Deep Biliary Cannulation Research Articles

Angled- or straight-tipped hydrophilic guidewire in biliary cannulation: a prospective, randomized, controlled trial

Deep biliary cannulation is the key for successful endoscopic retrograde cholangiopancreatography (ERCP) procedures. Guidewire-assisted cannulation is associated both with a higher success rate and a reduced risk of post-ERCP pancreatitis compared with standard catheter cannulation. However, to our knowledge there are no prospective, randomized studies comparing the use of different guidewires in biliary cannulation. The goal of this study was to compare the performance of an angled-tipped guidewire (AGW) with a straight-tipped guidewire (SGW) in achieving successful deep biliary cannulation. Patients with intended biliary cannulation of an intact papilla were prospectively randomized to angled- or straight-tipped hydrophilic guidewire arms in a tertiary, referral, university hospital setting. Randomized cannulation method was applied either until successful cannulation of the bile duct or until 2 min had passed. Crossover was not included in the study protocol. The main outcome measurements were the cannulation success rate and duration of cannulation. Of the 239 consecutive patients, 155 patients were randomized: in the final analysis 70 patients were included in the AGW arm and 83 patients in the SGW arm. Cannulation time [median; seconds (s)] was shorter with the AGW compared with the SGW (20 vs. 63 s, p = 0.01). There was no difference in the cannulation success rate or the complication rate between the two study groups. AGW may facilitate biliary cannulation in ERCP.

New modification of deep biliary cannulation using endoscopic–radiologic rendezvous technique for palliative treatment of malignant obstructive jaundice

AimTo describe a new simple modification of deep biliary cannulation using combined endoscopic–radiologic technique and evaluate its technical and clinical success for palliative treatment of malignant obstructive jaundice. Patients and interventionWe used this technique in 25 patients with inoperable malignant biliary obstruction and failed endoscopy procedures alone. Using angiographic methods, an introducer of long arterial sheath, over a guide wire was passed to overcome the site of obstruction. Our amendments lie in using a stiff introducer to allow support of the guide wire during its navigation through the obstruction site, followed by passage of the introducer together with the guide wire to the duodenum, while the introducer in place; the hydrophilic guide wire with its slippery end should be replaced with a long ordinary guide wire which is used in ERCP because it could be easily grasped with the dormia basket. ResultsTechnical success rates were 100%, internal biliary stents were successfully placed in a one-step procedure at the appropriate position in all patients with adequate duct drainage. Clinical success rates were 92% within 48–72h and 8% within 7days. Minor complications occurred in 4/25 (16%) patients, with no reported major complication. The median procedure time was 40min. ConclusionThis simple modification was technically and clinically successful for palliative treatment of inoperable malignant biliary obstruction with failed endoscopy procedures alone.

The ERCP quality network benchmarking project: a preliminary comparison of practice in UK and USA

ObjectiveThe Endoscopic retrograde cholangiopancreatography (ERCP) Quality Network is a voluntary system for submission of data to generate individual report cards and benchmarking. The aim of this study was to compare...

Sa1127 Colonoscopy Attendance and Quality After Implementation of an Internet Based Educational Program

