Difficult Cannulation Research Articles

Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP

Certain appearances of the major duodenal papilla have been claimed to make cannulation more difficult during ERCP. This study uses a validated classification of the endoscopic appearance of the major duodenal papilla to determine if certain types of papilla predispose to difficult cannulation. Patients with a naïve papilla scheduled for ERCP were included. The papilla was classified into 1 of 4 papilla types before cannulation started. Time to successful bile duct cannulation, attempts, and number of pancreatic duct passages were recorded. Difficult cannulation was defined as after 5 minutes, 5 attempts, or 2 pancreatic guidewire passages. A total of 1401 patients were included from 9 different centers in the Nordic countries. The overall frequency of difficult cannulation was 42% (95% confidence interval [CI], 39%-44%). Type 2 small papilla (52%; 95% CI, 45%-59%) and type 3 protruding or pendulous papilla (48%; 95% CI, 42%-53%) were more frequently difficult to cannulate compared with type 1 regular papilla (36%; 95% CI, 33%-40%; both P< .001). If an inexperienced endoscopist started cannulation, the frequency of failed cannulation increased from 1.9% to 6.3% (P<.0001), even though they were replaced by a senior endoscopist after 5 minutes. The endoscopic appearance of the major duodenal papilla influences bile duct cannulation. Small type 2 and protruding or pendulous type 3 papillae are more frequently difficult to cannulate. In addition, cannulation might even fail more frequently if a beginner starts cannulation. These findings should be taken into consideration when performing studies regarding bile duct cannulation and in training future generations of endoscopists.

Clinical practice guidelines for safe performance of endoscopic ultrasound/ultrasonography-guided biliary drainage: 2018.

Endoscopic ultrasound/ultrasonography‐guided biliary drainage (EUS‐BD) is a relatively new modality for biliary drainage after failed or difficult transpapillary biliary cannulation. Despite its clinical utility, EUS‐BD can be complicated by severe adverse events such as bleeding, perforation, and peritonitis. The aim of this paper is to provide practice guidelines for safe performance of EUS‐BD as well as safe introduction of the procedure to non‐expert centers. The guidelines comprised patient–intervention–comparison–outcome‐formatted clinical questions (CQs) and questions (Qs), which are background statements to facilitate understanding of the CQs. A literature search was performed using the PubMed and Cochrane Library databases. Statement, evidence level, and strength of recommendation were created according to the GRADE system. Four committees were organized: guideline creation, expert panelist, evaluation, and external evaluation committees. We developed 13 CQs (methods, device selection, supportive treatment, management of adverse events, education and ethics) and six Qs (definition, indication, outcomes and adverse events) with statements, evidence levels, and strengths of recommendation. The guidelines explain the technical aspects, management of adverse events, and ethics of EUS‐BD and its introduction to non‐expert institutions.

Clip-and-snare traction facilitates difficult biliary cannulation during ERCP.

Clip-and-snare traction facilitates difficult biliary cannulation during ERCP.

Managing Difficult Cannulations in Endoscopic Retrograde Cholangiopancreatography: A Prospective Randomized Control Trial Study of Precut Needle Knife Sphincterotomy versus Transpancreatic Sphincterotomy Technique

Objective: To evaluate the success rate of cannulations and rate of procedure-related complications between needle knife sphincterotomy (NKS) and transpancreatic sphincterotomy (TPS) techniques, and to evaluate the most effective cannulation time to proceed with NKS or TPS. Methods: This study recruited 52 patients with inaccessible bile ducts by the standard cannulation at Khon Kaen Hospital from May 2012 to May 2015. Patients were randomly allocated to the NKS group (N=21) or the TPS group (N=21). Successful cannulations, and complications between NKS and TPS were collected and assessed. Results: Successful cannulations by TPS and NKS were achieved in 14 cases (53.8%) and 13 cases (50%) respectively (p value = 0.781). Post ERCP pancreatitis was found in 2 cases using TPS, and in 3 cases using NKS. There were 3 cholangitis cases in TPS group, and 2 cholangitis cases in NKS group. Perforations were found in 3 cases and 1 case in TPS and NKS group, respectively. There were 4 deaths in this study, one case in TPS group and 3 cases in NKS group. Complications and mortality between TPS and NKS were not statistically significant (P>0.05). After 40 minutes of the ERCPs, there was less chance for a successful cannulation. Unsuccessful cannulations between TPS and NKS was not statistically different according to the Kaplan-Meier analysis. Conclusion: TPS and NKS are able to increase successful cannulations. There are no significant differences in the cannulation success rate and rate of complications between the TPS and NKS. The appropriate time to terminate a cannulation in difficult cases is found to be 40 minutes.

