Double-guidewire Technique Research Articles

A Prospective Multicenter Randomized Feasibility Trial of Double-guidewire Techniques for Difficult Biliary Cannulation Comparing a New Double-guidewire-supported Sphincterotome (MagicTome) to a Conventional Device.

Objective To evaluate the effectiveness and safety of the double-guidewire technique (DGT) using a new double-guidewire-supported sphincterotome (MagicTome) for patients who required endoscopic retrograde cholangiopancreatography (ERCP) for biliary cannulation. Methods This prospective multicenter randomized feasibility trial involved patients with difficult biliary cannulation at any of the three study sites from June 2017 to October 2018. Patients were assigned to the DGT with MagicTome (MDGT) initially performed group and the conventional DGT (CDGT) initially performed group. The success rates of biliary cannulation by MDGT and CDGT and the ERCP-related complications were evaluated. Results Twenty-eight patients were included in this study. No significant difference was observed in the success rates of first attempts and crossover attempts between the groups (p=0.69 and p=1.00). Furthermore, no significant difference was observed in the success rate of biliary cannulation between MDGT and CDGT (62.5% and 75.0%, respectively; p=0.48). CDGT was successful in two of four patients with malignant biliary obstruction. MDGT was successful in all four patients with malignant biliary obstruction, including the two for whom CDGT was unsuccessful. Post-ERCP pancreatitis occurred in only one MDGT case. Conclusion MDGT is safe for biliary cannulation and can be used in cases where biliary cannulation by CDGT is difficult.

The role of double-guidewire technique in preventing postendoscopic retrograde cholangiopancreatography pancreatitis

Background and study aimsPostendoscopic retrograde cholangiopancreatography (ERCP) complications increase with repeated cannulation attempts. We evaluated several advanced biliary cannulation techniques, which have been used when the standard approach fails, to increase the success rate and decrease post-ERCP complications. We aimed to evaluate the use of double-wire technique in terms of success rates and effects on post-ERCP pancreatitis (PEP) and to assess the value of pancreatic duct stenting following needle-knife sphincterotomy in difficult biliary cannulation. Patients and methodsA single-center, retrospective, randomized study was conducted on patients who underwent ERCP in Notre Dame De Secours University Hospital at Byblos, Lebanon, after obtaining the hospital’s ethics committee approval.Patients were divided into three groups. The first group consisted of patients who had an ERCP and was divided into two subgroups, namely, one usingdouble-guidewire technique (DGT) only and another using an extra technique of precut with double-guidewire and pancreatic plastic stent placement. The second group of patients who had only ERCP was the control group. Finally, the third group endured the precut technique alone. ResultsWe could not prove any significant association between the intervention and the occurrence of pancreatitis when comparing double-wire technique plus ERCP to ERCP alone.When DGT with a pancreatic plastic stent was used, the incidence of PEP was significantly lower than that in other techniques. ConclusionDGT has a neutral effect on the reduction of PEP compared with the classic ERCP, but the technique can decrease the time of examination and increase success in difficult cases. ERCP using the double-guidewire with placement of a pancreatic plastic stent can contribute to decreasing PEP.

Evaluation of post-ERCP pancreatitis after biliary stenting with self-expandable metal stents vs. plastic stents in benign and malignant obstructions.

Background and study aims There are conflicting data regarding the risk of post-ERCP pancreatitis (PEP) with self-expandable metallic stents (SEMS) compared to polyethylene stents (PS) in malignant biliary obstructions and limited data related to benign obstructions. Patients and methods A retrospective cohort study was performed of 1136 patients who underwent ERCP for biliary obstruction and received SEMS or PS at a tertiary-care medical center between January 2011 and October 2016. We evaluated the association between stent type (SEMS vs PS) and PEP in malignant and benign biliary obstructions. Results Among the 1136 patients included in our study, 399 had SEMS placed and 737 had PS placed. Patients with PS were more likely to have pancreatic duct cannulation, pancreatic duct stent placement, double guidewire technique, sphincterotomy and sphincteroplasty as compared to the SEMS group. On multivariate analysis, PEP rates were higher in the SEMS group (8.0 %) versus the PS group (4.8 %) (OR 2.27 [CI, 1.22, 4.24]) for all obstructions. For malignant obstructions, PEP rates were 7.8 % and 6.6 % for SEMS and plastic stents, respectively (OR 1.54 [CI, 0.72, 3.30]). For benign obstructions the PEP rate was higher in the SEMS group (8.8 %) compared to the PS group (4.2 %) (OR 3.67 [CI, 1.50, 8.97]). No significant differences between PEP severity were identified based on stent type when stratified based on benign and malignant. Conclusions PEP rates were higher when SEMS were used for benign obstruction as compared to PS. For malignant obstruction, no difference was identified in PEP rates with use of SEMS vs PS.

