Cannulation Of Common Bile Duct Research Articles

Frequency of common factors for post endoscopic retrograde cholangiopancreatography pancreatitis.

To determine the frequency of factors leading to post endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Case series. Department of Gastroenterology, Liaquat National Hospital, Karachi, from November 2007 to October 2008. Fifty (50) patients of diagnosed cases of post-ERCP pancreatitis were included in this study. The collected data included age, gender, previous post-ERCP pancreatitis, recurrent pancreatitis, recurrent abdominal pain, number of attempts of common bile duct (CBD) cannulation, difficult CBD cannulation, precut sphincterotomy, biliary sphincterotomy, pancreatic duct contrast injections, primary diagnosis, device used, therapeutic procedure undertaken and the pancreatic enzymes level. Results were described as frequency percentages. Out of 50 patients, 32 (64%) were females. The average age of the patients was 52.23 ± 13.4 years. Frequency of common factors regarding post-ERCP pancreatitis were age ² 60, (n = 38, 76%) patients, female gender (n = 32, 64%), precut sphincterotomy (n = 34, 68%), pancreatic duct contrast injections (n = 27, 54%), biliary sphincterotomy (n = 25, 50%). Higher number of attempts of CBD cannulation and difficult CBD cannulation were recognized as factors for post ERCP pancreatitis. Other factors like previous history, post-ERCP pancreatitis, recurrent pancreatitis, and recurrent abdominal pain were not found in this study. Age, female gender, precut papillotomy, pancreatic duct contrast injections and biliary sphincterotomy were common factors for post-ERCP pancreatitis. Risk stratification will allow endoscopists to better identify patients who are at risk and permit detailed informed consent in high-risk groups or to adapt the measures to prevent the complications and reduce the risk related with the procedure.

A prospective randomized controlled study of selective common bile duct cannulation guided by loach guide wire and zebra guide wire in ERCP

Objective To compare curve-tip angiography guide wire （loach guide wire） and ultrasmooth hydrophilic guide wire （ zebra guide wire） in selective common bile duct （CBD） cannulation of endoscopic retrograde cholangiopanereatography （ERCP）. Methods A total of 196 patients were randomly assigned to loach guide wire group to receive cannulation guided by loach guide wire first （ n = 98 ） and zebra guide wire group to use zebra guide wire first （n = 98 ）. If cannulation was not successful after 10 minutes, a further attempt was made for an additional 10 minutes using the alternative guide wire. If still not successful after 10 minutes, other cannulation accessories would be used. The primary and overall selective cannulation time, success rate, and post-procedure abdominal pain and serum amylase were assessed. Results The primary success rate of selective CBD cannulation was higher in the loach guide wire group （93.9%） than that in zebra guide wire group （86. 7%, P 〈0. 05）, while there was no significant difference in cannulation time between 2 groups （ P 〉 0. 05 ）. The cannulation success rate after crossover was higher in loach guide wire group （76.9%） than that in zebra guide wire group （0. 0% , P 〈0. 05）. There was no significant difference in post-procedure serum amylase or occurrence rate of post ERCP pancreatitis between 2 groups （ P 〉 0. 05 ）. Conclusion Loach guide wire is superior to zebra guide wire in ERCP selective CBD cannulation, which can replace zebra guide wire in difficult cannulation. Key words: Cholangiopanereatography, endoscopic retrograde ; Loach guide wire ; Zebra guide wire

