Precut Papillotomy Research Articles

Feasibility of the Mucosa-Tracking Technique in Precut Papillotomy with the Iso-Tome as an Alternative to the Needle-Knife Technique

The aim of this study was to evaluate whether the mucosa-tracking technique is effective for improving precutting-related pancreatitis and the sustained failure of bile duct cannulation in precut papillotomy (PP) with the Iso-Tome (MTW Endoskopie). From September 2004 to June 2006, PP was performed with the Iso-Tome if biliary cannulation failed by conventional methods for approximately 5 minutes. The pink intrapapillary mucosa (PIPM) exposed by PP was tracked and classified into four groups: fully exposed and oriented to the direction of the bile duct (group A) or the pancreatic duct (group B), partially exposed (group C), or unexposed (group D). The success rate of bile duct cannulation (SRBC), the procedure time required for successful bile duct cannulation (PTBC), and the complications in the first session were compared between the mucosa-exposed groups (MEGs; group A, B, and C) and the mucosa-unexposed group (MUEG; group D). A total of 59 patients (25 females, 34 males) with a mean age of 65.2 years were enrolled. The MEGs and MUEG comprised 52 (88.1%) and 7 (11.9%) patients, respectively. SRBC in the first session was 86.4% (51/59) in total and 92.3% (48/52) in the MEGs, compared to only 42.9% (3/7) in the MUEG (p=0.005). The mean PTBC in the MEGs and MUEG was 8.7 minutes and 16.3 minutes, respectively (p=0.23). Complications occurred in 6.8% of the patients (4/59; all pancreatitis); there were no differences between the MEGs (5.8%, 3/52) and MUEG (14.3%, 1/7; p=0.41). All four patients with pancreatitis were managed medically. The mucosa-tracking technique in PP with the Iso-Tome is a feasible and useful method of enhancing SRBC. PIPM is an important endoscopic landmark for successful PP.

Can early precut implementation reduce endoscopic retrograde cholangiopancreatography-related complication risk? Meta-analysis of randomized controlled trials

Precut papillotomy is considered a risk factor for endoscopic retrograde cholangiopancreatography (ERCP)-related complications; however whether the complication risk is due to precut itself or to the prior prolonged attempts is still debated; therefore, early precut implementation has been suggested to reduce the complication rate. We conducted a meta-analysis of randomized controlled trials (RCTs) comparing cannulation and complication rates of early precut implementation with persistent attempts by the standard approach. RCTs that compared cannulation and complication rates of the early precut implementation and of persistent attempts by the standard approach were included. Summary effect sizes were estimated by odds ratio (OR) with a random-effects model and by Peto OR. Six RCTs with a total of 966 subjects met the inclusion criteria. Overall cannulation rates were 90 % in both randomization groups (OR 1.20; 95 % confidence interval [CI] 0.54 - 2.69). Post-ERCP pancreatitis developed in 2.5 % of patients randomized to the early precut groups and in 5.3 % of patients from the persistent attempts groups (OR 0.47; 95 %CI 0.24 - 0.91). The overall complication rates, considering pancreatitis, bleeding, cholangitis, and perforation rates, were 5.0 % in the early precut groups and 6.3 % in the persistent attempts groups (OR 0.78; 95 %CI 0.44 - 1.37). RCTs that investigated the issue of timing of the precut procedure were limited. Current evidence suggests that in experienced hands the early implementation of precut and persistent cannulation attempts have similar overall cannulation rates; early precut implementation reduces post-ERCP pancreatitis risk but not the overall complication rate. Further studies are needed to confirm these findings.

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.