Introduction: Selective deep biliary cannulation fails in 15-30% of cases even in experienced hands. Repeated and prolonged attempts at cannulation increases risk of post ERCP pancreatitis. Supra papillary needle knife fistulotomy (NKF) is a very useful, yet controversial rescue technique in cases of difficult biliary cannulation. This allows access when cannulation via the orifice cannot be achieved. Concerns have been expressed about its safety. Aims/ Background: The aim of this retrospective study was to evaluate efficacy and safety of NKF by a gastroenterologist, with experience in this technique. Method: This was a single centre study of data from a single operator who uses NKF. A needle knife is used to enter the intramural duct clear of the orifice. The cut is then extended if necessary with a standard sphincterotome. The study was retrospective, looking at data from January 2000 to May 2011, by searching the data available on the endoscopy software ‘ENDOSCRIBE', medical notes and radiology reports. Results: All the patients fulfilled either clinical or radiologic criteria for ERCP. A total of 2639 ERCP were done in this period, with 82.75% (2184/ 2639) performed by the endoscopist who uses NKF. 200 (7.5% of all and 9.1% of the operator's procedures) involved NKF. The age group of the patients ranged from 20 to 96 (mean age 67.5years). The majority 52.5% (105/200) were above 70 years, with only 5% (9/200) being less than 30 years. 63.5% (127/200) were women, 64% (128/200) jaundiced and 70% (140/200) had a dilated common bile duct. Overall biliary cannulation rate in this extremely difficult cohort of patients was 58% (116/200) and 80.17% (93/116) had definitive treatment. NKF was successful, in 82.9% (39/47) of patients with choledocholithiasis who had dilated ducts and in 81.25% (26/32) of strictures with dilated ducts. 0.5% (1/200) had bleeding, mild pancreatitis (3xelevation of amylase) in 3.5% (7/200), necrotising pancreatitis (CT proven) in 1% (2/200) and perforation in 1% (2/200). The overall complication rate, considering each of the above as a separate event, was 15% (15/100) for the first 100 procedures and 6% (6/100) for the latter half of the study group. Conclusion: This is one of the largest data from UK looking at needle knife fistulotomies in ERCP, in difficult to access common bile ducts, often being referred after several previously failed attempts. NKF is a safe and effective procedure in a selected group of patients, as long as it is done by an experienced endoscopist. The learning curve for the procedure is steep and complication rate goes down as the technique improves with experience, which has a pivotal role in the success of the procedure. Gender Distribution

Sa1126 Ten Year Data on Needle Knife Fistulotomy in a University Teaching Hospital

Introduction: Selective deep biliary cannulation fails in 15-30% of cases even in experienced hands. Repeated and prolonged attempts at cannulation increases risk of post ERCP pancreatitis. Supra papillary needle knife fistulotomy (NKF) is a very useful, yet controversial rescue technique in cases of difficult biliary cannulation. This allows access when cannulation via the orifice cannot be achieved. Concerns have been expressed about its safety. Aims/ Background: The aim of this retrospective study was to evaluate efficacy and safety of NKF by a gastroenterologist, with experience in this technique. Method: This was a single centre study of data from a single operator who uses NKF. A needle knife is used to enter the intramural duct clear of the orifice. The cut is then extended if necessary with a standard sphincterotome. The study was retrospective, looking at data from January 2000 to May 2011, by searching the data available on the endoscopy software ‘ENDOSCRIBE', medical notes and radiology reports. Results: All the patients fulfilled either clinical or radiologic criteria for ERCP. A total of 2639 ERCP were done in this period, with 82.75% (2184/ 2639) performed by the endoscopist who uses NKF. 200 (7.5% of all and 9.1% of the operator's procedures) involved NKF. The age group of the patients ranged from 20 to 96 (mean age 67.5years). The majority 52.5% (105/200) were above 70 years, with only 5% (9/200) being less than 30 years. 63.5% (127/200) were women, 64% (128/200) jaundiced and 70% (140/200) had a dilated common bile duct. Overall biliary cannulation rate in this extremely difficult cohort of patients was 58% (116/200) and 80.17% (93/116) had definitive treatment. NKF was successful, in 82.9% (39/47) of patients with choledocholithiasis who had dilated ducts and in 81.25% (26/32) of strictures with dilated ducts. 0.5% (1/200) had bleeding, mild pancreatitis (3xelevation of amylase) in 3.5% (7/200), necrotising pancreatitis (CT proven) in 1% (2/200) and perforation in 1% (2/200). The overall complication rate, considering each of the above as a separate event, was 15% (15/100) for the first 100 procedures and 6% (6/100) for the latter half of the study group. Conclusion: This is one of the largest data from UK looking at needle knife fistulotomies in ERCP, in difficult to access common bile ducts, often being referred after several previously failed attempts. NKF is a safe and effective procedure in a selected group of patients, as long as it is done by an experienced endoscopist. The learning curve for the procedure is steep and complication rate goes down as the technique improves with experience, which has a pivotal role in the success of the procedure. Gender Distribution

Feasibility of the Novel 3-Step Protocol for Biliary Cannulation—A Prospective Analysis