Pharmacokinetics of Valproic Acid in Guinea-pigs with Biliary Abnormality

To explore whether biliary cannulation, biliary obstruction or gall bladder obstruction could alter the disposition of valproic acid, guinea-pigs were subjected to common bile duct cannulation or ligation, gall bladder-neck ligation or sham surgery as a control. They were then given an intravenous (i.v.) dose of sodium valproate (50 mg kg-1) and the pharmacokinetics of valproic acid in each group were compared. In the cannulated group, significant decreases (P less than 0.05) in the area under the elimination curve (AUC), the volume of distribution at steady-state (Vdss) and the mean residence time (MRT) were observed. Significant increases (P less than 0.05) in the elimination rate constant (kz) and total clearance (CLtot) of valproic acid were noted. In the biliary obstructed guinea-pigs, the Vdss was significantly decreased (P less than 0.05). In the gall bladder obstructed guinea-pigs, there was a secondary peak of valproate plasma concentration, and the kz was significantly decreased. The biliary excretion of unchanged and conjugated valproic acid was 2.0 +/- 0.7 (s.e.m.) and 19.7 +/- 3.6 (s.e.m.)% of dose, respectively, and was almost completely reabsorbed in the enterohepatic recycling. Urinary excretion of unchanged and conjugated valproic acid, as well as non-conjugate metabolic clearance of valproic acid, were not significantly different among the four groups. The results suggest that the pharmacokinetics of valproic acid in guinea-pigs are particularly sensitive to interruption of the enterohepatic cycle. Biliary obstruction may elevate plasma concentrations owing to the decreased Vdss of valproic acid. Gall bladder obstruction may cause fluctuation of valproate plasma concentrations. The data indicate that the apparent total clearance of valproic acid is significantly less than the intrinsic clearance owing to enterohepatic recycling.

Mo1443 A Single Session of Supervised ERCP Mechanical Simulator (EMS) Practice Prepares Novice Trainees for Superior Clinical Performance

Trainees with one session of supervised EMS practice had significantly higher success rate in cannulating the common bile duct (CBD) during early training (AJG 2010, in press). The impact of additional unsupervised practice is unknown. To evaluate the effects of multiple vs single-session practice on clinical outcomes. 8 ERCP-naive trainees per year were randomized to study (n=4) and control (n=4) groups in 2007 and 2009, respectively. All trainees received 4 hours of ERCP didactic discussions. The study groups underwent one session of supervised EMS practice. In 2009, the study group continued biweekly unsupervised EMS practice over 3 months. All trainees received routine clinical ERCP training; success of selective CBD cannulation and performance score (1=poor, 2=fair, 3=neutral, 4=good, 5=excellent, rated by trainers blinded to the randomization) were recorded. The group-averaged effects of single and multiple practices were estimated and compared by generalized estimation equation (GEE) with pooled data from 2007 and 2009, adjusting for number of ERCPs before each ERCP, difficulty of papilla (prior papillotomy and multiple stenting as easy) and year of study. Baseline characteristics of the procedures were comparable between study and control groups in both years (not shown). Clinical performance was superior in study groups compared to control groups in all outcome measures (all p<0.05) (Table 1). The adjusted odds ratio (OR) by GEE analysis further confirmed both single and multiple sessions practice conferred significant benefits with no difference between the 2 study groups (Table 2).Table 1Factors associated with success of deep CBD cannulation by traineesYear 2007Year 2009Clinical performanceSingle EMSControlMultiple EMSControlCBD cannulation success, n(%)31/40 (77.5)20/39 (51.3)40/58 (69.0)23/53 (43.4)Steps⁎Steps: selective CBD cannulation, ampullary/biliary dilation, biliary stenting. accomplished (%), mean (SD)75 (35)53 (45)80 (32)53 (41)Performance score, mean (SD)3.8 (0.9)3.2 (0.7)4.0 (0.7)3.2 (0.7) Steps: selective CBD cannulation, ampullary/biliary dilation, biliary stenting. Open table in a new tab Table 2Effects of single/multiple EMS practices on clinical performance: pooled analysisCannulation successPerformance scoreGEE analysisOR95% CIPOR95% CIPSingle EMS3.80⁎P=.83;2.07-6.96<.0013.82⁎⁎P=.74.1.60-9.10.003Multiple EMS3.33⁎P=.83;1.27-8.76.0156.19⁎⁎P=.74.2.98-12.86<.001Per 1 ERCP1.010.99-1.03.2451.031.00-1.06.022Easy papilla4.012.66-6.05<.0011.160.85-1.58.3412009 vs 20070.580.27-1.24.1600.730.31-1.74.483 P=.83; P=.74. Open table in a new tab As an educational tool a single supervised practice session with the EMS appears to augment the novice trainees' understanding sufficiently to significantly enhance clinical performance (success of CBD cannulation) in the first three months of training. The superior performance was unmistakable to blinded clinical trainers.