Strategies for difficult endoscopic cannulation of major duodenal papilla

Objective To improve the success rate of selective cannulation of major papilla during endoscopic retrograde cholangiopancreatography （ERCP）. Methods When cannulation failed with conven- tional methods, ultra-fine guide wire combined with taped cannulation, precut papillotomy, guide wire pancreatic occupation technique, and percutaneous transhepatic eholangial drainage （PTCD） assisted rendezvous technique was applied to improve the success rate of eannulation of major papilla. Results A total of 5743 patients received ERCP in our hospital during last 5 years, with a success rate of cannulation of major papilla at 98.6% （5664/5743）. For 396 patients with difficult cannulation under conventional methods, ultra fine guide-wire technique was applied in 20, pancreatic occupation technique in 67, precut technique in 294 and PTCD assisted rendezvous technique in 15, which achieved a success rate of 80. 0% （317/396）. Conclusion Application of combined techniques according to the features of papilla can increase success rate of difficult cannulation. Key words: Cholangiopancreatography, endoscopic retrograde ; Intubation ; Bile ducts ; Duodenal papilla

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 BALLOON ENDOSCOPE FACILITATES ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN ROUX-EN-Y ANASTOMOSIS PATIENTS

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the treatment of patients with pancreaticobiliary disorders, but endoscopic therapy is very difficult to carry out in patients with a Roux-en-Y anastomosis. We herein present the results of ERCP for patients with a Roux-en-Y anastomosis using a double-balloon endoscope. Six patients (six men with a mean age of 69 years) who had undergone prior gastric resection with Roux-en-Y reconstruction were enrolled in the present study and underwent ERCP and associated procedures. ERCP was carried out with a double balloon endoscope, which has one balloon attached to the tip of the endoscope and another attached to the distal end of the soft overtube. In all patients, entering the Y loop was successfully accomplished, and the papilla of Vater was also reached in all cases (100%). Cannulation was successful in four patients (66.7%). The final diagnosis was choledocholithiasis in two patients, biliary fistula in one patient and pancreatic cancer in one patient. A needle-knife precut papillotomy was carried out after placement of a bile duct stent in two patients, and injection of N-butyl-2-cyanoacrylate into a biliary fistula was carried out in one patient. None of the patients suffered from any complications. A double balloon endoscope is therefore considered to be useful for carrying out ERCP and associated procedures in patients with a Roux-en-Y anastomosis.

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

Purpose: While some gastroenterologists provide their own sedation for ERCP, others utilize anesthesiologists. There is limited information comparing cannulation success and complication rates between these two approaches. Theoretically, anesthesiologist directed sedation may lead to an improved 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. The goal of our study was to compare ERCP cannulation success and complications between gastroenterologist directed sedation (GDS) and anesthesiologist directed sedation (ADS). Methods: All ERCPs completed by senior advanced endoscopists at a tertiary referral center over a two year period were reviewed. During the first year, all ERCP sedation was performed with GDS utilizing a narcotic and 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 (papillotomy, stent placement, etc.) were excluded. Demographics, procedure indications, cannulation success, use of pre-cut papillotomy, sedation provider, and procedural complications (pancreatitis, cholangitis, hemorrhage, perforation, and death) were recorded. Pearson's chi-square and Fisher's Exact tests were used to compare the groups. Results: A total of 373 patients were studied; 183 (49.1%) GDS, 190 (50.9%) ADS. 179 (48.0%) patients were male. Mean patient age was 59.1 yr. The results are summarized in Table 1. Seven patients (3.8%) in the GDS category could not be sedated. There were two deaths, one in each group; one death was due to cholangitis/sepsis, the other was due to post-ERCP pancreatitis. Overall cannulation success rates were similar between the two groups; however, the GDS group required more pre-cut papillotomies to achieve cannulation. This did not lead to a difference in complication rates.Table 1Conclusion: Ductal cannulation rates between GDS and ADS are similar. GDS was associated with a higher rate of pre-cut papillotomy. However, this was not associated with an increase in post procedure complications.

