Difficult Bile Duct Cannulation Research Articles

Can early precut reduce post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with difficult bile duct cannulation?

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a variety of adverse events (AEs). One of the most important AEs is post-ERCP pancreatitis (PEP), which is most common in cases of difficult biliary cannulation. Although the precut technique has been reported as a PEP risk factor, recent studies indicate that early precut could reduce PEP, and that precut itself is not a risk factor. To evaluate the safety of the precut technique, especially in terms of PEP. We conducted a retrospective study, spanning the period from November 2011 through December 2021. It included 1556 patients, aged ≥ 20 years, who underwent their initial ERCP attempt for biliary disease with a naïve papilla at the Kawasaki University General Medical Center. We compared the PEP risk between the early precut and the delayed precut group. The PEP incidence rate did not significantly differ between the precut and non-precut groups. However, the PEP incidence was significantly lower in the early precut group than the delayed precut group (3.5% vs 10.5%; P = 0.02). The PEP incidence in the delayed precut group without pancreatic stent insertion (17.3%) was significantly higher compared to other cases (P < 0.01). Our findings indicate that early precut may reduce PEP incidence. If the precut decision is delayed, a pancreatic stent should be inserted to prevent PEP.

Endoscopic Ultrasound-Guided Rendezvous Technique Versus Precut Sphincterotomy as Salvage Technique in Patients With Benign Biliary Disease and Difficult Biliary Cannulation : A Randomized Controlled Trial.

The standard salvage technique used for difficult bile duct cannulation is precut sphincterotomy, whereas endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a relatively newer method. Prospective comparative data between these 2 techniques as salvage for biliary access in patients with benign biliary disease and difficult bile duct cannulation is lacking. To compare EUS-RV and precut sphincterotomy as salvage technique for difficult bile duct cannulation in benign biliary obstruction. Participant-masked, parallel-group, superiority, randomized controlled trial. (Clinical Trials Registry of India: CTRI/2020/07/026613). Tertiary care academic institute from July 2020 to May 2021. All patients with benign biliary disease and difficult bile duct cannulation requiring salvage strategy. Patients were randomly assigned by computer-generated randomized blocks sequence in 1:1 fashion to either EUS-RV or precut sphincterotomy. Patients with failure in EUS-RV were crossed over to precut sphincterotomy and vice versa. The primary outcome measure was technical success. The other outcome measures included procedure time, radiation dose, and adverse events. In total, 100 patients were randomly assigned to EUS-RV (n = 50) and precut sphincterotomy (n = 50). The technical success rate (92% vs. 90%; P = 1.00; relative risk, 1.02 [95% CI, 0.90 to 1.16]), median procedure time (10.1 vs. 9.75 minutes), and overall complication rate (12% vs. 10%; relative risk, 1.20 [CI, 0.39 to 3.68]) were similar between the 2 groups. Five patients (10%) in the EUS-RV group and 5 patients (10%) in the precut sphincterotomy group had developed post-endoscopic retrograde cholangiopancreatography pancreatitis. All failed cases in either salvage group could be successfully cannulated when crossed over to the other group. Single center study done by experts. Endoscopic ultrasound-guided rendezvous technique and precut sphincterotomy have similar success rates as salvage techniques in the technically challenging cohort of difficult bile duct cannulation for benign biliary disease, with acceptable complications rates. None.

Double guide-wire technique versus transpancreatic biliary sphincterotomy for difficult biliary cannulation: Real life experience from a referral center.

During ERCP for biliary indication, when a difficult bile duct (BD) cannulation occurs, with unintended access to the main pancreatic duct (PD), both double guidewire technique (DGW) and transpancreatic biliary sphincterotomy (TPBS) can be performed. We aimed to compare the technical success and adverse events (AEs) rate of these techniques. A retrospective analysis of patients with naïve papillae referred to the Pancreas Institute of Verona from January 2016 and July 2021 to undergo ERCP for biliary indications was performed. Overall, 202 patients (53.5% males, mean age 67.2 years) were evaluated (96 DGW, 106 TPBS). Malignant biliary stricture was the most common ERCP indication (78.2%). The rate of success in deep biliary cannulation was significantly higher in the DGW group (94.8%) compared to TPBS (79.2%) at the first attempt (p=0.001). This result was also confirmed in the subgroup of patients with malignant distal stricture (72/77, 93.5% vs 63/80, 78.8%, p=0.01). No significant difference in AEs rate, particularly in PEP incidence was found between the two groups. DGW demonstrated a higher success rate and similar safety profile compared with TPBS in difficult biliary cannulation. Based on this retrospective study, DGW should be preferred over TPBS in case of unintended PD cannulation. Further prospective studies are needed to confirm our results.

