOC is done routinely in all the laparoscopic cholecystectomies (LCs) undertaken in our unit. We carried out a prospective audit over a period of 18 months, recording the IOC time in consecutive patients undergoing laparoscopic cholangiography (LC) with and without laparoscopic common bile duct exploration (LCBDE). The total IOC time was considered to consist of two components: cystic duct cannulation (CDC) time and fluoroscopy time. The IOC time was further analysed according to the difficulty of cannulation and the operator experience. Special consideration was given to the LCBDE cases. We also describe the detailed steps of our CDC technique. Over a period of 18 months 243 patients underwent LC. IOC was completed in 240 patients (98.8% success rate). Of those, 194 were females (81%). The mean age was 50 years (range 18-85 years). The mean total IOC time was 6 min, with a CDC time of 2 min, and fluoroscopy time of 4 min. On further analysis, CDC was considered easy in 86% of cases with a mean CDC time of 1.5 min and total IOC time of 4.3 min. When cannulation was difficult (14% of cases) a cholangiography clamp had to be used to prevent leakage of contrast. In difficult cases, the CDC and IOC mean times were 5 and 8.5 min, respectively. As would be expected, trainees spent more time performing cannulation and completing the IOC than the specialist surgeon (3.8 versus 1.8 min, and 7.2 versus 5.6 min, respectively). These differences were statistically but not clinically significant. Similarly, the IOC time was also significantly increased in LCBDE (13 min). This was mainly due to an increase in fluoroscopy time (10 min) rather than CDC time (3 min). The IOC time could be optimised by using a simple and learnable cannulation technique to less than 5 min in most LCs. Surgeons should not, therefore, refrain from using this important investigation on selective or routine basis, subject to their policy for dealing with patients with suspected bile duct stones.

Needle-knife fistulotomy versus standard method for cannulation of common bile duct: a randomized controlled trial.

Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy has become widely available for the treatment of pancreatobiliary diseases; however, it has mortality and complications. The aim of this study was to compare the success rates and complications of two different methods of common bile duct cannulation. From June 2003 though February 2004, patients who were candidates for endoscopic retrograde cholangiopancreatography and/or endoscopic sphincterotomy were randomly divided into two groups: standard cannulation (group A) and suprapapillary needle-knife fistulotomy (group B). Postendoscopic retrograde cholangiopancreatography pancreatitis, cholangitis, bleeding, and perforation were evaluated. Two hundred and eighteen cases (86 males and 132 females with a mean+/-SD age of 56.2+/-17.5 years) were enrolled in this study. Group A, contained 112 patients and group B included 106 patients. In group A, the final cannulation success was achieved in 100 patients (89.3%). Cannulation was successful in 88 patients (83.0%) in group B. Difficulty in cannulation occurred more frequently in group A (25.5% vs. 2.6%, P=0.002). There were two patients in group B and three patients in group A who developed pancreatitis after endoscopic retrograde cholangiopancreatography. Perforation occurred in one patient in group B, which was improved with medical support. Bleeding and cholangitis were not occurred in any of the groups. The overall complication rate was 3/112 in group A and 3/106 in group B. Needle-knife fistulotomy is safe and can be applied as an effective alternative to standard technique for common bile duct cannulation in expert hands.

Identification of significant difficulty of selective deep cannulation by a simple predictive model: an endoscopic scale for teaching ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure associated with a risk of serious complications. This cohort study was designed to assess the accuracy of an endoscopic method aimed at discriminating procedures eligible to teach ERCP: patients with and without significant difficulty of selective deep cannulation (DSDC). Clinically relevant variables were analyzed in a cohort of 400 consecutive patients (estimation group = 250 patients; validation group = 150 patients) who underwent an ERCP procedure. Multivariate analysis identified fixated duodenum, inflamed duodenum, soft major papilla, previous biliary surgery, and papilla with ectopion as independent predictors of DSDC. We constructed a model and a score system combining these five variables. The area under the ROC curve was 0.81 for the estimation group and 0.80 for the validation group. Using the best cutoff score (> 1.63), absence of significant DSDC could be excluded with high accuracy (negative predictive value = 89.2%) in 111 (44.4%) of 250 patients. Similarly, it could be excluded with the same certainty in 77 (51.3%) of the 150 patients in the validation group. A combination of easily accessible variables accurately predicts the absence of significant DSDC in half the patients who underwent the ERCP procedure. This score system discriminates procedures eligible to teach ERCP.