Traditionally, a 2-step protocol has been used for deep biliary cannulation. The purpose of the present prospective study was to find out the feasibility and safety of the novel sequential 3-step protocol (traditional cannula with guidewire, double-guidewire, and needle-knife techniques) for deep biliary cannulation. All consecutive patients admitted for endoscopic retrograde cholangiopancreatography (ERCP) to a single, very experienced ERCP endoscopist during the year 2009 with intended biliary cannulation and with unhindered access to a native papilla (n=105) were included in the present study. The overall success rate for deep biliary cannulation was 99% (104/105). Cannulation with cannula and guidewire was attempted in all patients and proved successful in 80% (84/105) of the attempts, the double-guidewire technique was applied in 19% (20/105) and was successful in 65% (13/20) of the cases, and the needle-knife technique was applied in 7% (7/105) with success in all cases. The median cannulation time was 1 minute (range, 0 to 27 min). The rate of post-ERCP pancreatitis was 3% (3/105) and post-ERCP cholangitis 2% (2/105). We conclude that in experienced hands, the novel sequential 3-step protocol for biliary cannulation tested herein proved to be an effective cannulation protocol with the overall success rate of 99%. The complication rate of these ERCP procedures (5%) was within acceptable limits.

Double-guidewire-assisted biliary cannulation: experiences from a single tertiary referral center

Even in experienced hands, a common problem with endoscopic retrograde cholangiopancreatography (ERCP) is difficulty reaching a deep biliary cannulation. The most recent alternative method for difficult biliary cannulation is the double-guidewire technique. The current prospective study aimed to clarify the feasibility and safety of the double-guidewire-assisted biliary cannulation at the authors' institution. All consecutive patients (n=284) admitted for biliary ERCP during 2009 who had unhindered access to a native papilla were included in the study. The application and success rates of the double-guidewire method for deep biliary cannulation and the complications of ERCP procedures using the double-guidewire technique were determined. The overall success rate for biliary cannulation in these cases also was determined, and the times from the first touch to the papilla to deep biliary cannulation and for the entire ERCP procedure were recorded. The double-guidewire-assisted cannulation technique was applied in 18% (50/284) of ERCPs with a success rate of 66% (33/50). In these 50 cases, the overall success rate for biliary cannulation was 98% (49/50). The median cannulation time was 8 min, and the median duration of the entire ERCP procedure was 20 min. The rate of post-ERCP pancreatitis was 2% (1/50). The double-guidewire technique is a feasible and safe method for difficult biliary cannulation with low rate of post-ERCP pancreatitis. However, it seems important to proceed to alternative cannulation techniques if the double-guidewire technique appears troublesome.

Wire-guided selective cannulation of the bile duct with a sphincterotome: a prospective randomized comparative study with the standard method

Objective. Wire-guided cannulation (WGC) is expected to reduce the incidence of post-ERCP pancreatitis (PEP). Our aim was to compare the incidence of PEP and the success rate of deep biliary cannulation using WGC or the standard cannulation method with contrast injection (STD). Material and methods. A total of 172 cases with an intact papilla were randomized into the STD group (n = 86) and the WGC group (n = 86). First a trainee endoscopist attempted the cannulation and if it was not successful, an expert endoscopist tried. When the cannulation was not successful within 10 min, the other method was conducted as a second attempt. The primary endpoint was the incidence of PEP and the secondary endpoint was the success rate of selective cannulation. Results. In successful cases, PEP occurred in 6.5% in the STD group and 3.0% in the WGC group in the first attempt. Overall rate of PEP was 6.0% (3, mild; 1, moderate and 1, severe) in the STD group and 2.3% (2, mild) in the WGC group, which were not significantly different. Selective cannulation rate in the first attempt was 73.8% in the STD group and 77.9% in the WGC group. After a crossover, the cannulation was successful in the second attempt in 36.4% and 42.1% and finally in 95.2% and 100% by the STD and WGC method, respectively. Conclusions. The incidence of PEP tended to be lower in the WGC method compared to the STD method. In addition, all cases of pancreatitis in the WGC group were mild. The success rate of cannulation was comparable between two groups.