Factors affecting the first‐attempt success rate of intravenous cannulation in older people

To determine the factors affecting the first-attempt success of peripheral intravenous catheter (PIVC) placement in older emergency department patients. In older patients who require intravenous treatment, establishing a PIVC as fast as possible is clinically important. This is a prospective, observational, descriptive study. Using a data collection form, researchers questioned both the patient and the nurse performing the procedure in terms of patient- and operator-related factors. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (See Supporting Information Appendix S1). A total of 472 patients were included in the final analyses. According to the logistic regression analysis, independent factors which affected first-attempt failure were found to be: choosing a nonupper extremity site for PIVC (OR: 4.72, 95% CI: 1.35-16.45, p-value: 0.015), history of difficult intravenous access (OR: 3.02, 95% CI: 1.72-5.29, p-value: <0.001), nurse having less than 2years of professional experience (OR: 3.45, 95% CI: 2.00-5.97, p-value: <0.001), nonpalpable veins observed after the application of tourniquet (OR: 2.21, 95% CI: 1.10-4.41, p-value: 0.025), a moderate degree of difficulty anticipated by the nurse prior to the procedure (OR: 4.32, 95% CI: 2.31-8.08, p-value: <0.001) and a high degree of difficulty anticipated by the nurse prior to the procedure (OR: 8.41, 95% CI: 4.10-17.24, p-value: <0.001). Factors affecting first-attempt success rates in peripheral intravenous catheter placement in older emergency department patients may be listed as follows: the anticipated difficulty of the procedure rated by the nurse, previous history of a difficult intravenous cannulation, choosing a nonupper extremity site for cannulation, the level of experience of the nurse and the palpability of the vein. Healthcare providers should consider alternative methods in the presence of factors affecting first-attempt success in older emergency department patients.

Safety and efficacy of enhanced recovery after surgery in elderly patients after therapeutic endoscopic retrograde cholangiopancreatography.

IntroductionThe number of elderly patients with biliary and pancreatic diseases has increased significantly. The characteristics of biliary and pancreatic diseases in the elderly increase the risk of treatment.AimTo study the safety and efficacy of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients with biliary and pancreatic diseases with the concept of enhanced recovery after surgery (ERAS).Material and methodsPatients receiving ERCP under ERAS were grouped into an elderly group (group A, n = 58, aged 75 years or above) and a young and middle-aged group (group B, n = 202, aged less than 60 years). The clinical parameters before, during and after the operation of the two groups were compared.ResultsBefore the operation, the incidences of cholangiocarcinoma and complications, nutritional screening score ≥ 3, ASA degree III and Child-Pugh grade A in group A were significantly higher than those in group B (p < 0.05), while the incidences of nausea and vomiting, abdominal pain, nutritional screening < 3 and ASA grade I in group A were significantly lower than those in group B (p < 0.05). Intraoperatively, the incidence of juxta-ampullary duodenal diverticulum (JAD) in internal or bottom papilla in the elder patients with difficult selective biliary cannulation (DSBC) was significantly higher than that in the young and middle-aged group (p < 0.05). In addition, the continuous ECG monitoring duration and the first exhaust time in group A were significantly longer than those in group B (p < 0.05).ConclusionsEndoscopic retrograde cholangiopancreatography under ERAS in elderly patients is as safe and effective as in young patients.

Difficult Central Venous Cannulation

Prasad, Chandrakant MD; Mahajan, Charu MD, DM; Sokhal, Navdeep MD, DM; Chouhan, Rajender S. MD Author Information

The Modified A-DIVA Scale as a Predictive Tool for Prospective Identification of Adult Patients at Risk of a Difficult Intravenous Access: A Multicenter Validation Study.

Peripheral intravenous cannulation is the most common invasive hospital procedure but is associated with a high failure rate. This study aimed to improve the A-DIVA scale (Adult Difficult Intra Venous Access Scale) by external validation, to predict the likelihood of difficult intravenous access in adults. This multicenter study was carried out throughout five hospitals in the Netherlands. Adult participants were included, regardless of their indication for intravenous access, demographics, and medical history. The main outcome variable was defined as failed peripheral intravenous cannulation on the first attempt. A total of 3587 participants was included in this study. The first attempt success rate was 81%. Finally, five variables were included in the prediction model: a history of difficult intravenous cannulation, a difficult intravenous access as expected by the practitioner, the inability to detect a dilated vein by palpating and/or visualizing the extremity, and a diameter of the selected vein less than 3 millimeters. Based on a participant’s individual score on the A-DIVA scale, they were classified into either a low, moderate, or high-risk group. A higher score on the A-DIVA scale indicates a higher risk of difficult intravenous access. The five-variable additive A-DIVA scale is a reliable and generalizable predictive scale to identify patients at risk of difficult intravenous access.