Precut Papillotomy: A Risky Technique Not Only for Experts but Also for Average Endoscopists Skilled in ERCP

To evaluate the success and complication rates of early precut papillotomy in difficult biliary cannulations performed by an average endoscopist skilled in ERCP. We studied 146 consecutive ERCPs during a 27-month period. Precutting was instituted if cannulation failed after 10-15 min. Standard papillotomy was performed in the rest. The analysis was divided into initial period (1st year) and subsequent period (following 15 months). The success rate of cannulation was 95% (139/146). Standard papillotomy was performed in 103/146 (71%) patients. In the remainder, cannulation was successful after precutting in 36/43 (84%) patients. The complication rate was 10% (8/103 in the standard vs. 7/43 in the precut group, P = 0.14). All complications of the standard group were mild. In the precut group, there were three moderate to severe complications. There were no differences between the two periods. Precut papillotomy can be an effective and relatively safe procedure when performed by an average endoscopist skilled in ERCP. Although the complication rate of precutting tended to be higher than standard papilotomy, this was reasonable since it increased the success of selective biliary cannulation in 25% of cases. Complication rates did not improve with experience.

Endoscopic precut sphincterotomy for cannulation of inaccessible common bile duct： transpancreatic septum precut versus needle-knife

Objective To evaluate the technique of transpancreatic septum precut for cannulation of inaccessible common bile duct in endoscopic retrograde cholangiopancreatography （ERCP）. Methods Data of 109 patients with difficult biliary cannulation in ERCP, of whom 56 underwent transpancreatic septum precut and 53 had needle-knife sphincterotomy from January 2006 to July 2008, were analyzed retrospectively, and the success rate of cannulation and the occurrence of complications were compared between the two methods. Results Of 109 patients accepted precut papillotomy, common bile duct cannulation was successfully achieved in 97. The success rates of transpancreatic septum precut group and needle-knife sphincterotomy group were 96. 4% （54/56） and 81.1% （43/53） respectively, which was significantly different （ P 〈 0.05 ）. Complications occurred in 11 cases, including bleeding（ n = 4）, acute pancreatitis （ n = 5 ）, cholangitis（n = 2 ）. The tolal frequency of complications of the transpancreatic septum pre-cut papillotomy group was lower than that of needle-knife sphincterotomy group（3.6% vs. 17. 0% , P 〈 0. 05 ）. Conclusion In patients with inaccessible bile ducts, transpancreatic septum precut is a safe and effective procedure in cannulation, exhibiting a higher success rate and lower occurrence of complication when compared with needleknife sphincterotomy. Key words: Cholangiopancreatography, endoscopic retrograde ; Common bile duct ; Precut ; Septnm ; Postoperative complications

Retrospective analysis of needleknife precut papillotomy in our practice

Retrospective analysis of needleknife precut papillotomy in our practice

Endoscopic retrograde cholangiopancreatography during pregnancy without radiation

To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy. Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCl and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure. The mean age of the patients was 28 years (range, 21-33 years). The mean gestational age for the fetus was 23 wk (range, 14-34 wk). Five patients underwent ERCP because of choledocholithiasis and/or choledocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen. Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.

Endoscopic Needle Knife Precut Papillotomy for Inaccessible Bile Duct following Failed Pancreatic Duct Access

Aims To evaluate the safety, effectiveness, success rate and complications of needle knife precut papillotomy for inaccessible bile duct after failed pancreatic ducts access. Methods Selective common bile duct cannulation was required for 582 patients from November 2004 to May 2008. Precut sphincterotomy was performed in 28 patients (16 male, 12 female; mean age 71). When standard bile duct cannulation was unsuccessful after more than 20 minutes, the bile duct was considered inaccessible. Group A consisted of patients where pancreatic duct access was possible and transpancreatic papillary septotomy was performed (20 patients). If pancreatic duct cannulation also failed, needle knife precut method was performed and these patients belonged to group B (8 patients). The success and complication rates of the two groups were compared using the Chi-square test. Results The success rates were 85% and 87.5% respectively. Of the 28 patients in group A, 6 had mild to moderate pancreatitis and one patient had mild bleeding. The complication rates were 35% and 0% respectively and the differences were not significant. Conclusion Needle knife precut papillotomy is useful and acceptable in patients after failed pancreatic duct access.