S1443: Does Guidewire Use Prevent Post-ERCP Pancreatitis? A Meta-Analysis of Randomized Controlled Trials

Deep biliary cannulation is important for performing therapeutic endoscopic biliary interventions with varying success rates (50-90%), depending upon experience. Cannulation technique is pivotal in pathogenesis of post-ERCP pancreatitis (PEP). Multiple methods, including the use of guidewire, precut technique, and medications, are used to improve cannulation. To date, the results for guidewire use for prevention of PEP and improving the rate of successful cannulation are conflicting. Therefore, we conducted meta-analysis to assess the role of guidewire use for prevention of PEP and improving cannulation rates.

T1533: Does Guidewire Use in the Pancreatic Duct During Deep Biliary Cannulation Prevent Post-ERCP Pancreatitis? A Meta-Analysis

T1533: Does Guidewire Use in the Pancreatic Duct During Deep Biliary Cannulation Prevent Post-ERCP Pancreatitis? A Meta-Analysis

Dye-free Wire-guided Cannulation of the Biliary Tree During ERCP is Associated With High Success and Low Complication Rates

Deep biliary cannulation (DBC) is a prerequisite to most endoscopic retrograde cholangiopancreatographies (ERCPs). Numerous techniques have been described to maximize success and minimize ERCP-related complications, most notably post-ERCP pancreatitis. Dye-free cannulation by using guidewires with hydrophilic tips has been proposed as a technique with a high rate of success and a low rate of complications. We report the outcomes 822 consecutive ERCP procedures by using dye-free guidewire cannulation techniques. To evaluate the success rate for DBC and rates of complications by using dye-free guidewire cannulation techniques. Retrospective. Consecutive ERCP procedures with intent to achieve DBC exclusively by using dye-free guidewire technique were included. Complication data on post-ERCP pancreatitis, bleeding, perforation, and cholangitis were extracted. University. Patients undergoing biliary ERCP. ERCP. Success, complication rates. Eight hundred and twenty-two ERCPs were performed on 744 patients. Five hundred and fifty-nine (68%) procedures were performed on inpatients, 263 (32%) on outpatients. DBC was successful in 801 of 822 (97%) ERCPs. In 795 of 801 (99%) ERCPs with successful DBC procedures, DBC was achieved in a dye-free fashion. Eleven patients (1.3%) developed post-ERCP pancreatitis-all cases were mild. Guidewire perforations occurred 11 times (1.3%), none required surgery. Ten of 11 patients with known or suspected (91%) guidewire perforation achieved successful DBC on repeat ERCP by the same endoscopist by using dye-free techniques. Retrospective. In this large retrospective case series, a high success rate of DBC was achieved by using dye-free guidewire techniques. This technique has associated lower rates of complications in comparison to those reported earlier.

A Case of Pancreatitis, Pneumothorax, Pneumomediastinum, Pneumoret-roperitoneum, and Subcutaneous Emphysema after ERCP

Purpose: 44 year old female presented to an outside hospital 3 hrs after eating, with right upper quadrant pain, nausea and vomiting with elevated LFTs concerning for biliary obstruction. She was started on iv fluids, antibiotics and underwent ERCP. The common bile duct could not be cannulated, a sphincterotomy was performed without deep biliary cannulation and there was concern for duodenal perforation so the procedure was aborted. Patient became short of breath post-ERCP. CT scan showed retroperitoneal and mediastinal air and right pneumothorax. She was transferred to Strong Memorial Hospital. On exam, she was tachycardic with chest wall crepitus and peritonitis. Surgery was consulted and she underwent exploratory laparotomy. A cholecystectomy, gastrostomy and right thoracostomy were performed. Two Jackson Pratt drains were placed in a peri-duodenal fluid collection, a site of perforation was not identified. Post-operatively, she was aggressively hydrated for pancreatitis and started on TPN. She clinically improved. Upper GI series was done on post-op day #5 and no leak was seen. Her diet was slowly advanced. Her chest tube was removed and she was discharged home on post-op day #9. Discussion: One of the most common complications after ERCP is pancreatitis which occurs in 2-5% of patients undergoing this procedure. Rates of duodenal perforation after ERCP are much lower, ranging from 0.1-1.0% of patients. There are several case reports of pneumothorax, pneumomediastinum and pneumoretroperitoneum after ERCP. Because these are rare complications, there is no consensus on management strategy. Most patients undergo exploratory laparotomy but there have been a couple of recent case reports of successful conservative management without surgery. This case illustrates an example of a patient who underwent exploratory laparotomy for pneumothorax, pneumomediastinum and pneumoretroperitoneum after ERCP. Decision was made for patient to undergo exploratory laparotomy given signs of peritonitis on exam although no perforation was identified at laparotomy. The patient recovered post-operatively and was discharged home.Figure

