Deep Cannulation Of Bile Duct Research Articles

Optimal dilation duration of 10 mm diameter balloons after limited endoscopic sphincterotomy for common bile duct stones: a randomized controlled trial

Limited endoscopic sphincterotomy (EST) combined with endoscopic papillary balloon dilation (EPBD) is widely used. However, the optimal duration of small balloon dilation in choledocholithiasis remains controversial. We aimed to determine the optimal duration for 10 mm diameter balloon dilation after limited EST in choledocholithiasis. In this randomized controlled clinical trial, 320 patients were randomly assigned to receive small balloon dilation (10 mm in diameter) for 1 min (n = 160) or 3 min (n = 160) after deep bile duct cannulation. No significant difference in success rate of stone extraction between the two groups was observed. The incidence of post-ERCP pancreatitis (PEP) was higher in the 1 min group (10.6%) than in the 3 min group (4.4%) (P = 0.034). The logistic regression analysis showed that guidewire into the pancreatic duct, cannulation time > 5 min and 1 min balloon dilation were independent risk factors for PEP. There were no significant differences in other post-ERCP adverse events such as acute cholangitis, bleeding, perforation, etc. between the two groups. In conclusion, 3 min in duration was determined to be the optimal dilation condition for the removal of common bile duct stones.

Enlarged fistulotomy of the papilla as access to the biliary tract during ERCP

BackgroundDemonstration of access to the bile duct through Enlarged Papillary Fistulotomy, a method different from conventional fistulotomy.AimsDemonstration of the EFP technique with dissection in layers of the papilla for accessing the common bile duct, its efficiency and safety, rescue of cases of failure in cannulation and cases of access failure by EFP in the first attempt, facilitating cannulation in the second attempt.MethodsCross-sectional study, with retrospective data collection from 2233 ERCP exams with 528 EFP procedures, analysis of success and complications.Results528 patients underwent EFP on the first attempt, with success in 465 cases (88.06%) and 63 failures (11.94%). Of these failures, 33 patients (52.38%) returned for a second EFP attempt, with success in 30 cases (90.9%) and failure in 3 cases (9.1%). Deep bile duct cannulation was achieved in 93.75% of EFP procedures, and cannulation failure occurred in 33 cases (6.25%).ConclusionEFP showed efficiency in CBD cannulation, did not induce post-ERCP pancreatitis, no cases of perforation or false tract, but resulted in higher rates of minor bleeding, rescued cases of access failure by EFP, facilitated the posterior approach on the second attempt, it is safe, effective, low risk and associated with few comorbidities.

Su1562 NEEDLE KNIFE SPHINCTEROTOMY FOR DIFFICULT BILIARY CANNULATION: FACTORS PREDICTING ITS FAILURE

Needle-knife sphincterotomy (NKS) is the most popular technique for accessing the bile duct when conventional cannulation methods fail. The success rate of NKS has been reported from 71-92%. Certain factors may influence the NKS results but have not been reported in the literature. This retrospective study is to analyze predicting factors for NKS failure. Between 2004 and 2016, 397 NKS procedures (6.3% of the ERCP procedures for patients with an intact papilla) were performed for difficult cases of biliary cannulation. All procedures were performed by five endoscopists (A-E), and only endoscopist A had NKS experience before the study. Deep bile duct cannulation was successfully performed in 300 patients after NKS (75.6%, NKS success group) and failed in 97 patients (24.4%, NKS failure group). To identify predicting factors, both patient and technique factors were compared. Patient factors included age, sex, CBD diameter, major papilla status (periampullary diverticulum, enlarged or swelling papilla, low set papilla, impacted stone at ampulla of Vater, periampullary tumor, and surgically altered anatomy), and final diagnosis (choledocholithiasis, malignant/benign biliary stricture, bile leak, and suspected Sphincter of Oddi dysfunction). Technique factors included endoscopists’ experience and major bleeding during NKS. Major bleeding was the bleeding that could interfere with or eventually caused the interruption of NKS. Logistic regression analysis was performed to identify predictors of NKS failure. There was no significant difference in the median patient age (71 vs. 72 years) and male patients (52.6% vs. 55.4%) between the groups. Endoscopists A, B, C, D, and E performed 188, 93, 51, 45, and 20 NKS procedures, respectively, during the study. Their NKS success rates were 79.8%, 76.3%, 72.5%, 64.4%, and 65%, respectively. To calculate the endoscopists’ experience, endoscopist A was used as a reference; endoscopists B and C were considered as intermediate experience; the endoscopists D and E together, they were considered inexperienced. Base on univariate analysis, periampullary diverticulum, surgically altered anatomy, endoscopists’ experience, and major bleeding during NKS were the predictors of NKS failure. By multivariate analysis, surgically altered anatomy (OR: 2.42, 95% CI: 1.04-5.64, p = 0.041), endoscopists’ experience (OR: 3.38, 95% CI: 1.65-6.92, p = 0.001 for endoscopists D+E), and major bleeding during NKS (OR: 22.68, 95% CI: 10.333-49.78, p <0.001) remained significant predictors. Surgically altered anatomy, endoscopists’ experience, and major bleeding during NKS were the predictors of NKS failure. Major bleeding during NKS was the strongest predictor. Therefore, any bleeding during NKS has to be stopped before major bleeding begins. NKS may be reserved for experienced endoscopists.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Optimal dilation time for combined small endoscopic sphincterotomy and balloon dilation for common bile duct stones: a multicentre, single-blinded, randomised controlled trial