Endoscopic salvage therapy after failed biliary cannulation using advanced techniques: A concise review.

Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) begins with successful biliary cannulation. However, it is not always be successful. The failure of the initial ERCP is attributed to two main aspects: the papilla/biliary orifice is endoscopically accessible, or it is inaccessible. When the papilla/biliary orifice is accessible, bile duct cannulation failure can occur even with advanced cannulation techniques, including double guidewire techniques, transpancreatic sphincterotomy, needle-knife precut papillotomy, or fistulotomy. There is currently no consensus on the next steps of treatment in this setting. Therefore, this review aims to propose and discuss potential endoscopic options for patients who have failed ERCP due to difficult bile duct cannulation. These options include interval ERCP, percutaneous-transhepatic-endoscopic rendezvous procedures (PTE-RV), and endoscopic ultrasound-assisted rendezvous procedures (EUS-RV). The overall success rate for interval ERCP was 76.3% (68%-79% between studies), and the overall adverse event rate was 7.5% (0-15.9% between studies). The overall success rate for PTE-RV was 88.7% (80.4%-100% between studies), and the overall adverse event rate was 13.2% (4.9%-19.2% between studies). For EUS-RV, the overall success rate was 82%-86.1%, and the overall adverse event rate was 13%-15.6%. Because interval ERCP has an acceptably high success rate and lower adverse event rate and does not require additional expertise, facilities, or other specialists, it can be considered the first choice for salvage therapy. EUS-RV can also be considered if local experts are available. For patients in urgent need of biliary drainage, PTE-RV should be considered.

National Survey Regarding the Management of Difficult Bile Duct Stones in South Korea.

This study aimed to investigate the patterns of preferred endoscopic procedure types and techniques for managing difficult common bile duct (CBD) stones in South Korea. The Committee of Policy and Quality Management of Korean Pancreatobiliary Association (KPBA) conducted a survey containing 19 questions. Both paper and online surveys were carried out; with the paper survey being conducted during the 2019 Annual Congress of KPBA and the online survey being conducted through Google Forms from April 2020 to February 2021. The response rate was approximately 41.3% (86/208). Sixty-two (73.0%) worked at tertiary hospitals or academic medical centers, and 60 (69.7%) had more than 5 years of endoscopic retrograde cholangiopancreatography experience. The preferred size criteria for large CBD stones were 15 mm (40.6%), 20 mm (31.3%), and 30 mm (4.6%). For managing of large CBD stones, endoscopic papillary large balloon dilation after endoscopic sphincterotomy was the most preferred technique (74.4%). When performing procedures in those with bleeding diathesis, 64 (74.4%) respondents favored endoscopic papillary balloon dilation (EPBD) alone or EPBD with small endoscopic sphincterotomy. Fifty-five respondents (63.9%) preferred the doubleguidewire technique when faced with difficult bile duct cannulation in patients with periampullary diverticulum. In surgically altered anatomies, cap-fitted forward viewing endoscopy (76.7%) and percutaneous transhepatic cholangioscopy (48.8%) were the preferred techniques for Billroth-II anastomosis and total gastrectomy with Roux-en-Y anastomosis, respectively. Most respondents showed unifying trends for the management of difficult CBD stones. The current practice patterns could be used as basic data for clinical quality improvements in the management of difficult CBD stones.

Endosonographic finding of the simultaneous depiction of bile and pancreatic ducts can predict difficult biliary cannulation on endoscopic retrograde cholangiopancreatography.