EUS-guided antegrade pancreatic guidewire placement for double-guidewire technique in single-balloon enteroscope-assisted ERCP.

Highlight Mandai and colleagues describe EUS-guided antegrade pancreatic guidewire placement followed by the double-guidewire technique in balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography in a patient with recurrent gastric cancer. This case suggests that EUS-guided antegrade pancreatic guidewire placement can be useful for the subsequent double-guidewire technique when EUS-guided biliary access has failed.

Successful pancreatic duct cannulation using double-guidewire technique.

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Combination prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients undergoing double-guidewire assisted biliary cannulation: A case-control study with propensity score matching.

Rectal indomethacin and pancreatic duct stenting (PDS) are recommended for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). However, the effects of the combination of the two methods on preventing PEP are controversial. We hypothesized that some group of difficult patients might benefit from the combination of indomethacin plus PDS (IP) compared with indomethacin alone (IN). Patients with native papilla who underwent endoscopic retrograde cholangiopancreatography in eight tertiary hospitals were screened. They were enrolled if the cannulation proved difficult and post-procedure indomethacin was administered. Propensity score matching (PSM) was used to balance the baseline characteristics between IP and IN groups. The primary outcome was PEP. Among 4456 patients with available cannulation-related data, 1889 (42.4%) patients had difficult cannulation and received indomethacin. After PSM, both IP and IN groups included 332 patients. PEP was comparable between the two groups (12.7% vs 10.2%, P=0.329). By subgroup analysis, the PEP rate was found to be lower in the IP group than in the IN group (7.3% vs 18.2%, P=0.026) in patients undergoing double-guidewire technique (DGT). The results of an additional analysis using PSM in DGT patients were consistent with the subgroup analysis results (7.8% vs 19.4%, P=0.036). The current study indicated that the combined prevention of PEP with indomethacin plus PDS was useful in PEP prevention in patients undergoing DGT. Other groups of patients with difficult cannulation may not benefit from the combination strategy.

Nafamostat Mesylate is Not Effective in Preventing Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with complications such as post-ERCP pancreatitis (PEP). Protease inhibitors, including nafamostat mesylate (NM), have been evaluated for prophylaxis against PEP. We describe the first multicenter randomized controlled trial assessing the prophylactic efficacy of NM against PEP. In this multicenter prospective study, we aimed to enroll 800 patients aged ≥ 20years with a planned ERCP between December 2012 and March 2019. The primary outcome was the incidence and severity of PEP in patients who did not receive NM (non-NM) versus those who did (NM; 20mg). Secondary outcomes included the incidence of PEP by NM initiation (pre- and post-ERCP), risk factors for PEP, and NM-related adverse events. Only 441 of the planned 800 patients were enrolled (non-NM: n = 149; NM: n = 292 [pre-ERCP NM: n = 144; post-ERCP NM: n = 148]). Patient characteristics were balanced at baseline with no significant differences between groups. PEP occurred in 40/441 (9%) patients (non-NM: n = 15 [10%]; NM: n = 25 [9%]), including 17 (12%) and eight (8%) in the pre-ERCP and post-ERCP NM groups, respectively. In the NM group, the incidence of PEP was lower in the low-risk group than in the high-risk group. Pancreatic injection and double-guidewire technique were independent risk factors for PEP. NM-related adverse events of hyperkalemia occurred in two (0.7%) patients. We found no evidence for the prophylactic effect of NM against PEP, regardless of the timing of administration; however, further studies are needed.

Modified double-guidewire technique using a unique double-lumen sphincterotome for difficult biliary cannulation.

ERCP is widely accepted as the standard therapeutic procedure for different pancreatobiliary disorders. Selective biliary cannulation remains difficult in 5% to 10% of cases, even in the hands of experienced operators.1 Although several techniques have been proposed as alternatives for persistent conventional biliary cannulation in difficult cases such as precut sphincterotomy and needle-knife precut, the double-guidewire technique (DGT) is still considered a promising salvage approach in such cases.