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.

Impacted Common Bile Duct Stone

Purpose: Case Presentation: A 29 year old white female, three weeks postpartum presented to the emergency room with intermittent right upper quadrant (RUQ) abdominal pain, which she rated as 5/10. She first noticed the pain her last trimester of pregnancy but had worsened over the last 3 weeks. She described the pain as colicky, intermittent and occurs mostly post prandial. Her past medical history, surgical history and family history were unremarkable. She denied any prescription or over the counter medications. The patient was seen in the morning for consultation. She was in no acute distress, resting comfortably and abdominal examination was benign. There were no clinical signs of cholangitis. Alkaline phosphatase was 208 units/L, AST was 245 units/L, ALT was 203 units/L and total bilirubin 0.7 mg/dL. Abdominal ultrasound revealed cholelithiasis and choledocholithiasis with the common bile duct dilated to 11 mm. Endoscopic Retrograde Cholangiopancreatography (ERCP) was decided to be the next appropriate step. In the pre-operative area of the endoscopy unit, the patient developed sudden onset of RUQ abdominal pain, which she rated as 10/10. She was immediately taken to the endoscopy suite in which an ERCP was performed. An impacted stone was seen at the ampulla and was the likely cause of her acute onset of pain. See Figure 1. A needle-knife sphincterotomy (NKS) was performed with immediate passage of the stone and sludge. Discussion: NKS is frequently used when the endoscopist encounters a difficult common bile duct (CBD) cannulation. Using the needle-knife, a cut is made in the 11 o'clock direction to help open the biliary orifice and to avoid any damage to the pancreatic duct. In cases of impacted stone in which cannulation of the CBD may not even be an option, a NKS is commonly used. After the NKS was performed in this patient, the sphincterotomy was extended and the CBD underwent balloon sweep which removed sludge and stone fragments. The patient's laboratory values returned to normal on the following day. She underwent a laparoscopic cholecystectomy as an outpatient.Figure

Endoscopic retrograde cholangiopancreatography (ERCP) for intradiverticular papilla: endoclip-assisted biliary cannulation

An intradiverticular papilla (IDP) can make biliary cannulation difficult during endoscopic retrograde cholangiopancreatography (ERCP), and endoscopists sometimes need to use special techniques to achieve deep common bile duct (CBD) cannulation [1] [2] [3]. We describe two difficult IDP cases in which successful biliary cannulation was achieved after using endoclips to facilitate a temporary change in the anatomical position of the major papilla.

A meta-analysis for the effect of prophylactic GTN on the incidence of post-ERCP pancreatitis and on the successful rate of cannulation of bile ducts

BackgroundGlyceryl trinitrate (GTN) has been shown to be able to relax the sphincter of Oddi (SO) both in animals and humans. Theoretically, the use of these compounds during and after endoscopic retrograde cholangiopancreatgraphy (ERCP) could relax the biliary and pancreatic sphincters, facilitating cannulation of common bile duct (CBD) during the procedure, or minimizing potential pancreatic outflow obstruction after the procedure. However, clinical trials evaluating the protective effect of GTN on the post-endoscopic retrograde cholangiopancreatgraphy pancreatitis (PEP) have yielded inconclusive results. This meta-analysis is to systematically assess the effect of prophylactic administration of glyceryl trinitrate (GTN) on the prevention of PEP and the effect on the cannulation of bile ducts.MethodsBy searching PubMed (1966 to September 2009), CENTRAL (Cochrane Controlled trials Register; issue 3, 2009) and EMBASE.com (1984 to September 2009), two independent reviewers systematically identified prospective randomized controlled trials (RCTs) detecting the effect of prophylactic GTN on the incidence of PEP and on the cannulation of bile ducts. A meta-analysis of these clinical trials was then performed.ResultsThere are 55/899(6.1%) patients suffering PEP in the treatment group versus 95/915(10.4%) patients in the placebo group. The overall pooled risk of PEP was significantly lower in the GTN group than in the placebo group (OR 0.56, 95% CI: 0.40 to 0.79, p = 0.001). Subgroup analyses suggested that GTN administered by the sublingual form (OR 0.34,95% CI:0.16 to 0.75, p = 0.007) is more effective than transdermal route(OR 0.64,95% CI:0.40 to 1.01, p = 0.05), and the protective effect of GTN was far more obvious in the centers with high incidence of PEP (OR 0.40, 95% CI:0.24 to 0.67, p = 0.0006) than those centers with a low incidence of PEP (OR 0.75, 95% CI: 0.47 to 1.20, p = 0.22). Additionally, the meta-analysis suggests that GTN was not helpful for the cannulation of bile ducts.ConclusionWe concluded that prophylactic administration of GTN may significantly reduce the incidence of PEP and not be helpful for the cannulation of bile ducts.