Can a Wire-Guided Cannulation Technique Increase Bile Duct Cannulation Rate and Prevent Post-ERCP Pancreatitis?: A Meta-Analysis of Randomized Controlled Trials

The most common technique used to achieve primary deep biliary cannulation is the standard contrast-assisted method. To increase the success rate and reduce the risk of complications, a wire-guided cannulation strategy has been proposed. Prospective studies provided conflicting results as to whether the wire-guided cannulation technique increases the cannulation rate and reduces post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis risk compared with the standard method. The objective of this study was to carry out a meta-analysis of randomized controlled trials (RCTs) that compares primary biliary cannulation and post-ERCP pancreatitis rates with the wire-guided method and the standard cannulation technique. Literature searches of electronic databases and online clinical trial registers up to March 2009 were conducted to identify RCTs comparing primary cannulation and post-ERCP pancreatitis rates with the wire-guided method and the standard cannulation technique. A meta-analysis of these clinical trials was performed. Five RCTs were included. Overall, the primary cannulation rates reported with the wire-guided cannulation technique and the standard method were 85.3 and 74.9%, respectively. The pooled analysis of all the selected studies comparing the wire-guided cannulation technique with the standard method yielded an odds ratio (OR) of 2.05 (95% confidence interval (CI): 1.27-3.31). The pooled analysis comparing the post-ERCP pancreatitis rates for the wire-guided-cannulation groups with those for the standard-method groups yielded an OR of 0.23 (95% CI: 0.13-0.41). This meta-analysis shows that the wire-guided technique increases the primary cannulation rate and reduces the risk of post-ERCP pancreatitis compared with the standard contrast-injection method. Further large, well-performed, randomized controlled studies are needed to confirm these findings.

Guidewire Use for Prevention of Post ERCP Pancreatitis: A Meta-Analysis of Randomized Controlled Trials

Background: Deep biliary cannulation is important for performing therapeutic endoscopic biliary interventions. Success rates for CBD cannulation with conventional methods ranges from 50-90%, depending upon experience. Cannulation technique is believed to be pivotal in pathogenesis of post-ERCP pancreatitis (PEP) with multiple attempts increasing the risk. Multiple methods, including the use of guidewire, pre-cut technique, and medications are used to improve cannulation. A guidewire for selective cannulation may decrease the need to perform invasive techniques and PEP by improving cannulation rate. To date, the results for guidewire use for prevention of PEP and improving the rate of successful cannulation are conflicting. Therefore, we conducted meta-analysis to assess the role of guidewire use for prevention of PEP and improving cannulation rates. Methods: MEDLINE, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, Pub Med, and recent abstracts from major conference proceedings were searched (through 10/08). RCTs comparing guidewire with conventional methods for cannulation rate and PEP were included. Standard forms were used to extract data by two independent reviewers. The effects of guidewire use were analyzed by calculating pooled estimates of PEP, hyperamylasemia, cannulation rate, need for pre-cut sphincterotomy, and pancreatic duct manipulation. Separate analyses were performed for each outcome by using odds ratio (OR) or weighted mean difference (WMD) by fixed and random effects models. Publication bias was assessed by funnel plots. All studies were graded by Jadad score. Heterogeneity among studies was assessed by calculating I2 measure of inconsistency. Results: Six trials met inclusion criteria. Trials were of adequate quality (Jadad score ≥ 2). Guidewire cannulation demonstrated a statistically significant decrease in the odds of PEP (OR 0.61; 95% CI: 0.40-0.93, p=0.02), hyperamylasemia (OR 0.28; 95% CI: 0.16-0.46, p<0.01), and the need for pre-cut sphincterotomy (OR 0.62; 95% CI: 0.44-0.87, p=0.007) with an increase in the rate of successful cannulation (OR 2.59; 95% CI: 1.08-6.19, p=0.03) as compared to standard technique. No significant effect was observed for bleeding (OR 1.09; 95% CI: 0.47-2.51, p=0.84), time required (OR -4.59; 95% CI: -15.71-6.53, p=0.42), number of attempts (OR -5.03; 95% CI: -13.73-3.67, p=0.26) and pancreatic duct manipulation (OR 0.82; 95% CI: 0.33-2.03, p=0.67). Funnel plot revealed no publication bias. Conclusions: The use of a guidewire for CBD cannulation decreases the odds of PEP and improves the rate of successful cannulation.

