Deep Cannulation Research Articles

Two-sphincterotomes-in-one-channel method: help in cannulation and sphincterotomy.

Deep cannulation of the desired channel (biliary or pancreatic) is the basic requirement to successfully perform a therapeutic endoscopic retrograde cholangiopancreatography (ERCP). In biliary cannulation, we have a broad armamentarium of standard and specialized techniques. However, failure rates can range from 1-10%. The consequences of failure in cannulation are serious: repetition of the ERCP, alternative procedures with morbidity and significant cost, as well as higher rates of complications (1). Therefore new techniques are arising that attempt to improve results without increasing these adverse effects. The performance of sphincterotomy is another very important step in completing biliary therapy (2). However, on some occasions the sphincterotomy is made more difficult due to the presence of a transverse duodenal fold that covers the papilla of Vater and impedes the safe completion of this technique.

Life‐threatening hemorrhage from the papilla following stent removal (with video)

A 73-year-old man was admitted with acute cholangitis due to stent occlusion. He had had type B chronic hepatitis for 14 years but no liver cirrhosis or coagulopathy. The stent was placed 2 months previously for the treatment of obstructive jaundice due to a very large hepatoma. Emergency endoscopic retrograde cholangiopancreatography was performed. Immediately after removing the stent, using snare forceps through the working channel of the endoscope, spurting and continuous bleeding was seen from the papilla. Biliary deep cannulation was successfully performed using a conventional catheter and guidewire. The tip of the catheter was advanced into the left intrahepatic bile duct for pressure hemostasis. Ten minutes later, the bleeding completely stopped and a 10-Fr stent was inserted into the bile duct.

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.

Sa1518 Precut Sphincterotomy At a Tertiary Referral Center for Pancreatic Diseases: A Prospective Study

BackgroundPrecutting is sometimes needed to facilitate deep cannulation of the biliary/pancreatic ducts during the course of endoscopic retrograde cholangiopancreatography (ERCP).ObjectivesTo identify the precut-related success and complication rates, and the treatments used in the event of ERCP failing.DesignObservational study on prospectively collected data.SettingA tertiary referral university hospital.PatientsPatients with papillae with no prior endoscopic treatment who underwent precutting between January 2007 and April 2010.Main Outcome MeasurementsSuccess and complication rates after precutting and after invasive radiological procedures used after ERCP had failed.ResultsERCP was performed in 783 patients, and 755 of these procedures were implemented with a therapeutic intent; a precut was made in 131 (17.3%): 64 were males (48.9%) and 67 were females (51.1%); their mean age was 65.5 ± 13.7 years. The overall success rate was 73.3% (96/131) with an inter-operator range of 63.1% to 83.3%. Among all the variables considered, uni- and multivariate analysis showed that only the “operator” variable was significant. The complication rate was 5.3% (7/131) with: 4 cases of mild pancreatitis (3%); 1 of severe pancreatitis (0.8%); 2 perforations (1.5%); and no hemorrhage or deaths. The difficulty encountered in performing the ERCP correlated inversely with the success rate (p<0.01), but not with the complication rate. The 35 patients whose ERCP was unsuccessful underwent: percutaneous transhepatic biliary drainage (PTBD) in 18 cases (51.4%); medical treatment and radiological follow-up in 11 (31.4%); and surgery in 6 (17.2%). PTBD carried a 22.2% rate of infectious/bleeding complications.Conclusion BackgroundPrecutting is sometimes needed to facilitate deep cannulation of the biliary/pancreatic ducts during the course of endoscopic retrograde cholangiopancreatography (ERCP). Precutting is sometimes needed to facilitate deep cannulation of the biliary/pancreatic ducts during the course of endoscopic retrograde cholangiopancreatography (ERCP). ObjectivesTo identify the precut-related success and complication rates, and the treatments used in the event of ERCP failing. To identify the precut-related success and complication rates, and the treatments used in the event of ERCP failing. DesignObservational study on prospectively collected data. Observational study on prospectively collected data. SettingA tertiary referral university hospital. A tertiary referral university hospital. PatientsPatients with papillae with no prior endoscopic treatment who underwent precutting between January 2007 and April 2010. Patients with papillae with no prior endoscopic treatment who underwent precutting between January 2007 and April 2010. Main Outcome MeasurementsSuccess and complication rates after precutting and after invasive radiological procedures used after ERCP had failed. Success and complication rates after precutting and after invasive radiological procedures used after ERCP had failed. ResultsERCP was performed in 783 patients, and 755 of these procedures were implemented with a therapeutic intent; a precut was made in 131 (17.3%): 64 were males (48.9%) and 67 were females (51.1%); their mean age was 65.5 ± 13.7 years. The overall success rate was 73.3% (96/131) with an inter-operator range of 63.1% to 83.3%. Among all the variables considered, uni- and multivariate analysis showed that only the “operator” variable was significant. The complication rate was 5.3% (7/131) with: 4 cases of mild pancreatitis (3%); 1 of severe pancreatitis (0.8%); 2 perforations (1.5%); and no hemorrhage or deaths. The difficulty encountered in performing the ERCP correlated inversely with the success rate (p<0.01), but not with the complication rate. The 35 patients whose ERCP was unsuccessful underwent: percutaneous transhepatic biliary drainage (PTBD) in 18 cases (51.4%); medical treatment and radiological follow-up in 11 (31.4%); and surgery in 6 (17.2%). PTBD carried a 22.2% rate of infectious/bleeding complications. ERCP was performed in 783 patients, and 755 of these procedures were implemented with a therapeutic intent; a precut was made in 131 (17.3%): 64 were males (48.9%) and 67 were females (51.1%); their mean age was 65.5 ± 13.7 years. The overall success rate was 73.3% (96/131) with an inter-operator range of 63.1% to 83.3%. Among all the variables considered, uni- and multivariate analysis showed that only the “operator” variable was significant. The complication rate was 5.3% (7/131) with: 4 cases of mild pancreatitis (3%); 1 of severe pancreatitis (0.8%); 2 perforations (1.5%); and no hemorrhage or deaths. The difficulty encountered in performing the ERCP correlated inversely with the success rate (p<0.01), but not with the complication rate. The 35 patients whose ERCP was unsuccessful underwent: percutaneous transhepatic biliary drainage (PTBD) in 18 cases (51.4%); medical treatment and radiological follow-up in 11 (31.4%); and surgery in 6 (17.2%). PTBD carried a 22.2% rate of infectious/bleeding complications. Conclusion