Endoscopic sphincterotomy is the established treatment for common bile duct stones. Balloon dilation offers an alternative. Prolonged dilation (300 s) with a 10 mm diameter balloon decreases the occurrence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). We aimed to determine the optimal duration of dilation for combined endoscopic sphincterotomy and balloon dilation for the removal of common bile duct stones. We did a multicentre, single-blinded, randomised controlled trial at 15 tertiary surgical centres in China. Eligible patients (≥18 years) with native papilla and common bile duct stones (≤1·5 cm in size and <2 cm in diameter) undergoing ERCP were randomly assigned (1:1:1:1:1) to receive balloon dilation for 0, 30, 60, 180, or 300 s after deep bile duct cannulation. Randomisation was done by an independent statistician using a computer-generated randomisation list with a block size of ten, stratified by centre. Patients and outcome assessors, but not endoscopists and investigators, were masked to treatment allocation. Balloon dilation was done with controlled radial expansion balloons according to common bile duct stone size. Stones were removed using stone retrieval balloons or baskets. The primary endpoint was overall frequency of post-ERCP pancreatitis. The primary efficacy analysis and safety analyses were done in the modified intention-to-treat population, which included all randomly assigned patients with successful cannulation, but excluded those who withdrew consent after randomisation. This study was registered with ClinicalTrials.gov, number NCT02510495, and is complete. Between July 29, 2015, and Dec 1, 2017, 3721 consecutive patients with common bile duct stones were recruited, 1718 of whom were excluded. The remaining 2003 patients underwent a small (3-5 mm) endoscopic sphincterotomy. 83 patients withdrew consent after the ERCP procedure, thus 1920 patients were included in the modified intention-to-treat analysis (0 s [n=371], 30 s [n=384], 60 s [n=388], 180 s [n=390], and 300 s [n=387]). Overall, post-ERCP pancreatitis occurred in 199 (10%) of 1920 patients (44 [12%] patients in the 0 s group, 28 [7%] in the 30 s group, 32 [8%] in the 60 s group, 36 [9%] in the 180 s group, and 59 [15%] in the 300 s group). Prolonged dilation (300 s) significantly increased the occurrence of post-ERCP pancreatitis compared with shorter balloon dilation (p=0·002). The frequency of post-ERCP pancreatitis was significantly lower in the 30, 60, and 180 s groups than in the 300 s group (relative risk [RR] 0·48, 95% CI 0·31-0·73; p=0·0005 vs the 30 s group; 0·54, 0·36-0·81; p=0·003 vs the 60 s group; 0·61, 0·41-0·89; p=0·01 vs the 180 s group). The frequency of post-ERCP pancreatitis was significantly higher in the 0 s group than the 30 s group (RR 1·62, 1·04-2·56; p=0·03). No difference in stone extraction (all ≥90%) was observed between groups. Following ERCP, 90 (5%) of 1920 patients had acute cholangitis, 14 (<1%) had acute cholecystitis, and five (<1%) had gastrointestinal bleeding, with no significant differences between groups. One (<1%) patient had Stapfer II perforation, which resolved spontaneously with conservative treatment. A balloon dilation time of 30 s for combined endoscopic sphincterotomy and balloon dilation reduced the frequency of post-ERCP pancreatitis and was determined to be the optimum dilation time for the removal of common bile duct stones. National Natural Science Foundation of China, Gansu Competitive Foundation Projects for Technology Development and Innovation.

Randomized Trial of Endoscopist-Controlled vs. Assistant-Controlled Wire-Guided Cannulation of the Bile Duct.