Comparing ERCP Practice and Outcomes By Level of Experience

The ERCP Quality Network is a voluntary reporting system which allows endoscopists to submit data on procedures to a central repository. The data are analyzed and available to contributors in the form of individual practice summaries (“report cards”) and in comparison with others in the system (“benchmarking”). No doctors or patients may be identified. By November 2008, 59 doctors from 3 countries provided data on 7896 ERCP cases. Contributors were classified as “Academic” or “Community” and by experience. Less experienced practitioners were defined by < 150 cases in the last year, or < 1000 total lifetime. Academic and community groups had the same percentage of “less experienced" (21% vs 22%). Not surprisingly, Academics performed more complex cases (46% grade 3, vs 28% Community-based, p <.0001), but success rates for deep biliary cannulation, bile duct stone extraction (< 10 mm) and minor papilla cannulation were similar and high. Table 1 compares practice patterns and outcomes by experience. Less experienced endoscopists had fewer Grade 3 cases, were more likely to use conscious sedation rather than anesthesia, did more “diagnostic” cases, used longer total case and fluoroscopy time and had significantly lower success rates for deep biliary cannulation, extraction of bile duct stones (< 10 mm) and minor papilla cannulation. Complication rates were reportedly similar. The ERCP Quality Network project demonstrates that practitioners are interested and willing to share their practice data anonymously and also provides some idea of appropriate benchmarks. The project is ready for substantial enlargement and will facilitate the development of a national system covering all aspects of endoscopy. The data should eventually be extractable from electronic reporting systems. This project is supported by Olympus America.

Timing of precut procedure does not influence success rate and complications of ERCP procedure: a prospective randomized comparative study

There is scarce information on whether performing the precut procedure early rather than after several cannulation attempts is associated with different success and complication rates. To compare the success and complication rates of precutting implemented either early or after prolonged attempts by the standard approach. Single-center prospective randomized study. Tertiary care center. Over the 2-year study period, 1078 therapeutic ERCP procedures were performed. One hundred forty-six patients (mean age 68.5 years [range: 34-88 years], 67 men and 79 women) met the selection criteria and were randomized into 2 groups (on a 1:3 basis): group A underwent precut immediately after randomization (36 patients) and group B underwent standard cannulation attempts for a further 20 minutes followed by needle-knife precut in case of failure (110 patients). Deep biliary cannulation and the incidence of post-ERCP complications. The precut procedure performed in group A allowed deep cannulation of the common bile duct in 33 of 36 patients (92%). In group B, cannulation was successfully achieved in 104 of 110 patients (95%). Among group B patients, biliary cannulation was achieved with the standard approach in 78 patients, whereas precutting was performed in 32 patients, and deep cannulation was achieved in 26 of them. The overall complication rate was 8% (3/36) in group A and 6% (7/110) in group B. Small sample size. Timing of pre-cutting does not appear to influence success and complication rates of ERCP procedures.