Comparative Evaluation of Transpapillary Drainage with Nasopancreatic Drain and Stent in Patients with Large Pseudocysts Located Near Tail of Pancreas

BackgroundEndoscopic transpapillary drainage is usually not advocated for large pseudocysts for fear of infection. We compared efficacy of transpapillary drainage with nasopancreatic drain (NPD) or stent alone in large pseudocysts (>6 cm) located near tail of pancreas. MethodsIn a prospective study, a 5-Fr stent/NPD was placed across/near pancreatic duct disruption in 11 patients (nine chronic and two acute pancreatitis) with large pseudocysts located near tail of pancreas. The patients were followed up for resolution of pseudocyst, need for surgery, and complications. ResultsPseudocysts diameter ranged from 7 to 15 cm. An attempt to place NPD was made in five patients and a stent in six patients. In NPD group, deep cannulation could not be achieved in one patient; it was treated successfully with percutaneous drainage. In four patients with partial duct disruption, NPD was successfully placed bridging disruption and all had resolution within 6 weeks. In stent group, five had partial and one had complete duct disruption, who later recovered by placement of a stent. Of five patients with partial disruption, one recovered uneventfully at 6 weeks with stent bridging disruption. Other four patients (bridging stent in three) developed febrile illness and infection of pseudocyst. They required additional percutaneous drainage and antibiotics. There was no recurrence of pseudocysts over follow-up of 16.4 months. ConclusionEndoscopic transpapillary drainage with NPD bridging disruption is associated with good outcome in patients with large pseudocysts at tail end of pancreas. However, there was increased frequency of infection when stent was used for drainage.

Does Anesthesiologist-Directed Sedation for ERCP Improve Deep Cannulation and Complication Rates?