Use of a double-lumen cytology brush catheter to allow double-guidewire technique for endoscopic interventions

Background and AimsSerial stent placement may be necessary during endoscopic interventions, but the passage of a guidewire alongside an initial stent can be challenging, time-consuming, and sometimes unsuccessful. We describe a modification of a cytology brush catheter to allow simultaneous placement of 2 guidewires to facilitate serial stent placement and demonstrate its application in different scenarios.MethodsThis is a retrospective series of 3 patients with different conditions (acute cholecystitis, pancreas pseudocyst, and severe biliary stricture) in whom placement of a second guidewire facilitated serial stent placement. A step-by-step demonstration of the technique is provided.ResultsSerial stent placement was successful in all patients without adverse events.ConclusionsA modified cytology brush catheter can be used to deliver 2 guidewires simultaneously during ERCP and EUS procedures. This technique may improve procedural efficiency, maintain a safety track, and augment therapy in certain situations.

Usefulness and Complications of Needle Knife Fistulotomy as a Rescue Procedure in Patients with Pancreaticobiliary Disease.

Needle knife fistulotomy (NKF) is a technique to facilitate pancreatic and biliary duct access during ERCP. The double-guidewire technique (DGT) is also used in cases of difficult cannulation, but it can increase the incidence of post-ERCP-pancreatitis (PEP). This study examined the success and complication rates of NKF after unsuccessful standard cannulation or DGT in patients with pancreaticobiliary disease. The data of 209 patients who received NKF as a rescue procedure between January 2009 and December 2016 were reviewed retrospectively. The cannulation success and complication rates were assessed. The overall cannulation success rate was 90.4%. The success rates of patients who received NKF after standard cannulation or DGT were similar (82.6% [142/172] and 73.0% [27/37], respectively, p=0.179). Furthermore, there was no significant difference in the incidence of procedure-related adverse events between the two groups (10.5% [18/172] and 16.2% [6/37], respectively, p=0.391). Endoscopic retrograde pancreatic drainage (ERPD) insertion decreased the incidence of PEP (0% [0/16] in ERPD and 14.6% [19/130] in non-ERPD, p=0.132) among patients who received PD cannulation. NKF is an effective and safe method that can be considered for rescue management after the initial failure of standard cannulation or DGT. NKF following standard cannulation can be preferred over NKF following DGT because of the higher success rate and the lower rate of pancreatitis, but the difference was not significant. PD stenting in patients at high risk of PEP can be considered to decrease pancreatitis.

Learning curve of double-guidewire technique by trainees during hands-on endoscopic retrograde cholangiopancreatography training.

Double-guidewire technique (DWT) has been successfully performed by experts in difficult biliary cannulation as an advanced technique. This study aimed to define the learning curve and safety of DWT by trainees during hands-on endoscopic retrograde cholangiopancreatography (ERCP) training. Patients were eligible for inclusion in the study if the biliary cannulation was difficult and the pancreatic duct was inadvertently cannulated. DWT was performed by two trainees randomly under trainers' guidance. The primary outcome was the success rate of DWT biliary cannulation of trainees. Cumulative sum analysis was used to generate visual learning curves. A total of 60 patients with difficult cannulation were enrolled. The main indications for ERCP were common bile duct stones (65%) and biliary stricture (31.7%). The learning curve analysis showed that to achieve a 70% rate of successful DWT, 12 procedures were needed for trainee A and 15 for trainee B. Higher targeted success rate of DWT could be achieved if the number of DWT procedures increased. Compared with the early stage of learning DWT (case 1 to 15 for each trainee), trainees had significantly higher DWT success rate in the late stage (36.7% [11/30] vs 80% [24/30], P=0.001). The final success rate of cannulation was 98.3% (59/60). The overall rate of post-ERCP pancreatitis and adverse events was 6.7% (4/60) and 8.3% (5/60), respectively. Double-guidewire technique was safely performed by two novel trainees during hands-on ERCP training. Fifteen procedures may be enough for trainees to achieve the competency of performing DWT. (Clinicaltrials.gov number: NCT03707613).

Double Guidewire Technique Using an Uneven Double Lumen Catheter for Endoscopic Ultrasound-Guided Interventions.