Deep common bile duct cannulation time at endoscopic retrograde cholangiopancreatography: a forgotten parameter for assessment of endoscopic competence?

The rate of successful deep common bile duct cannulation (DCBD) at endoscopic retrograde cholangiopancreatography (ERCP) is usually used as a surrogate marker of competence at ERCP. There are few data regarding the time spent on cannulation at ERCP. This prospective study aimed to evaluate the time spent on DCBD cannulation at ERCP and to provide a rationale for establishing the DCBD cannulation time as another parameter in assessment of ERCP competence. This is a prospective study performed in a single tertiary university-based referral center. DCBD cannulation time as well as the fluorescence time and the cost of cannulation tools during DCBD cannulation were measured. The mean DCBD cannulation was 12.5±13.6 minutes. Eighty-percent of the cannulation was achieved within 10 min, 10% achieved in 10-30 min, and the remaining in longer than 30 min. The longer cannulation time was associated with increased the cost of cannulation ($79/cannulation versus $387/ cannulation, P

A control study on selective biliary cannulation technique reducing incidence of post-ERCP pancreatitis

Objective To determine if using a soft-tipped guidewire to cannulate the common bile duct may ameliorate development of PEP(post-ERCP pancreatitis)and facilitate cannulation of the CBD(common bile duct).Methods A total of 78 patients treated treateed in our hospital underwent ERCP through conventional direct cannulation(52 diagnostic ERCPs,26 therapeutics ERCPs)from 1998 to 2001 were randomly selected as group A while 112 patients underwent ERCP through guide wire-directed cannulation(21 diagnostic ERCPs,91 therapeutics ERCPs)from 2007 to 2008 as group B.Then we retrospectively studied and compared the following parameters between the two groups:1)Success rate of biliary access;2)visualization rate of pancreatic duct;3)the level of serum amylase,severity of abdominal pain and the rate of PEP.Meanwhile,the correlation between grading of pancreatic duct visualization and PEP was analyzed.Results The success rate of biliary access of the guidewire group(106/112 cases)was significantly greater than the conventional group(33/78 cases)(94.64%vs.42.30%,P 0.05) in terms of the rate of hyperamylasemia between the two groups.The significant correlation was found between the grading of pancreatic duct visualization and the occurrence of PEP.Condusion Guidewire-directed selective access to the bile duct lowers likdihood of PEP by facilitating cannulation and lowering the visualization rate of pancreatic duct.The occurrence of PEP could be predicted by the grading of pancreatic duct visualization,which is a very important but not the unique factor leading to PEP. Key words: Pancreatitis; Guidewire directed selective biliary cannulation; Direct cannulation; Endoscopic retrograde cholangiopancreatography; Grading of pancreatic duct visualization

S1445: A Randomized Clinical Trial Comparing the Use of a Pancreatic Duct Stent or a Pancreatic Duct Guidewire to Facilitate Bile Duct Cannulation

Among cases of difficult biliary cannulation, alternatives to precut sphincterotomy include use of a pancreatic duct (PD) stent (PDS) or guidewire (PDW) to facilitate common bile duct cannulation (CBDC). We present the preliminary results from an ongoing, multicenter, randomized trial.