Biliary cannulation is frequently the most difficult component of endoscopic retrograde cholangiopancreatography (ERCP). Techniques employed to improve safety and efficacy include wire-guided access and the use of sphincterotomes. However, a variety of options for these techniques are available and optimum strategies are not defined. We assessed whether the use of endoscopist- vs. assistant-controlled wire guidance and small vs. standard-diameter sphincterotomes improves safety and/or efficacy of bile duct cannulation. Patients were randomized using a 2 × 2 factorial design to initial cannulation attempt with endoscopist- vs. assistant-controlled wire systems (1:1 ratio) and small (3.9Fr tip) vs. standard (4.4Fr tip) sphincterotomes (1:1 ratio). The primary efficacy outcome was successful deep bile duct cannulation within 8 attempts. Sample size of 498 was planned to demonstrate a significant increase in cannulation of 10%. Interim analysis was planned after 200 patients-with a stopping rule pre-defined for a significant difference in the composite safety end point (pancreatitis, cholangitis, bleeding, and perforation). The study was stopped after the interim analysis, with 216 patients randomized, due to a significant difference in the safety end point with endoscopist- vs. assistant-controlled wire guidance (3/109 (2.8%) vs. 12/107 (11.2%), P=0.016), primarily due to a lower rate of post-ERCP pancreatitis (3/109 (2.8%) vs. 10/107 (9.3%), P=0.049). The difference in successful biliary cannulation for endoscopist- vs. assistant-controlled wire guidance was -0.5% (95% CI-12.0 to 11.1%) and for small vs. standard sphincerotome -0.9% (95% CI-12.5 to 10.6%). Use of the endoscopist- rather than assistant-controlled wire guidance for bile duct cannulation reduces complications of ERCP such as pancreatitis.

Optimal Positioning for ERCP: Efficacy and Safety of ERCP in Prone versus Left Lateral Decubitus Position

Background. ERCP is customarily performed with the patient in prone position. For patients intolerant of prone positioning, ERCP in left lateral decubitus (LLD) position offers a potential alternative. Aims. To compare efficacy and safety of ERCP in the LLD position versus prone position. Methods. Consecutive ERCP reports from August 2009 to October 2010 at Mayo Clinic Arizona were reviewed. Inclusion criteria. Age &gt; 18 years, native papilla, and biliary indication. Primary outcome measure. Bile duct cannulation rate. Secondary outcomes. Times to ampullary localization and bile duct cannulation and complication rate. Results. ERCPs reviewed from 59 patients in two positions: 39 prone and 20 LLD. Cannulation Rate. 100% prone versus 90% in LLD (P=0.11). Median (IRQ) times. (1) Ampullary localization: 90 sec (70–110) prone versus 100 sec (80–118) (P=0.16); (2) bile duct cannulation: 140 sec (45–350) prone versus 165 sec (55–418) LLD (P=0.54). Complications. No periprocedure; postprocedure 4 (10%) prone versus 3 (15%) LLD (P=0.65). Conclusion. ERCP performed in LLD position allowed deep bile duct cannulation in 90% of patients without significantly increased procedural times or rate of complications as compared to prone position.

Comparison of Deep Bile Duct Cannulation with Cannulatome Versus Cannulatome with Guide Wire: A Prospective Randomized Trial

Background: During the endoscopic retrograde cholangiopancreatography (ERCP) the main step is the cannulation of major duodenal papilla to obtain deep cannulation of bile duct, and it is correlated to pancreaticobiliary complications being that acute pancreatitis is the most frequent. Aim: compare the rate of success to achieve selective cannulation of common bile duct using a cannulatome and cannulatome with guide-wire; compare the amylase, lypase and C reactive protein serum level between the groups and evaluate the incidence of pancreatitis in the groups. Patients and Methods: From July 2002 to October 2003 341 ERCP were performed at our institution. Three hundred consecutive patients were randomized to duodenal papilla cannulation using cannulatome (Group I) and cannulatome with guide wire (Group II). All the endoscopic procedures were performed by the first author. All patients were hospitalized for 24 hours after ERCP. Amylase , lipase, C-reactive protein were assessed before, 4, 12 and 24 hours after the procedure. CT scan was performed if the patient complained of pain and presented an amylase over three times the normal level. Results: The frequency of cannulations of pancreatic duct were similar in both Groups (p=0,161). Deep biliary cannulation without precut was more frequent in Group II (p=0,023). The precut was applied more frequently in Group I (p=0,01). Group II presented a significant lower incidence of acute pancreatitis (p=0,04). More patients in Group I presented hiperamylasemia at 4, 12 and 24 hours (p=0,0087; p=0,045; p=0,0475, respectively). The number of pancreatic cannulations was related to hiperamylasemia and acute pancreatitis. The acute pancreatitis post ERCP were significantly higher in Group I (p=0,037). Conclusion: The biliary access with cannulotome loaded with guide wire is related to higher success rate of selective biliary cannulation and less pancreatic trauma.