Thus far, no curved linear array endoscopic ultrasound (CLAEUS) findings were established as predictors of difficult selective bile duct cannulation (SBDC). This study aimed to identify CLAEUS findings to predict endoscopic retrograde cholangiopancreatography (ERCP) cases with difficult SBDC. This single-center, retrospective cohort study was conducted between July 2014 and June 2017. This study included all consecutive patients who underwent CLAEUS prior to naïve ERCP. A CLAEUS finding of the simultaneous depiction of bile and pancreatic ducts at the second portion of the duodenum (D2) (simultaneous depiction) was selected as a possible predictor of difficult SBDC, and the κ values in the evaluation of inter- and intra-observer variabilities for "simultaneous depiction" were 0.65 and 0.77, respectively, with substantial correlation. Among the 986 patients who underwent ERCP, 80 patients were relevant for evaluation. Logistic regression analysis revealed strong association between "simultaneous depiction" and difficult SBDC (odds ratio 15.4, 95% confidence interval 4.2-56.0; p<0.001). Among patients who underwent CLAEUS prior to naïve ERCP, a strong correlation was observed between "simultaneous depiction" and the risk of difficult SBDC. An endoscopist can prepare for difficult SBDC by "simultaneous depiction." The finding enables pertinent planning when performing ERCP, such as setting time limits and selecting alternative devices, techniques, and skilled endoscopists, for difficult SBDC with minimal complications including post-ERCP pancreatitis. However, a future prospective study is necessary to establish the procedure algorithm for suspected difficult SBDC cases based on CLAEUS.

Modified transprepancreatic septotomy reduces postoperative complications after intractable biliary access

This study aimed to assess the clinical value of transprepancreatic septotomy indwelling guide wire or pancreatic duct stent in intractable endoscopic retrograde cholangiopancreatography (ERCP) for bile duct cannulation.Of the 2107 patients treated by ERCP, a total of 81 cases with difficult bile duct cannulation underwent transprebiliopancreatic septotomy (referred to as the septotomy group, 37 cases) and transprepancreatic septotomy with pancreatic duct stent (modified septotomy group, 44 cases). Success rates of cannulation and postoperative complications for both methods were compared.Among them, 77 cases were successfully administered bile duct cannulation. The success rates of the septotomy and modified septotomy groups were 91.89% and 97.73%, respectively, with no significant difference (P = .489). Of the 77 patients, 12 cases had complications. The septotomy group included 7 acute pancreatitis, 1 bleeding, and 1 biliary tract infection cases; while in the modified septotomy group, there were 1 acute pancreatitis, 1 bleeding, and 1 biliary tract infection cases. The occurrence rate of acute pancreatitis in the modified septotomy group was lower than that of the septotomy group (2.33% vs 20.59%) with a significant difference (P = .026).These findings indicate that transprepancreatic septotomy with pancreatic duct stent seems to be a safe and feasible operation with reducing complication rates.

Tu1496 Primary Fistulotomy in Patients With Bile Duct Cannulation: Result Compared Endoscopist's Experience

Needle-knife fistulotomy (NKF) is still considered a risk factor of endoscopic retrograde cholangio-pancreatography (ERCP) – related complications and commonly used to overcome difficult bile duct cannulation. So, there are limited data on primary NKF for the access to bile duct in patients with naïve papilla. And experience of endoscopist was an important risk factor for post-ERCP pancreatitis (PEP) in conventional ERCP. It also limited data on complication rate between endoscopist’s experience in NKF. So, we aimed to evaluate the safety and complications of primary implementation of NKF. And we also compared complication rate between two endoscpoists which had a different experience.

Mo1290 Efficacy of Eus-Rendezvous and Hybrid Rendezvous Techniques for Difficult Bile Duct Cannulation

Mo1290 Efficacy of Eus-Rendezvous and Hybrid Rendezvous Techniques for Difficult Bile Duct Cannulation

Application of needle-knife precut papillotomy in difficult common bile duct cannulation of endoscopic retrograde pancreatic duct radiography

Objective To investigate the effects and safety of needle-knife precut papillotomy in difficult common bile duct cannulation of endoscopic retrograde pancreatic duct radiography(ERCP). Methods The data of 104 cases treated with needle-knife precut papillotomy were retrospectively analyzed.The effect of pre incision and short-term complications were observed, and compared with 1326 cases(conventional group) of conventional selective intubation in the same period of ERCP. Results Successful cannulation of the bile duct was achieved in 97 of 104 patients who underwent needle-knife precut papillotomy, the total success rate was achieved in 93.3%.The complications of needle-knife precut papillotomy occurred in 8 patients(7.7%), including mild bleeding in 4 cases, mild pancreatitis in 2 cases and billiary infection in 2 cases.There were 1326 cases conventional selective intubation in the same period of ERCP, and 98 cases(7.4%) with complication.There was no significant difference in the incidence of complications between the needle knife cut group and the conventional selective intubation group(χ2=0.055, P>0.05 ). Conclusion In case of difficult common bile duct cannulation of ERCP, needle-knife precut sphincterotomy surgery can be safely and effectively catch the high -ERCP the success of treatment, is worthy of wider application. Key words: Endoscopic retrograde pancreatic duct radiography; Difficult common bile duct cannulation; Needle-knife precut papillotomy

Needle-knife papillotomy and fistulotomy improved the treatment outcome of patients with difficult biliary cannulation.