A Randomized Trial of Topical Epinephrine and Rectal Indomethacin for Preventing Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in High-Risk Patients.

Rectal indomethacin and topical spray of epinephrine have separately shown efficacy in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) in randomized controlled trials. We hypothesized that the combination of indomethacin and topical spray of epinephrine on the duodenal papillae would further reduce PEP than when indomethacin was used alone. We conducted a comparative effectiveness, multicenter, double-blinded, randomized trial of rectal indomethacin alone vs a combination of rectal indomethacin and topical spray of epinephrine for the prevention of PEP in high-risk patients. The primary outcome was the incidence of PEP and the secondary outcome was the severity of PEP. A 2-tailed Fisher's exact test was used to analyze the difference in the proportion of patients with PEP in the indomethacin alone vs the combination group. A total of 960 patients (mean age 52.33 ± 14.96 years; 551 [57.4%] females) were randomized and 959 completed follow-up. The baseline demographic and clinical characteristics were similar between the 2 groups. Women <50 years of age (25.4%) and difficult cannulation (84.9%) were the most common PEP risk factors. The incidence of PEP was 6.4% in the indomethacin alone group (n = 482) compared to 6.7% in the combination group (n = 477; P = 0.87). Severe PEP was found in 5 (12%) and 7 (16%) patients in the indomethacin alone and combination groups, respectively (P = 0.88). The overall mortality was 0.6%, which was unrelated to the primary outcome. The combination of rectal indomethacin and topical spray of epinephrine does not reduce the incidence of PEP compared to rectal indomethacin alone in high-risk patients; https://clinicaltrials.gov/ct2/show/NCT02116309.

Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist.

Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.

Risk factors increasing post-ERCP complications: a referral center experience

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is an important therapeutic tool in patients with hepato-pancreatobiliary diseases. In the present study, we sought to determine predictors of post-ERCP complications. Methods: A retrospective analysis of patients who underwent ERCP in between January 2010- November 2011 was done. Demographics, ERCP findings, success rate and complications were evaluated with special emphasis on the difficulty in cannulation procedure, the primary etiology of the disease (benign/malign) and age. Chi-square analysis was applied for statistical analysis. The differences were considered statistically significant, if the p value was less than 0.05. Results: A total of 112 ERCP was performed in 81 patients. Thirty-eight were male (46.9 %) and 43 were female (53.1%). Mean age was 61.3 (range 17-88), and 31 patients was seventy years and older (38.3 %). Complications were detected in 28 patients (34.6 %). Nine cases with difficult or unsuccessful cannulation (69.2 %) had complications (p=0.001). Patients with benign diseases showed less complications (21/70), in comparison with those with malignancies (7/11) (30 % vs. 63.6 %, respectively; p< 0.05). Complication rate in patients 70 years and older was 32.2 % (n=10) compared to 35.3 % in patients younger than 70 (n= 18) (p >0.05). Conclusion: Risk factors such as difficult or incomplete cannulation and malignancy are considered as possible predisposing factors for complications. Age is an independent factor.

Double Guidewire Technique versus Transpancreatic Sphincterotomy for Difficult Biliary Cannulation

Background: The standard biliary cannulation technique has been reported to fail in approximately 5– 20% of cases so, several supplementary techniques have been recommended to facilitate access to the common bile duct (CBD); Double-guidewire technique (DGT) and transpancreaticsphincterotomy (TPS) are effective method in cases of standard biliary cannulation failure. Objective: To compare the outcomes between DGT and TPS in patients with difficult biliary cannulation regarding the procedure duration, success rate and complications. Patients and Methods: This was a randomized study conducted in Al-Hussein University Hospital, Endoscopy Unit in the period between May, 2016 to October, 2017. A total of 40 patients, who bile duct cannulation was not possible and selective pancreatic duct cannulation was achieved were randomized into DGT (n = 19) and TPS (n = 21) groups. DGT or TPS was done for selective biliary cannulation. We measured the technical success rates of biliary cannulation, median cannulation time, and procedure related complications. Results: The distribution of patients after randomization was balanced, and both groups were comparable in baseline characteristics. There was no significant difference between both groups regarding age and sex distribution, clinical presentation, laboratory findings and sonographic findings. Successful cannulation rate and mean cannulation times in DGT and TPS groups were 94.7% vs 95.2% and 20.1 ± 8.7min vs 21.5 ± 7.8min, P = 0.602, respectively. There was no significant difference between the two groups. Conclusion: When free bile duct cannulation was difficult and selective pancreatic duct cannulation was achieved, DGT and TPS facilitated biliary cannulation and showed similar success rates. However, post-procedure pancreatitis and Cholangitis were significantly higher in the DGT group.