While some gastroenterologists provide their own sedation for endoscopic retrograde cholangiopancreatography (ERCP), others utilize anesthesiologists. There is limited information comparing cannulation success and complication rates between these two approaches. Theoretically, anesthesiologist-directed sedation (ADS) may lead to an improved deep cannulation rate by virtue of using deeper and more constant levels of sedation and by removing the minute-by-minute medication management and physiologic monitoring responsibilities from the endoscopy team. To compare ERCP deep cannulation success and complications between gastroenterologist-directed sedation (GDS) and ADS. All ERCPs completed by senior advanced endoscopists at a tertiary referral center over a 2-year period were reviewed. During the first year, all ERCP sedation was performed with GDS utilizing a narcotic and a benzodiazepine. Due to a change in division policy and practice, during the second year, all ERCP sedation was provided by ADS. Patients with prior papillary interventions were excluded. Demographics, procedure indications, deep cannulation success, sedation provider, and procedural complications were recorded. A total of 367 patients were studied: 178 (48.5%) GDS and 189 (51.5%) ADS. There was no difference in the groups with respect to race, age, and gender. Four patients (2.3%) in the GDS group could not be sedated. There were two deaths, one in each group; one death was due to cholangitis/sepsis and the other was due to post-ERCP pancreatitis. The overall cannulation success rates were similar between the two groups (94.4% vs. 95.2%, P=0.36). Deep ductal cannulation rates between GDS and ADS are similar.

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.

Comparison of Safety and Efficacy of ERCP in Prone and Left Lateral Decubitus Positions

Purpose: Endoscopic retrograde cholangiopancreatography (ERCP) is conventionally done with the patient in the prone position, however, this can be challenging in certain circumstances including significant ascites and indwelling percutaneous catheters. ERCP in the supine position has been found to be generally appropriate when prone positioning is deemed challenging, but little data exist on another alternative which is occasionally used by endoscopists, the left lateral decubitus (LLD) position. Our aim was to compare efficacy and safety of ERCP in the prone versus left lateral decubitus position. Methods: Consecutive electronic medical records of ERCPs completed by one senior endoscopist from August 2009 to May 2010 at the Mayo Clinic in Arizona were evaluated. Studies were included if patients were older than 18 years with a native papilla for biliary indications. We sequentially compared records of patients who had ERCP in LLD versus prone position. The primary outcome measures were cannulation success rate, time to initial ampullary localization, time to deep ampullary cannulation, peri-procedural complications (respiratory and cardiac), and post-procedural complications. Data are presented as mean (SD) or median (IRQ; interquartile range). Results: ERCP was completed in 34 patients (16 prone, 18 LLD). Groups were not significantly different in gender, age, peri-procedural respiratory or cardiac complications, and post-procedural complications. The cannulation success rate was 100% in the prone position and 94% in LLD (P=1.00). Median time from scope insertion to initial ampullary localization was 75 seconds (IRQ 60-90 seconds) in prone position and 100 seconds (IRQ 80-113 seconds) in LLD. Median time from initial ampullary impaction to deep ampullary cannulation was 168 seconds (IRQ 51-758 seconds) in the prone position and 155 seconds (IRQ 53-413 seconds) in LLD. Mean time from scope insertion to initial ampullary localization was 98 (79) seconds in prone position and 101 (29) seconds in LLD position (P=0.894). Mean time from initial ampullary impaction to deep ampullary cannulation was 475 (629) seconds in prone position and 316 (461) seconds in the LLD (P=0.404). Conclusion: In patients undergoing ERCP in LLD and prone positions, there was no significant difference in ampullary cannulation rate, time to initial ampullary localization, or time to deep ampullary intubation according to position. Also, there was no significant difference in rates of peri- and post-procedural complications. ERCP in the left lateral decubitus position can be performed efficaciously and safely when the standard prone position is deemed to be technically challenging.

Does Procedure Start Time (AM vs PM) Affect ERCP Deep Cannulation Success and Complication Rates?