ERCP cannulation and sphincterotomy devices

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic, and a MAUDE (Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but, in many cases, data from randomized controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the governing board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review the MEDLINE database was searched through February 2009 for articles related to cannulation and sphincterotomy devices by using the keywords ERCP, standard catheter, sphincterotome, cannulation, sphincterotomy, precut, major papilla, minor papilla, needle-knife, complication, pancreatitis, biliary, and pancreatic in different search term combinations. Technology Status Evaluation Reports are scientific reviews provided solely, for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, ordiscouraginganyparticulartreatmentorpayment for such treatment.

Modified rendezvous intrahepatic bile duct cannulation technique to pass a PTBD catheter in ERCP

The rendezvous procedure combines an endoscopic technique with percutaneous transhepatic biliary drainage (PTBD). When a selective common bile duct cannulation fails, PTBD allows successful drainage and retrograde access for subsequent rendezvous techniques. Traditionally, rendezvous procedures such as the PTBD-assisted over-the-wire cannulation method, or the parallel cannulation technique, may be available when a bile duct cannot be selectively cannulated. When selective intrahepatic bile duct (IHD) cannulation fails, this modified rendezvous technique may be a feasible alternative. We report the case of a modified rendezvous technique, in which the guidewire was retrogradely passed into the IHD through the C2 catheter after end-to-end contact between the tips of the sphincterotome and the C2 catheter at the ampulla's orifice, in a 39-year-old man who had been diagnosed with gallbladder carcinoma with a metastatic right IHD obstruction. Clinically this procedure may be a feasible and timesaving technique.

Can endoscopic palliation of large neoplasm increase the risk of pancreatitis after endoscopic retrograde cholangiopancreatography?

Recently, a patient presented with severe acute pancreatitis after biliary self-expandable metallic stent (SEMS) placement for palliation of an unresectable pancreatic cancer. This case induced us to consider the risk of acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). The use of biliary SEMS represents the best therapeutic option for the treatment of neoplastic obstructive jaundice because it has a lower mortality and morbidity than surgery. It does not pose as a risk factor for inducing postERCP acute pancreatitis (PEAP) or other complications but increases only the risk of cholangitis [1]. However, SEMS is considered to be the first therapeutic palliation procedure for patients with unresectable pancreatic cancer. It offers better results than surgical palliation in terms of lower procedure-related complications and improves life quality [2, 3] Moreover, studies have shown the feasibility of simultaneous SEMS positioning for treating combined biliary and duodenal obstructions [4, 5]. We thought the PEAP in our case may have been attributable either to obstruction of the Wirsung caused by SEMS positioning or to direct damage due to the stent expansion, although no evidence for this exists in the literature. However, the causes more likely were a prolonged manipulation of the papilla due to a difficult cannulation or an excessive main pancreatic duct opacification. In a recent study, Cotton et al. [6] showed that the cited maneuvers can increase fatal post-ERCP complications. Although Schutz and Abbott [7] state that only technical success depend on the ERCP degree of difficulty and that complications do not, Cotton et al. [6] think that complicated procedures (grade 3 of the modified Madhotra classification [8]) pose higher risk for the development of complications because the approach to the papilla can be extremely complex. We think that large neoplasms (diameter, [4 cm) modifying the common bile duct (CBD) anatomy (kinking, coiling, stretching) also should be considered as a factor increasing the complexity of ERCP and thus the possibility of procedure-related pancreatitis. However, but at this writing, no author considers this to be a risk factor. To simplify the CBD cannulation, Ito et al. [9] recently have suggested inserting a pancreatic guidewire to achieve a selective biliary cannulation. This still needs a randomized study. Several authors have stated that the use of pancreatic stents probably is the best way to prevent PEAP [10–16]. Different series have shown that the use of this device reduces the incidence of PEAP from a range of 11.1% to 66.7% for patients with no stent to a range of 5% to 14.4% for patients with a stent. When the main pancreatic duct cannulation is obtained first, as often happens if the neoplastic lesion does not involve the duct, the clinician should place a pancreatic stent at once before proceeding to the CBD. The use of small-caliber (maximum, 5 Fr) short (2–3 cm) stents [17] and elimination of flaps before insertion [18] allow a spontaneous migration in 2 to 3 weeks without the need for endoscopic removal. Pancreatic stent positioning G. Fanello (&) M. Benedetti G. Martino M. Marengo R. L. Meniconi F. Papini P. Chirletti Department of Surgery, ‘‘F. Durante’’–General Surgery Unit, ‘‘Sapienza’’ University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161 Rome, Italy e-mail: gianfranco.fanello@uniroma1.it