Needle-knife papillotomy and fistulotomy (NKPF) is a new, modified technique designed for difficult biliary cannulation. The safety and efficacy of performing NKPF based on characteristics of main duodenal papilla (MDP) was evaluated. We performed a retrospective review of consecutive patients with intact papilla who were established as candidates for therapeutic ERCP at tertiary referral center. A total of 532 patients were included in conventional endoscopic retrograde cholangiopancreatography (ERCP) group in which repeated cannulation was tried in patients with difficult bile duct cannulation; and 598 patients enrolled in early NKPF group according to predefined parameters. Based on the characteristics of MDP, different types of NKPF were performed. The endoscopic data (mean procedure time, anatomy of the main papilla), rate of cannulation success, and post-ERCP complications were collected. A total of 82 patients underwent NKPF. The mean procedure time of the small papilla group was longer than bulging papilla group (P<0.05). The success rate of biliary cannulation in the small papilla group (69.3%) was lower than in the bulging papilla group (100%, P<0.01). The overall successful biliary cannulation of patients in the NKPF group was significantly higher than in the conventional group (98.8 vs 90.8%, P>0.05). The total complication rate was 6.6% among conventional group patients and 5.7% among NKPF group, respectively. The overall complication rate and rates of specific complications (pancreatitis, bleeding, cholangitis, and perforation) in the two groups were similar (P>0.05). Early NKPF based on characteristics of MDP raised the success rate of biliary cannulation when conventional cannulation failed and did not increase the complication rate post-ERCP. Clinic Trials. gov number, Hongwei-1102-12.

Combined precut in difficult biliary cannulation

precut sphincterotomy refers to a variety of endoscopic techniques that are used in order to access the bile duct when conventional methods of cannulation have failed. There are not significant data (such as efficacy, safety) about the use of different techniques of precutting at the same session. We have described our experience with combined precut sphincterotomy (CPS) and we have compared our results to the use of an isolated precut. we have performed 247 precuts of a total of 2.390 ERCPs. Patients were distributed according to the type of precut practiced: Needle-knife, transpancreatic and combined precut sphincterotomies. "Combined precut" consisted in performing first a transpancreatic sphincterotomy and, if the access was not achieved, then performing a needle-knife sphincterotomy in the same session. The data about safety and efficacy were prospectively collected. The complications were defined according to the consensus criteria. we performed precutting techniques in 247 patients. Needle-knife, transpancreatic, and combined precuts were performed in 125 (6.9%), 74 (4.1%) and 48 (2.6%) patients, respectively. Bile duct cannulation was successful in 48 patients (100%) in the group of combined precut, 121 patients (96.8%) in the transpancreatic group, and 67 patients (90.5%) in the needleknife group (p = 0.03). There were not differences in complications rates between the three groups. There was no pancreatitis in the combined precut group. The complications were successfully managed with conservative treatment. combined precut sphincterotomy seems to be a safe and successful technique in those cases of difficult bile duct cannulation.

Needle‐knife fistulotomy in patients with periampullary diverticula and difficult bile duct cannulation

Needle-knife fistulotomy has commonly been used for overcoming difficult bile duct cannulation. Periampullary diverticula (PAD) can be an impediment to endoscopic retrograde cholangiopancreatography (ERCP) procedures. There are little data on needle-knife fistulotomy in patients with PAD. We evaluated the efficacy and safety of needle-knife fistulotomy between patients with and without PAD. Data from December 2005 to October 2010 were reviewed. Patients who underwent needle-knife fistulotomy were divided into the group with PAD and the group without PAD (control group). The technical success and complications were compared. A total of 3012 ERCP cases were analyzed. Needle-knife fistulotomy was performed in 154 out of 3012 cases (5.1%) with 138 of these patients (89.6%) experiencing successful bile duct cannulation. The overall cannulation success rate was not significantly different between PAD group (n=33) and control group (n =121) (93.9% vs 88.4%; P=0.523). There was no significant difference in pancreatitis, bleeding and perforation between the two groups. Needle-knife fistulotomy can be performed effectively and safely in patients with periampullary diverticula and difficult bile duct cannulation.