Endoscopic ultrasonography (EUS)-guided interventions are often performed using a single guidewire (SGW), but there are a few reports on the use of double guidewire (DGW) technique to facilitate multiple drainage placement during EUS-guided drainage of pancreatic fluid collections. This DGW technique may have advantages other than multiple drainage placement during EUS-guided interventions such as scope stabilization, support for stone extraction and device insertion. Consecutive patients who underwent EUS-guided interventions between Feb 2012 and Apr 2019 were retrospectively reviewed. The rate and reasons of DGW technique, and clinical outcomes were evaluated. DGW technique was performed, using an uneven double lumen cannula (UDLC), which facilitates insertion of 0.025-in. and 0.035-in. guidewires. A total of 249 EUS-guided interventions were analyzed, and DGW technique was utilized primarily in 65 cases (25.7%) and as a salvage after failed SGW technique in 18 cases (7.1%). The reasons for DGW technique were 60 multiple drainage placement, 10 scope stabilization, 7 device insertion, 5 safety guidewire, and 4 antegrade stone removal. Insertion of UDLC and DGW was successful in 100%. Technical success rate of preplanned interventions was 92.7% (96.9% in primary DGW and 77.8% in salvage DGW technique). Adverse events were observed in 19.5% after DGW but were not related to DGW technique. DGW technique using UDLC during EUS-guided interventions was technically feasible and safe. In addition to multiple drainage insertion, it can potentially support complex EUS-guided interventions.

Su1213 DOUBLE GUIDEWIRE TECHNIQUE USING A DOUBLE LUMEN CANNULA FOR INTERVENTIONAL EUS

There are a few reports on the use of double guidewire (DGW) technique to facilitate multiple drainage placement for EUS-guided drainage of pancreatic fluid collections (PFC). However, this technique can provide advantages other than multiple drainage placement during interventional EUS, such as scope stabilization, support for stone extraction or device insertion.

A Double-Guidewire Technique to Facilitate Deep Cannulation and Stenting in a Patient With Altered Gastrointestinal Anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered gastrointestinal (GI) anatomy remains a challenging procedure. We experience particular difficulty passing a catheter and devices in patients who have biliary stricture or severe deformity, despite successful biliary guiding. A 70-year-old man with Roux-en-Y reconstruction for gastric cancer suffered pancreatic head cancer with biliary stricture. Seven months after biliary stenting, he developed acute occlusive suppressive cholangitis due to stent occlusion. We extracted the stent and inserted a guidewire into the intrahepatic bile duct. However, we were unable to pass the catheter due to severe stricture of the lower common bile duct and axis-dismatch between the bile duct and the catheter. After inserting another of the same guidewire into the bile duct, we were able to easily pass the catheter into the bile duct, resulting in the successful insertion of a new plastic stent. A double-guidewire technique is useful and worth attempting for the deep insertion of devices through biliary strictures in patients with an altered GI anatomy. J Med Cases. 2019;10(1):1-3 doi: https://doi.org/10.14740/jmc3220

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.

Double Guidewire Technique versus Transpancreatic Sphincterotomy for Difficult Biliary Cannulation

Double Guidewire Technique versus Transpancreatic Sphincterotomy for Difficult Biliary Cannulation

A Double-Guidewire Technique to Facilitate Deep Cannulation and Stenting in a Patient With Altered Gastrointestinal Anatomy

A Double-Guidewire Technique to Facilitate Deep Cannulation and Stenting in a Patient With Altered Gastrointestinal Anatomy

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

Wire-guided cannulation over a pancreatic stent method increases the need for needle-knife precutting ın patients with difficult biliary cannulations

Cannulation of the major papilla can be problematic, and selective biliary cannulation may fail in up to 18% of cases. Various techniques, such as double-guidewire technique (DGWT), wire-guided cannulation over a pancreatic stent (WGC-PS), the precut endoscopic sphincterotomy (needle-knife precutting technique (NKP), and transpancreatic septostomy have been used to improve the success rate of biliary cannulation. We conducted a prospective, randomized study in order to compare the biliary cannulation success rates of DGWT and WGC-PS techniques in patients with inadvertent passage of guidewire to the pancreatic duct. A total of 100 patients were included in the study and randomized to DGWT (n= 50) or WGC-PS (n= 50) groups. The primary outcome was successful selective cannulation, defined as deep cannulation with selective injection of radiographic contrast material into the common bile duct within 5 minutes by DGW or WGC-PS techniques without performing precut sphincterotomy. Successful selective cannulation was achieved in 45 patients in the DGWT group (90%) and in 27 patients in the WGC-PS group (54%) (P< .001). Five patients (10%) in the DGWT group and 23 (46%) in the WGC-PS group required NKP for biliary access (P< .001). The overall cannulation rate was 98% for DGWT and 98% for WGC-PS (P= 1.00). In patients with unintentional passage of a guidewire into the pancreatic duct during biliary cannulation attempts, the WGC-PS technique significantly increased the need for NKP compared with DGWT.

French comment on article Transpancreatic precut papillotomy versus double-guidewire technique in difficult biliary cannulation: prospective randomized study

French comment on article Transpancreatic precut papillotomy versus double-guidewire technique in difficult biliary cannulation: prospective randomized study