ERCP Mechanical Simulator (EMS) Practice Enhances Traineesʼ Success with Common Bile Duct (CBD) Cannulation

Purpose: Background: EMS practice in the early stage of clinical ERCP training has been reported to be beneficial (GIE 2009; 69:AB141). Its role in augmenting performance of trainees with some clinical ERCP experience is unknown. Hypothesis: EMS practice is a predictor of success in CBD cannulation when introduced to EMS naive trainees after 6 months of usual clinical training.Table 1: Success with deep CBD cannulationTable 2: Factors associated with success of selective CBD cannulation by trainees (GEE analysis)Methods: Design: A randomized controlled cross-over study. 8 trainees attended didactic lectures on ERCP. Randomization was stratified based on site (n=2). Study group (SG) trainees participated in a one day handson simulator practice of selective bile duct cannulation supervised by JWL. Control group (CG) trainees did not participate in EMS practice. Subsequent clinical ERCP performance of all trainees was documented objectively. Primary outcome was successful deep CBD cannulation (0=fail, 1=success). After 6 months, CG trainees were crossed over to participate in one session of EMS practice. Performance of all trainees was tracked for another 6 months. The primary outcome was correlated to EMS practice status (with or without), overall clinical ERCP experience (days entered into ERCP training) and level of difficulty (normal papilla, diverticula, prior papillotomy or stenting) for CBD cannulation. Statistical analysis was performed using generalized estimation equations (GEEs) to fit the parameters of a generalized linear model where unknown correlations are present. The equations allow for correlation without explicitly defining a model for the origin of the dependency and are most suitable when the random effects and their variances are not of direct interest. The average response over the population (“population-averaged” effects) is estimated rather than the regression parameters that would enable prediction of the effect of changing one or more components of an unknown factor on a given individual. Results: Deep CBD cannulation was attempted in 153 of 224 and 142 of 225 cases in each of the two consecutive 6 months period, respectively. The table summarizes the odds ratio of trainee success in deep CBD cannulation taking all pre and post crossover data into consideration. EMS practice is a significant factor in predicting success while difficult papilla predicts cannulation failure. Conclusion: A single session of EMS practice enhances the success rate of CBD cannulation regardless of when it is introduced - at the beginning or after 6 months of usual clinical training. The results provide evidence to support the use of mechanical simulator practice, offered at the beginning or midway through clinical ERCP training, to augment the ERCP training experience. Disclosure: Cook Endoscopy - educational grant and equipment support Olympus America - educational grant and equipment support Dr Joseph Leung is supported by Cook Asia (speakers honorarium) during his sabbatical leave to conduct the research study in Taiwan. Partial research funding support from ACG Research Grant. This research was supported by an industry grant from Cook Endoscopy and Olympus Tokyo provided equipment support for simulator practice. The ERCP mechanical simulator is not commercially available and is used for teaching and research purposes.

Deep Common Bile Duct Cannulation Time at Endoscopic Retrograde Cholangiopancreatography: A Forgotten Parameter for Assessment of Endoscopic Competence?