New role of the dual knife for precut papillotomy in difficult bile duct cannulation

The dual knife is usually used for endoscopic submucosal dissection (ESD). To date, however, there have been no clinical trials of the safety and effectiveness of precut papillotomy using the dual knife for biliary access in patients failing conventional endoscopic retrograde cholangiopancreatography (ERCP) cannulation. We herein report 18 patients who underwent precut papillotomy with the dual knife. All had intact papilla, and had failed deep cannulation of the bile ducts. After successful biliary cannulation and standard endoscopic sphincterotomy, if necessary, stone removal or plastic or metal stent insertion was attempted. Selective bile-duct cannulation was achieved in all 18 patients (100%), at an average time of 4.2 min (range, 3-6 min). Of these 18 patients, six had malignant bile duct obstruction and 12 had common bile duct stones. One patient developed post-ERCP pancreatitis, which resolved after conservative management. There were no deaths related to the procedure.

Su1403 The Quality of Bowel Preparation for Screening Colonoscopy in an Inner City Health Care Center

excluded. PEP was diagnosed by typical pancreatic-type abdominal pain and elevation of amylase/lipase 3X ULN following ERCP. Severity of PEP was defined by established criteria4. Results: 549 OLTs with duct-to-duct anastomosis were performed during the study period. Of the OLT recipients, 100 patients (63% male; 89% Caucasian; mean age 51 13) underwent ERCP (122 total ERCPs). ERCP was performed at a median of 96 days (IQ range, 30-387) following OLT. Findings at ERCP included: anastomotic stricture in 29% (35/122), bile leak in 16% (19/122), stones/sludge in 9% (11/122), and papillary stenosis in 6% (7/122). Difficult cannulation was noted in 22% (27/122) and biliary sphincterotomy was performed during 66% (81/122) of the ERCPs. Prophylactic pancreatic stents were placed during 12 procedures (10%). PEP occurred following 5 cases (4 male, 1 female). Of the PEP cases, ERCP finding of anastomotic stricture was observed in 4 of 5 cases. Four cases of PEP occurred after documented difficult cannulation and 2 cases occurred despite pancreatic stent placement. Two patients developed PEP during a repeat ERCP after a post-transplant ERCP had been performed previously without sphincterotomy. There were no episodes of severe acute pancreatitis; three were moderate in severity, and 2 were mild. Conclusions: The rate of PEP in patients following liver transplant is comparable to that previously documented in the general population1,2. However, ERCP evidence of an anastomotic stricture and difficult bile duct cannulation appear to be risk factors for development of PEP in the OLT population.

Mo1326 Wire-Guided Cannulation Over a Pancreatic Duct Stent Versus Double-Guide Wire Technique for Difficult Bile Duct Cannulation

Cannulation of the common bile duct (CBD) can be difficult in certain instances. Use of a pancreatic duct (PD) stent to facilitate biliary cannulation has been described. The aim of this study was to compare the performance between using a PD stent in conjunction with wire-guided cannulation (WGC) and double-guide wire technique (DGT) for difficult bile duct cannulation.

Proximally migrated pancreatic stent successfully removed using needle-knife and forceps: Complication after precut papillotomy assisted by pancreatic stenting

Pancreatic stent-assisted ampullary precut papillotomy is a rescue method for cases with difficult bile duct cannulation during endoscopic retrograde cholangiopancreatography (ERCP). We describe a case in which post-ERCP pancreatitis (PEP) developed due to the proximal migration of pancreatic stent, after precut papillotomy. Removal of the migrated pancreatic stent was achieved after needle-knife incision of the pancreatic duct's orifice followed by retrieval of the stent using rat-tooth forceps, which resulted in rapid resolution of the PEP. Caution is needed when pancreatic stent is placed after papillary incision. Needle-knife incision of the pancreatic duct orifice followed by forceps removal is an effective technique for rescuing pancreatic stent migration.

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

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

Management of difficult bile duct cannulation in ERCP

In Encoscopic Retrograde Cholangiopancreatography (ERCP), the main concern is to gain access into the bile duct while avoiding the pancreatic duct because of the risk of post-ERCP pancreatitis. Difficult cannulation is defined as a situation where the endoscopist, using his/her regularly used cannulation technique, fails within a certain time limit or after a certain number of unsuccessful attempts. Different methods have been developed to manage difficult cannulation. The most common solution is to perform a precut papillotomy either with a needle knife or with a sphincterotome with or without a guide wire. This review describes different methods to overcome cases of difficult cannulation. We will discuss the success rate and complication rates associated with different methods of reaching the biliary tract.

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

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