Purpose: Physician fatigue has been proposed as a cause for lower completion and adenoma detection rates in colonoscopies performed later in the workday. ERCP is considered more technically demanding than routine screening colonoscopy and also highly operator dependent; therefore its quality and success may similarly be affected by fatigue. The goals of this study were to compare successful deep cannulation and complication rates between ERCPs performed in the morning (AM) and afternoon (PM). Methods: All ERCPs performed by senior therapeutic endoscopists over a two year period were reviewed. Patients with prior papillary interventions (papillotomy, stent placement, etc.) were excluded. Procedure reports and electronic medical records were reviewed for time of procedure (AM vs. PM), deep cannulation success, complications (pancreatitis, cholangitis, hemorrhage, perforation, and death), trainee involvement and sedation modality (moderate vs. MAC). AM was defined as procedure start time before 12pm and PM after 12pm. Results: 296 patients were studied; 114 (38.5%) AM and 182 (61.5%) PM. 139 (47.0%) patients were male. Mean patient age was 59.1 yr. Deep cannulation success was 95.3% overall; 98.3% AM and 94.0% PM (95 CI: -0.9-8.9, P=0.08). Complication rates were also similar between the two groups (8.8% AM vs. 7.1% PM, P=0.61). The results are summarized in Table 1.Table 1: ResultsConclusion: Procedure start time, AM vs. PM, does not appear to affect cannulation success or complication rates in ERCP.

An analysis of the efficacy and safety of a strategy of early precut for biliary access during difficult endoscopic retrograde cholangiopancreatography in a general hospital

The use of early precut during endoscopic retrograde cholangiopancreatography (ERCP) is controversial because of its association with a higher risk of complications. This study examined the efficacy and safety of a strategy of early precut for biliary access during difficult ERCP in a general hospital. Data from January 2007 to June 2009 were reviewed. Criteria for performing early precut were: (i) inadvertent guidewire cannulation of pancreatic duct on three occasions; (ii) biliary stone impacted at papilla; (iii) inability to achieve deep cannulation within 10 min. Study exclusion criteria were: (i) the inability to visualize the papilla because of anatomical distortions; (ii) complete tumour occlusion of distal bile duct; (iii) failure to adhere to inclusion criteria. The efficacy and safety of this strategy of early precut for biliary access was analyzed. A total of 765 ERCP cases were analyzed. A precut was performed in 55 out of 765 cases (7.2%). There were no significant differences in terms of age, gender and diagnoses between the precut and no precut groups. After precut immediate biliary cannulation was achieved in 89% of patients and this increased to 98.2% with a repeat ERCP. The overall complication rate after ERCP was 2.1% (bleeding: 0.7%; pancreatitis: 1.3%; perforation: 0.3%). The only complication after the precut was pancreatitis, and this was not significantly different from the group without a precut (1.8 vs 1.3%). The strategy of early precut for biliary access was safe and effective.

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

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

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.

347a: Can a Wire-Guided Cannulation Technique Reduce Risk of Post-ERCP Pancreatitis and Facilitate Bile Duct Deep Cannulation?

To compare the performance of the guidewire cannulation (GWC) technique and the conventional cannulation (CC) technique in selective bile duct cannulation.Design: Multicenter randomized, controlled trial.Setting: Nine tertiary referral centers.

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.

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.

A case of idiopathic recurrent pancreatitis successfully treated using octreotide and endoscopic stent

35-year-old female visited another hospital complaining of repeated abdominal pain, and the condition was diagnosed as idiopathic recurrent pancreatitis. She was transferred to our hospital to scrutinize the cause of recurrent pancreatitis. We performed endoscopic retrograde pancreatography to find the cause, but we failed in deep cannulation into the pancreatic duct because of a strong duodenum inflammation. Pancreatitis repeatedly recurred after the examinations.Octreotide was used to improve pancreatitis and suppress inflammation of the duodenum. Cannulation into distal pancreatic duct became possible after resolution of pancreatitis and duodenal inflammation. After insertion of a pancreatic duct stent had been inserted, the relapse of pancreatitis was not seen.

Advances in endoscopic retrograde cholangiopancreatography cannulation

Endoscopic retrograde cholangiopancreatography is an important tool in the diagnosis and treatment of pancreatobiliary diseases. A critical step in this procedure is deep cannulation of the bile duct as failure of cannulation generally results in an aborted procedure and failed intervention. Expert endoscopists usually achieve a high rate of successful cannulation while those less experienced typically have a much lower rate and a greater incidence of complications. Prolonged attempts at cannulation can result in significant morbidity to patients, anxiety for endoscopists, unnecessary radiation exposure and inefficient patient care. Here we review the most common endoscopic techniques used to achieve selective biliary cannulation. Pharmacologic aids to cannulation are also discussed briefly in this review.

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.