Purpose: The rate of successful deep common bile duct (DCBD) cannulation at endoscopic retrograde cholangiopancreatography (ERCP) is often used as a surrogate marker of competence at ERCP. An 80% cannulation rate is often used to define competence, and this is usually achieved after performing about 200 ERCPs. Limited data exist in the current literature regarding the use of time spent on cannulation during ERCP as a standard to assess competence. The objective of this study is to evaluate the time spent on DCBD at ERCP and to provide a rationale for establishing the DCBD time as another parameter in assessment of ERCP competence. Methods: This prospective study was performed at a single tertiary university-based referral center on consecutive patients who presented for ERCP, between September 2003 and June 2004. The DCBD cannulation times, fluoroscopy times, and the cost for cannulation tools during DCBD cannulation were assessed. Patients who had a history of sphincterotomy, biliary stenting, or a recent ERCP within 7 days prior to the study were excluded. Results: A total of 102 patients were enrolled in the study. Of these, successful cannulations were achieved in 94 patients (92%). The procedure was aborted in four patients secondary to sedation problems or presence of unstable vitals. The remaining ninety patients completed the procedure. Of these, 38 were females and 52 were males with a mean age of 58 years. The mean DCBD cannulation time was 12.5±13.6 minutes. Eighty-percent of the cannulations were achieved within 10 minutes, 10% were achieved in 10 to 30 minutes, and the remaining 10% took longer than 30 minutes. The longer cannulations were associated with an increased cost of cannulation and increased radiation exposure (Table 1).Table: Table. Comparison of cost and radiation exposure during cannulationConclusion: Our study suggests that shorter cannulation times could reduce the expense of ERCP and decrease the radiation exposure during the procedure. Therefore, in addition to the success rate of DCBD cannulation, the DCBD cannulation time should be considered as another parameter in assessment of endoscopic competence in ERCP.

Double-guidewire technique for difficult bile duct cannulation: a multicenter randomized, controlled trial

ERCP can be associated with serious complications. Difficulty in common bile duct (CBD) cannulation is one of the main risk factors for post-ERCP pancreatitis. The double-guidewire technique (DGT) has been considered a promising alternative approach in difficult cannulation situations. To compare the performance of DGT with the standard cannulation technique (SCT) in patients in whom CBD cannulation is difficult to perform. Multicenter randomized, controlled trial. Six tertiary referral centers. A total of 188 patients with difficult CBD cannulation defined by completion of 5 unsuccessful cannulation attempts were enrolled. Ninety-seven patients were assigned to the DGT group and 91 to the SCT group. Both techniques were compared for an extra 10 cannulation attempts. CBD cannulation rate, number of attempts required to cannulate, and ERCP-related complications. Successful CBD cannulation was achieved in 46 of 97 (47%) patients in the DGT group compared with 51 of 91 (56%) in the SCT group (OR 0.85; 95% CI, 0.64-1.12). The median number of attempts required for each group was 9 and 7, respectively (P = .128). The incidence of post-ERCP pancreatitis was 17% in the DGT group and 8% in the SCT group (OR 2.13; 95% CI, 0.89-5.05). Reduced number of enrolled subjects and a lack of detailed information regarding the number and extent of pancreatic duct contrast injections. In patients with difficult CBD cannulation, DGT was not superior to SCT in achieving CBD cannulation. DGT might be associated with a higher risk of post-ERCP pancreatitis.

Endoscopic precut sphincterotomy for cannulation of inaccessible common bile duct： transpancreatic septum precut versus needle-knife