Vascular access related complications with ipsilateral upper limb oedema in hemodialysis

Background: Central vein-related obstruction is a growing problem in maintenance hemodialysis (MHD). Prior to central vein temporary access, failure to implement “fistula first policy” is an important contributor for this problem. It interferes with the outcomes in dialysis adding to mechanical vascular perturbations, resulting in limb, facial, and chest wall edema. Keeping them in view, we undertook this study on MHD patients, presented with central vein-related vascular access problems and ipsilateral upper limb edema, with the aim to investigate the vascular anatomical obstructive lesions causing the clinical syndrome and their management. Materials and Methods: This cross-sectional study included 25 patients of end-stage renal disease on MHD who manifested with vascular access dysfunction, presented with ipsilateral upper limb edema, and were the study subjects. All patients were evaluated with thorough clinical, laboratory, and computed tomographic (CT) angiography (CTAngio) studies to address the issues. Results: All patients had ipsilateral upper limb edema and 36% of them had in addition facial edema. Fifty percent had difficult cannulation with raising venous pressure during HD sessions and difficulty in securing hemostasis at the end of dialysis. CTAngio revealed central vein stenosis in 48%, peripheral stenosis in 20%, and combined central and peripheral stenosis in 32% patients. Cephalic arch involvement was noted in 16% patients. Depending on the patients preference, dialysis switched over to peritoneal dialysis in 24%, new vascular access was created in 20%, and balloon angioplasty in 16% during management. Conclusions: This study describes the central venous-related problems in MHD patients. We reiterate the importance of three early warning signs: high venous pressure, difficulty to achieve hemostasis at the end of dialysis, and ipsilateral limb, face, chest wall edema as the presage signs to suspect and exclude the underlying central vein obstructions. A continuum of management is discussed.

EUS-guided biliary drainage for difficult cannulation.

EUS-guided biliary drainage (EUS-BD) has been recognized as a new alternative to failed ERCP. The alternatives for failed/impossible ERCP in cases of difficult and selective bile duct cannulation include percutaneous transhepatic BD (PTBD) with precut papillotomy. EUS-BD is reportedly more convenient than PTBD and more successful than precut papillotomy, suggesting that EUS-BD is the next step following failed/impossible ERCP.

Anesthetic management in a super obese parturient undergoing elective caesarean section: A case report

Obesity has become a global epidemic nowadays with a considerable rise in prevalence among reproductive age group. In obese parturients, the perinatal and maternal morbidity are more common, so it is more likely to plan for elective caesarean section. Morbidly obese parturients along with physiological and pharmacological variations pose significant challenges such as patient positioning, difficult intravenous cannulation, anticipated difficult airway, risk of aspiration, associated comorbidities, postoperative ventilatory support, and risk of thromboembolism under general anesthesia. Hence, regional anesthesia is the preferred technique; however, it can also be challenging with factors such as identification of midline and epidural space, number of attempts, accidental dural puncture, and correct placement of catheter. Here, we report a case of a 34-year-old super obese parturient with gestational hypertension and hypothyroidism who underwent elective caesarean section under combined spinal epidural anesthesia.

Strategy for difficult biliary cannulation in ERCP

Strategy for difficult biliary cannulation in ERCP

Veno-arterial extracorporeal membrane oxygenation and prolonged use of mechanical compression device combine for good outcome after hypothermic cardiac arrest: a case report

The use of mechanical compression devices to deliver chest compressions in conjunction with veno-arterial extracorporeal membrane oxygenation (VA ECMO) in the setting of cardiac arrest is growing. Herein, we report a case of hypothermic cardiac arrest requiring VA ECMO and prolonged use of an external compression device. A 38-year-old morbidly obese male (BMI 66.5) was admitted after being found down by a river. The patient was hypothermic (27.4 ℃; outside temperature 4 ℃) and in active asystolic cardiac arrest. A LUCAS chest compression system (Jolife, Lund, Sweden) was placed and transesophageal echo (TEE) was performed. This revealed cardiac standstill and suboptimal placement of the LUCAS device which was repositioned under TEE guidance. After difficult VA-ECMO cannulation, LV venting was required but coagulopathy, hypothermia, and body habitus precluded immediate endovascular mechanical unloading device placement. Therefore, the LUCAS was continued. After 380 minutes of VA ECMO, 460 minutes of LUCAS device support, and gradual rewarming to normothermia, the patient was cardioverted to sinus tachycardia and an Impella CP was placed. Over the next 96 hours infusions were reduced and biventricular function normalized. The Impella CP was removed on day 7, VA ECMO on day 12, and extubation occurred on day 15. He discharged with no neurologic deficits on day 34, a right sided above knee amputation his only notable hospital complication. The combined support of an external compression device and VA ECMO allowed for return of spontaneous circulation despite a downtime greater than 100 minutes. Further, TEE guidance allowed for optimal LUCAS positioning.