Oral Administration of Edible Oil Prior to ERCP

Purpose: Selective cannulation of the duct of intent is the first crucial step during ERCP. A prior report has shown that a liquid fatty meal prior to ERCP relaxes the sphincter of Oddi & facilitates biliary cannulation. Aim: To assess the effect of oral administration of oil prior to ERCP on deep biliary cannulation at a tertiary care ERCP center involving both trainees & expert faculty endoscopists. Methods: Patients undergoing ERCP for biliary etiology & arriving > 1 hr prior to the procedure were given 45 ml corn oil (42 gm fat; Crisco, Orrville, OH) by mouth. Patients not receiving oil served as controls. Only patients with a virgin papilla were included. Exclusion criteria: prior sphincterotomy, prior unsuccessful ERCP, indwelling stent, acute pancreatitis, altered anatomy, gastroparesis, or sphincter of Oddi manometry. Appearance of the papillary orifice, deep biliary cannulation time, fluoroscopy time, rate of successful cannulation, & complications were noted for both fellows & faculty endoscopists. Results: Oil was administered to 38 patients (mean age 52 yrs;50% male) while 42 pts served as controls (mean age 55 yrs;57% male). The papillary orifice was gaping or open in 26/38 (68%) & 22/41 (53%) patients in the oil & control groups respectively. Bile flow from the papilla was seen in 63% & 43% pts in the 2 groups. There was no difference in time to successful cannulation for fellows in each group (3.3 min, range 0.5–14.5 min; and 3.5 min, range 0.2–8.3 min respectively). Fluoro time for biliary cannulation for fellows was 0.9 min (0.1–2.1) & 1.3 min (0.3–5) in the two groups respectively. Fellows were successful in deep biliary cannulation in 22/35 (63%) & 23/38 (61%) respectively. Faculty endoscopists were successful in 15/15 (100%) and 13/14 (93%) respectively after fellows had failed. Faculty endoscopists were successful in all cases performed without fellows (3/3 and 4/4 in each group & precut sphincterotomy was not required). Overall cannulation success rate was 38/38 (100%) & 40/41 (98%) respectively, including precut sphincterotomy in 5/38 (6%) & 3/41 (7%) in the oil & control groups. Biliary cannulation was unsuccessful in 1/41 (2%) in the control group despite precut sphincterotomy. The procedure was aborted in 1 patient in the control group due to arrhythmia. There were no complications (including aspiration, pancreatitis) in either group. Conclusion: Papillary orifice was more open after oil, & bile flow was seen in more patients receiving oil than in controls. However, there was no difference in the success rate of biliary cannulation, cannulation time or fluoro time in the two groups. Further studies with larger numbers of patients may be necessary to demonstrate a beneficial effect, especially at major ERCP centers.

Pancreatic sphincterotomy versus needle knife precut in difficult biliary cannulation

In endoscopic retrograde cholangiopancreaticography (ERCP) difficult cannulation is an independent risk factor for complications. Altogether 6,209 ERCPs were performed in Helsinki University Central Hospital in the period 1996-2006. In 558 cases (9%) without a previous sphincterotomy, direct access into the biliary duct could not be achieved. In this group access was attempted by first performing a pancreatic sphincterotomy in 351 difficult cannulation cases (63%). A needle knife precut without a pancreatic sphincterotomy was performed in 178 cases (32%). All the necessary clinical and laboratory information was available for 262 of the 351 patients who had undergone a pancreatic sphincterotomy and for 157 of the 178 patients who had been subjected to needle knife precutting, and these data were further evaluated in this study. The pancreatic sphincterotomy technique was successful in 255 cases (97.3%). Post-ERCP pancreatitis developed in 8.8% of the pancreatic sphincterotomy group. In 147 patients, biliary cannulation was successful following a pancreatic sphincterotomy, and the post-ERCP pancreatitis rate for those patients was 9.3%. In 108 patients, a needle knife papillotomy, in addition to a pancreatic sphincterotomy, was necessary and resulted in a post-ERCP pancreatitis rate of 8.2%. In the needle knife precut group only, post-ERCP pancreatitis developed in 5.1% of cases. Biliary cannulation succeeded less frequently following needle knife precutting than following the pancreatic sphincterotomy technique (71.3% versus 97.3%, p<0.001). There was no significant difference in the post-ERCP pancreatitis rate between the precut and pancreatic sphincterotomy techniques (p=0.16). In difficult cannulation, a pancreatic sphincterotomy to achieve deep biliary duct cannulation can be performed with a high success rate (failure rate less than 3%). The corresponding success rate using the needle knife precut technique is 71%. In both methods the risk for post-ERCP pancreatitis is comparable to that of a standard biliary sphincterotomy.