Objective To evaluate the technique of transpancreatic septum precut for cannulation of inaccessible common bile duct in endoscopic retrograde cholangiopancreatography （ERCP）. Methods Data of 109 patients with difficult biliary cannulation in ERCP, of whom 56 underwent transpancreatic septum precut and 53 had needle-knife sphincterotomy from January 2006 to July 2008, were analyzed retrospectively, and the success rate of cannulation and the occurrence of complications were compared between the two methods. Results Of 109 patients accepted precut papillotomy, common bile duct cannulation was successfully achieved in 97. The success rates of transpancreatic septum precut group and needle-knife sphincterotomy group were 96. 4% （54/56） and 81.1% （43/53） respectively, which was significantly different （ P 〈 0.05 ）. Complications occurred in 11 cases, including bleeding（ n = 4）, acute pancreatitis （ n = 5 ）, cholangitis（n = 2 ）. The tolal frequency of complications of the transpancreatic septum pre-cut papillotomy group was lower than that of needle-knife sphincterotomy group（3.6% vs. 17. 0% , P 〈 0. 05 ）. Conclusion In patients with inaccessible bile ducts, transpancreatic septum precut is a safe and effective procedure in cannulation, exhibiting a higher success rate and lower occurrence of complication when compared with needleknife sphincterotomy. Key words: Cholangiopancreatography, endoscopic retrograde ; Common bile duct ; Precut ; Septnm ; Postoperative complications

The Early Use of the Double-Wire Technique to Facilitate Difficult Biliary Cannulation and Its Impact On Post-ERCP Pancreatitis

Background: Common bile duct (CBD) cannulation can be difficult in up to 15% of ERCPs performed by experienced endoscopists. This situation leads to increased incidence of both unsuccessful procedures and post-ERCP pancreatitis. We report our outcomes using the double-wire technique early in accessing difficult biliary systems and the complication rates associated with this technique. Methods: 882 patients underwent ERCP at our institution from October 2006 to September 2008. Charts were reviewed retrospectively.

Difficult Biliary Cannulation: Use of Physician Controlled Wire-Guided Cannulation Over a Pancreatic Duct Stent to Reduce the Rate of Precut Sphincterotomy

Background: Successful cannulation of the common bile duct (CBD) remains the benchmark for endoscopic retrograde cholangiopancreatography (ERCP). Difficult cannulation, particularly with the use of precut sphincterotomy, has been shown to be a risk factor for post-ERCP pancreatitis. While use of a pancreatic duct (PD) stent to facilitate biliary cannulation has been described, the majority of patients required precut sphincterotomy to achieve CBD cannulation. We report the performance characteristics of this technique in conjunction with physician controlled wire-guided biliary cannulation to minimize the need for precut. Methods: We performed a retrospective, cohort analysis of ERCPs performed by two experienced endoscopists at independent medical centers. Both endoscopists routinely use a PD stent to facilitate biliary cannulation prior to resorting to a precut sphincterotomy and to reduce the risk of post ERCP pancreatitis. All patients with native papillae undergoing ERCP between January, 2006 and April, 2008 were included. Routine cannulation and failure to cannulate either the PD or CBD were excluded. In cases of difficult biliary access where the PD is cannulated, a soft, 5Fr pancreatic stent is left in the PD without performing a pancreatic sphincterotomy. Following this, physician controlled wire-guided biliary cannulation is attempted using the PD stent to direct the sphincterotome into the biliary orifice. If cannulation is unsuccessful after several minutes, a precut sphincterotomy is performed over the PD stent or the procedure is terminated. We reviewed medical records to determine rates of PD stent placement to facilitate biliary cannulation as well as rate of precut sphincterotomy. Outcomes included biliary cannulation rate, frequency of precut sphincterotomy, and incidence of procedure-related complications. Results: 2,345 ERCPs were identified, 1,544 with native papillae. Among these, CBD and PD cannulation failed in 16 (1.0%), while 76 (4.9%) patients received a PD stent to facilitate biliary cannulation. Successful cannulation was achieved in 71 of 76 (93.4%) patients, 60 (78.9%) of whom did not require precut sphincterotomy. Complications included mild post-ERCP pancreatitis in 4 (5.3%) and aspiration in 1 (1.3%). Precut sphincterotomy was complicated by hemorrhage controlled during the procedure in 2 of 16 (12.5%). Conclusions: Physician controlled wire-guided cannulation over a PD stent facilitates biliary cannulation and significantly reduces the rate of precut sphincterotomy. Future studies should compare the use of a PD stent with other noninvasive techniques to promote safe and effective biliary cannulation.