A simple and novel marking method for correctly identifying the precutting direction to achieve safe and efficacious precut sphincterotomy (with video).

Background and study aims Failure to recognize the right direction and precise incision length during precutting has been reported. To address these concerns, we developed a marking method that places a marking on the cutting endpoint before starting precutting. This preliminary study aimed to assess the effectiveness and safety of precut sphincterotomy using our new marking method. Patients and methods Between April 2015 and May 2017, 21 patients from our tertiary referral center were included in this study. Precut sphincterotomy using our marking method was employed for difficult common bile duct cannulation cases. Before starting precutting, a marking was placed slightly before the upper margin of the bulge of the papilla in the 11- to 12-o’clock direction as a cutting endpoint by cauterization with a needle knife. Results Technical success was obtained in all 21 procedures. There were no post-endoscopic retrograde cholangiopancreatography (ERCP) complications except for one mild case of post-ERCP pancreatitis. Conclusion Our new marking method before precutting enabled precise incision and quick bile duct cannulation without causing severe complications.

Comparison of efficacy and safety of transpancreatic septotomy, needle-knife fistulotomy or both based on biliary cannulation unintentional pancreatic access and papillary morphology

BackgroundPrecut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography (ERCP). However, scarce data are available on different precut techniques for difficult biliary cannulation. This study aimed to evaluate the efficacy and safety of transpancreatic septotomy (TPS), needle-knife fistulotomy (NKF) or both based on the presence of unintentional pancreatic access and papillary morphology. MethodsBetween March 2008 and December 2016, 157 consecutive patients undergoing precutting for an inaccessible bile duct during ERCP were identified. Precut techniques were chosen depending on repetitive inadvertent pancreatic cannulation and the papillary morphology. We retrospectively assessed the rates of cannulation success and procedure-related complications among three groups, namely TPS, NKF, and TPS followed by NKF. ResultsThe baseline characteristics of the three groups were comparable. The overall success rate of biliary cannulation reached 98.1%, including 111 of 113 (98.2%) with TPS, 35 of 36 (97.2%) with NKF and 8 of 8 (100%) with NKF following TPS, without significant difference among groups. The incidences of total complications and post-ERCP pancreatitis were 9.6% and 7.6%, respectively. There was a trend towards less frequent post-ERCP pancreatitis after NKF (0%) compared with 11 cases (9.7%) after TPS and one case (12.5%) after NKF following TPS, but not significantly different (P = 0.07). No severe adverse event occurred during this study period. ConclusionsThe choice of precut techniques by the presence of unintended pancreatic access and the papillary morphology brought about a high success rate without increasing risk in difficult biliary cannulation.

Clinical value of double guidewire technique for perforation of duodenal papilla by guidewire in endoscopic retrograde cholangiopancreatography

Objective To evaluate the efficacy and safety of double guidewire technique in perforation of duodenal papilla caused by guide wire during endoscopic retrograde cholangiopancreatography (ERCP) intubation. Methods A retrospective analysis was performed on data of 57 patients whose duodenal papilla were perforated by guidewire in ERCP from January 2008 to September 2016. Among the 57 patients, 30 patients were cannulated with double guidewire technique (double guidewire group) and 27 patients were performed with traditional technique (standard group) for continue. The biliary intubation success rate, intubation time, and post-ERCP complication rate were compared between the two groups. Results The rate of successful intubation of the double guidewire group was significantly higher than that of the standard group[96.7% (29/30) VS 74.1% (20/27), χ2=5.545, P=0.019]. The intubation time of the double guidewire group was significantly shorter than that of the standard group (21.8±7.8 min VS 40.7±8.4 min, t=8.076, P=0.000). The double guidewire group had a similar incidence of post-ERCP complication compared to the standard group[13.3% (4/30) VS 11.1% (3/27), χ2=0.292, P=0.596], and the complication in two groups was hyperamylasemia. Conclusion Double guidewire technique is safe and effective for difficult biliary cannulation because of perforation of duodenal papilla with a higher success rate and less time compared to classic technique. Key words: Cholangiopancreatography, endoscopic retrograde; Cannulation; Bile ducts; Duodenal papilla