A new method for deep cannulation of the bile duct by straightening the pancreatic duct

Deep cannulation of the common bile duct is essential for performing endoscopic stent insertion. However, in some patients with acute angulation of the distal bile duct, deep cannulation is difficult. This is a description of a new method for overcoming this technical difficulty, based on inserting double guidewires (one in the pancreatic duct, the other in the bile duct) through the single accessory channel of a conventional duodenoscope.

Endoscopic management of major bile leaks complicating hepatic resections for hepatocellular carcinoma

Nine patients with postoperative biliary leaks are presented. These were selected from 128 adult patients with hepatocellular carcinoma who underwent hepatic resections at our hospital between March 1990 and July 1995. Types of hepatic resections as defined by Couinaud7 included nonanatomic resection (40), anatomic resection of 3 or less segments (25), left lateral segmentectomy (6), right or left hepatectomy (41), extended hepatectomy (12), and trisegmentectomy (4). Of the 9 patients (7%) who developed bile leaks postoperatively, there were 7 men and 2 women with median age of 49 years (range 35 to 71 years) (Table 1). Types of resections in these patients were right hepatectomy (2), left hepatectomy (2), left extended hepatectomy (2), right extended hepatectomy (1), right hepatectomy with caudate lobe excision (1), and nonanatomic resection (1). One patient who presented with obstructive jaundice from a left lobe tumor invading the common hepatic duct required reconstruction of the common hepatic duct in addition to left hepatectomy. The incidence of bile leaks after extended hepatectomy was significantly higher (4 in 16 vs. 5 in 112, p = 0.01, Fisher’s exact test). The median tumor size was 8 cm (range 3 to 10 cm). Resection margins were free of tumor in all patients. All 9 patients except 1 had cirrhosis confirmed at laparotomy. ERCP was performed at a median of 19 days (range 11 to 80 days) from surgery. The indications for referral were recurrent infected bilomas in 5 patients, high output fistula (greater than 500 mL daily from subhepatic drains) in 2 patients and nonhealing fistula beyond 2 weeks in 2 patients. Radiologic-guided percutaneous aspirations and pigtail catheter drainage (median 3 sessions, range 1 to 5 sessions) were required in patients with infected bilomas prior to ERCP. The volume of aspirates from bilomas varied from 100 mL to 1.5 L. At ERCP in 1 patient with a previous Billroth II gastrectomy, the papilla could not be accessed because of a redundant afferent limb. He was managed conservatively and his bilocutaneous fistula was healed 2 months later. In another patient, deep cannulation of common bile duct was not achieved. Percutaneous transhepatic biliary drainage was not attempted because of a coagulopathy. She subsequently died of sepsis and liver failure. ERCP was successful in 7 patients. Endoscopic sphincterotomy was performed in 2 patients in whom deep cannulation of the bile duct had been difficult. Bile leaks were demonstrated in all patients to be at or proximal to the liver hilum at segmental branches of intrahepatic ducts. In 5 patients without associated strictures, 10F stents were inserted across the sphincter with the proximal ends of the stents near the site of leakage (Figure 1). A nasobiliary drain was initially placed in 1 patient and subsequently changed to a stent following drying of the fistula. After stent insertion, a significant reduction in fistula output was noted in all patients. Fistulas healed in a median of 11 days (range 9 to 47 days). The effect of stenting was best appreciated in patients with high fistula output. The output often fell from 1.5 L to 300 mL on the day after stenting. Two patients had associated strictures with proximal fistulation, one at a reconstructed common hepatic duct and the other from a segment II duct. In the patient with a common hepatic duct stricture, a stent was inserted across an anastomotic stricture proximal to the site of leakage after balloon dilation of the stricture. Distal migration below the stricture occurred twice leading to recollection of bilomas. Longer stents were placed on two occasions. The fistula took 31 days to heal, 18 days from the last stent placement. In the other patient with a tight segmental II duct stricture following right trisegmentectomy, a nasobiliary drain was initially placed. This subsequently became dislodged. At a second ERCP, the stricture was found to be resistant to balloon dilation and a 6.5F stent was inserted across the stricture. Because of the poor bile duct drainage, healing of fistula was slow. The patient was left with a persistent discharge sinus that finally healed after 110 days. Stents were removed in all cases from 6 to 8 weeks after fistula healing. The duration of follow-up in these patients ranged from 2 to 69 months. No median-term complication was noted. Two patients had died of tumor recurrence, one at 2 and the other at 4 months from surgery.