Prospektive randomisierte Untersuchung zur Kanülierungstechnik bei der ERCP: Einfluss auf technischen Erfolg und die Post-ERCP-Pankreatitis

BACKGROUND AND STUDY AIMS: Inadvertent injection of contrast agent into the pancreatic duct is believed to be an important contributor to pancreatitis occurring after endoscopic retrograde cholangiopancreatography (post-ERCP pancreatitis, PEP). Our aim was to examine whether primary deep biliary cannulation with a guide wire is associated with a lower rate of PEP than conventional contrast-assisted cannulation. PATIENTS AND METHODS: From August 2003 to April 2006 all patients with an intact papilla who were referred for ERCP were eligible. Patients with pancreatic or ampullary cancer were excluded. Patients were randomized to undergo sphincterotome biliary cannulation using either contrast injection or a guide wire. The ERCP fellow attempted initially for 5 min. If unsuccessful, the consultant attempted for 5 min using the same technique, followed by crossover to the other technique in the same sequence and then needle-knife sphincterotomy where appropriate. Patients were assessed clinically after the procedure, then followed up with telephone interviews after 24 hours and 30 days, and serum amylase and lipase tests after 24 hours. RESULTS: Out of 1654 patients undergoing ERCP, 413 were included in the study. PEP occurred in 29 / 413 (7.0 %): 16 in the guide-wire arm, 13 in the contrast arm (p = 0.48). The overall cannulation success rate was 97.3 %. Cannulation was successful without crossover in 323 / 413 patients (78.2 %): 167 / 202 (81.4 %) in the guide-wire arm and 156 / 211 (73.9 %) in the contrast arm (p = 0.03). Multivariate analysis demonstrated female sex (OR = 2.7, p = 0.04), suspected sphincter of Oddi dysfunction (OR = 5.5, p = 0.01), and complete filling of the pancreatic duct with contrast agent (OR = 3.5, p = 0.02) to be independently associated with PEP. The risk of PEP increased incrementally with each attempt at the papilla (OR 1.4 per attempt, p = 0.04) to greater than 10 % after four or more attempts. CONCLUSIONS: The guide-wire technique improves the primary success rate for biliary cannulation during ERCP but does not reduce the incidence of PEP compared to the conventional contrast technique. The incidence of PEP increases incrementally with each attempt at the papilla.

A prospective randomized trial of cannulation technique in ERCP: effects on technical success and post-ERCP pancreatitis

Inadvertent injection of contrast agent into the pancreatic duct is believed to be an important contributor to pancreatitis occurring after endoscopic retrograde cholangiopancreatography (post-ERCP pancreatitis, PEP). Our aim was to examine whether primary deep biliary cannulation with a guide wire is associated with a lower rate of PEP than conventional contrast-assisted cannulation. From August 2003 to April 2006 all patients with an intact papilla who were referred for ERCP were eligible. Patients with pancreatic or ampullary cancer were excluded. Patients were randomized to undergo sphincterotomy biliary cannulation using either contrast injection or a guide wire. The ERCP fellow attempted initially for 5 minutes. If unsuccessful, the consultant attempted for 5 minutes using the same technique, followed by crossover to the other technique in the same sequence and then needle-knife sphincterotomy where appropriate. Patients were assessed clinically after the procedure, then followed up with telephone interviews after 24 hours and 30 days, and serum amylase and lipase tests after 24 hours. Out of 1654 patients undergoing ERCP, 413 were included in the study. PEP occurred in 29/413 (7.0 %): 16 in the guide-wire arm, 13 in the contrast arm ( P = 0.48). The overall cannulation success rate was 97.3 %. Cannulation was successful without crossover in 323/413 patients (78.2 %): 167/202 (81.4 %) in the guide-wire arm and 156/211 (73.9 %) in the contrast arm ( P = 0.03). Multivariate analysis demonstrated female sex (OR = 2.7, P = 0.04), suspected sphincter of Oddi dysfunction (OR = 5.5, P = 0.01), and complete filling of the pancreatic duct with contrast agent (OR = 3.5, P = 0.02) to be independently associated with PEP. The risk of PEP increased incrementally with each attempt at the papilla (OR 1.4 per attempt, P = 0.04) to greater than 10 % after four or more attempts. The guide-wire technique improves the primary success rate for biliary cannulation during ERCP but does not reduce the incidence of PEP compared to the conventional contrast technique. The incidence of PEP increases incrementally with each attempt at the papilla.