No difference between supine and prone position for ERCP in conscious sedated patients: a prospective randomized study

Endoscopic retrograde cholangiopancreatography (ERCP) is usually performed with the patient prone or in the left lateral position. The supine position could be more comfortable and may facilitate airway management. On the other hand, technical difficulties and a greater risk of adverse cardiorespiratory events have been shown when ERCP is performed in a supine patient. Our aim was to assess, in a tertiary referral center, the differences between performing ERCP with the patient supine or prone, in terms of technical features and complications both during and after the procedure. Between December 2005 and May 2006, 120 patients (66 female, mean age 62 years) who had an intact papilla and were candidates for therapeutic ERCP were prospectively randomized to undergo ERCP under conscious sedation with midazolam, in the prone (n = 60) or supine (n = 60) position, by an expert endoscopist (tutor) or a trainee. The following parameters were recorded: difficulty of cannulation and difficulty of ECRP procedure, time needed to visualize the papilla, time needed to achieve opacification and cannulation, exam duration, episodes of tachy/bradycardia and desaturation, episodes of duodenoscope displacement into the stomach, and complications. Ninety-eight patients underwent ERCP for benign disease and 22 for malignant biliary strictures. The ERCP success rate was 98.3 % in the tutor group and 43.3 % in the trainee group. No significant differences were found between the two groups of operators (tutors and trainees) in the recorded parameters and complication rates encountered in prone versus supine patients. Our results show that ERCP success rates and complications (intraoperative and postoperative) are similar whether ERCP is performed with the patient prone or supine, even when operators are of differing skill levels. Training, technique, and a proper learning phase are recommended in order to perform ERCP with no differences whether the patient is prone or supine.

Pure versus mixed electrosurgical current for endoscopic biliary sphincterotomy: a meta-analysis of adverse outcomes

Endoscopic biliary sphincterotomy (ES) can cause bleeding, pancreatitis, and perforation. This has, in part, been attributed to the type of electrosurgical current used for ES. No consensus exists on the optimal type of electrosurgical current for ES to maximize safety. To compare the rates of complications in patients undergoing ES via pure current versus mixed current. A systematic review of published, prospective, randomized trials that compared pure current with mixed current for ES. Patients undergoing ES, with random assignment to either current group. Data were standardized for pancreatitis and postsphincterotomy bleeding. There were insufficient data to analyze perforation risk. A random-effects model was used. Bleeding, pancreatitis, and perforation. A total of 804 patients from 4 trials that compared pure current to mixed current were analyzed. The aggregated rate of pancreatitis was 3.8%, 95% confidence interval (CI) 1.0%-6.6%, for the pure-current group versus 7.9%, 95% CI 3.1%-12.7%, for the mixed-current group; the difference was not statistically significant. The rate of bleeding (all severity groups) for the pure-current group was 37.3% (95% CI 27.3%, 47.3%), which was significantly higher than that of the mixed-current group (12.2% [95% CI 4.1%, 20.3%]). Mild bleeding was significantly more frequent with pure current (28.9% [95% CI 16.3, 41.4]) compared with mixed current (9.4% [95% CI 2.1%, 16.8%]). Variables, including endoscopist skill and cannulation difficulty, were difficult to measure. The rate of pancreatitis in patients who underwent ES when using pure current was not significantly different from those when using mixed current. Pure current was associated with more episodes of bleeding, primarily mild bleeding. Data were insufficient to analyze the perforation risk.

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

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

There Is Less Interobserver Variability When Using Total Cannulation Time As a Measure of Cannulation Difficulty At ERCP Compared to the Total Number of Attempts

There Is Less Interobserver Variability When Using Total Cannulation Time As a Measure of Cannulation Difficulty At ERCP Compared to the Total Number of Attempts

Prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography

Sphincter of Oddi manometry is the gold-standard method for sphincter of Oddi dysfunction. The prevalence of sphincter of Oddi dysfunction among patients referred to endoscopic retrograde cholangiopancreatography is largely unknown. To evaluate prospectively the prevalence of biliary sphincter of Oddi dysfunction (B-SOD) among Brazilian patients referred to endoscopic retrograde cholangiopancreatography and to study the safety of sphincter of Oddi manometry in this setting. Biliary sphincter of Oddi manometry was intended in 110 patients referred to endoscopic retrograde cholangiopancreatography. The number of attempts to obtain deep cannulation with the manometry catheter was recorded and patients were divided into two groups: up to 5 (easy cannulation) and >5 attempts (difficult cannulation). Sphincter of Oddi manometry was successful in 71/110 patients (64.5%). Sphincter of Oddi dysfunction was found in 18/71 patients (25%). Endoscopic retrograde cholangiopancreatography findings were: normal in 16, biliary stones in 39, malignant biliary strictures in 9 and benign biliary strictures in 7. There was no statistical difference in sphincter of Oddi dysfunction prevalence regarding disease, gender or difficulty of cannulation. Only 2/71 patients developed post-procedure mild pancreatitis. We have found a high prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography. Gender, nature of disease or difficulty of cannulation did not influence the prevalence of sphincter of Oddi dysfunction among these patients. Sphincter of Oddi manometry is a safe procedure for the evaluation of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography.

Retrograde tracheal intubation

Cook et al. report airway rescue using a Proseal™ laryngeal mask airway paired with fibrescope-guided placement of an Aintree intubation catheter®[1]. They recognised that their patient had the ‘full house’ for airway problems, with recognised difficulties in facemask ventilation, tracheal intubation and subglottic cannulation. Their creative pairing of equipment is to the authors' credit, especially in the setting of airway rescue for a hypoxic, unstable patient. We suggest that there would have been a good case for awake definitive airway management in addition to the precautionary cricothyroidotomy given the anticipated airway difficulties noted. The authors mention that an awake, transnasal fibreoptic approach had failed on a previous occasion. This, we surmise, influenced the authors in their choice of cricothyroidotomy with jet ventilation under general anaesthesia as their first management option. We suggest a retrograde technique, a method that has received little recent attention in the realm of airway management. Retrograde approaches are fairly simple to perform under local or general anaesthesia, have a high safety profile and can succeed when other techniques fail. A retrograde approach, however, needs sufficient space around the patient's neck to allow airway cannulation via the cricothyroid membrane. Sanchez & Morrison give a useful description of the range of retrograde options available [2], including a method by which a retrograde approach is used with a fibrescope [3], which we describe below. After patient consent and preparation, including topical airway anaesthesia, a 16 G epidural needle is used to cannulate the airway through the cricothyroid membrane with the bevel facing rostrally. An angiographic guidewire of sufficient length (we use a Teflon coated wire, diameter 0.889 mm and 145 cm long; Medtronic Vascular, Danvers, MA) is threaded into the airway through the needle and usually protrudes out from the patient's mouth. A sufficient length of wire is pulled through the mouth, taking care not to pull the wire completely into the neck (a clip applied to the wire near the neck will prevent this). The guidewire is then passed into the working channel of a lubricated fibrescope loaded with a suitable tracheal tube. The guidewire allows the fibrescope to traverse the upper airway into the larynx until the fibrescope abuts the larynx at the level of the cricothyroid membrane. At this stage the guidewire can be pulled out, either rostrally or caudally through the neck. Choosing the former option may reduce lower airway contamination from the oral cavity. Once the fibrescope is no longer constrained by the guidewire it falls into the airway, allowing further advancement of the fibrescope into the tracheal lumen and subsequent passage of the tracheal tube. A modification to guidewire removal is to pull the guidewire rostrally until it lies in the trachea, when it can be advanced into the trachea, preserving a pathway for any further airway instrumentation. This method results in orotracheal intubation. Should nasotracheal intubation be required, an additional step prior to use of the fibrescope is needed to re-direct the guidewire from the oral to the nasal route. A suitable gastric tube is inserted into the patient's nose and lifted from their pharynx either digitally or by Magill's forceps so the tip now exits from the mouth. The guidewire is threaded into the tip of the gastric tube, re-directing the guidewire from mouth to nose, at which time the gastric tube can be removed from the patient. Retrograde techniques using a guidewire require that the wire be of sufficient length to traverse a patient's airway and the length of a fibrescope and central venous catheter wire are not suitable. Whilst there are other retrograde techniques available, we feel that pairing of guidewire to fibrescope has great merit, allowing visualisation of the intubation sequence.

Impact of Periampullary Duodenal Diverticula at Endoscopic Retrograde Cholangiopancreatography: A Proposed Classification of Periampullary Duodenal Diverticula

To propose a classification schema to describe periampullary duodenal diverticula (PDD) found at endoscopic retrograde cholangiopancreatography (ERCP), and to study the characteristics of these diverticula. Among 400 consecutive patients in whom an ERCP was performed, PDD were present in 131 (32.8%), being these patients significantly older than the remaining, served as controls. PDD were classified in 3 different types according to the position of the major duodenal papilla: type I (16.3%), inside the diverticulum; type II (10.2%), in the margin of the diverticulum; and type III (6.5%), near the diverticulum. PDD were not associated with a more difficult cannulation of the biliary tract. PDD are common, especially in older patients, and do not significantly increase the difficulty of deep cannulation.