Quantitative assessment of technical proficiency in performing needle-knife precut papillotomy

Although needle-knife precut papillotomy (NKPP) is considered a useful alternative for achieving selective biliary cannulation, controversy remains regarding the technical proficiency needed to perform the procedure and its safety. This study evaluated whether procedural experience with NKPP predicted either successful cannulation or the development of complications. This study retrospectively investigated 104 patients, out of 589 consecutive patients with native papillary, who underwent NKPP performed by a single endoscopist between October 2002 and July 2006. To demonstrate changes in NKPP, the 104 patients were divided chronologically into two groups according to periods: period A (October 2002 to September 2004) and period B (October 2004 to July 2006). Of the 104 consecutive patients who underwent NKPP, 41 (41/267, 15%) were treated in period A and 63 (63/322, 20%) in period B. There was no significant difference in the overall success rate between periods A (90%) and B (98%) (p = 0.08). However, the initial success rate was higher in period B (95%) than in period A (80%) (p < 0.05). The complication rates were not significantly different between the two groups (10% vs 16%; p = 0.56). Although all complications involved pancreatitis, severe pancreatitis was not observed. Whereas the initial success rate for NKPP can increase with procedural experience, the complication rate does not seem to decrease. Furthermore, the need for NKPP does not appear to decrease with increasing endoscopic retrograde cholangiopancreatography (ERCP) experience.

Intramural incision technique: a useful and safe procedure for obtaining ductal access during ERCP

Intramucosal incision technique is a useful procedure to achieve ductal access in patients undergoing ERCP. However, the procedure has been underused. Our purpose was to evaluate the efficacy and safety of the intramucosal incision technique and to compare it with standard precut needle-knife papillotomy. A large teaching hospital. Patients undergoing endoscopic sphincterotomy. If a complete or an incomplete false tract formed during probing for the biliary ductal system, the intramucosal incision technique was attempted. Needle-knife precut papillotomy was performed in those in whom bile duct access could not be obtained even after 4 attempts at cannulating the bile duct. The success rate and complications of the intramucosal incision technique were compared with those for kneedle-knife papillotomy. The intramucosal incision technique was attempted in 23 patients and was successful in 22. A definitive procedure could be performed in all 22 patients, and mild pancreatitis developed in only one of them (4.5%). During the same period, needle-knife papillotomy was attempted in 169 patients. Biliary access was gained in 159 (94%) patients. Complications occurred in 14 (8.2%) patients (mild pancreatitis in 6, moderate pancreatitis in 2, bleeding requiring endoscopic therapy in 5, and perforation in 1 patient). Single center study. Intramucosal incision technique is a very useful and safe procedure and should be performed if a false tract has formed during probing for ductal access during ERCP.

Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation, especially with regard to postoperative anatomic factors

Biliary cannulation is the first step in therapeutic endoscopic retrograde cholangiopancreatography. This study aimed to evaluate unsuccessful cases of biliary cannulation in which the standard procedure was changed to a needle-knife precut papillotomy (NKPP), with particular attention given to postoperative anatomic factors. Between October 2002 and February 2006, a total of 501 consecutive patients with an intact duodenal papilla were retrospectively investigated. After biliary cannulation using standard maneuvers was unsuccessful within 20 min, NKPP was performed in 80 cases (16%). The clinical backgrounds for difficult biliary cannulation were compared between patients who had standard maneuvers (n = 421, 84%) and those who underwent NKPP. For 76 difficult cannulation cases (95%), successful cannulation after NKPP was accomplished, and the total success rate reached 99% (497/501). Multivariate analysis indicated that female gender (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.34-3.79), left lobe hypertrophy after hepatectomy (OR, 6.25; 95% CI, 2.52-15.54), history of Billroth I reconstruction after gastrectomy (OR, 7.49; 95% CI, 2.55-22.02), and malignant biliary stricture (OR, 2.31; 95% CI, 1.21- 4.41) were significant risk factors associated with unsuccessful standard procedures used for biliary cannulation. Complications after NKPP were observed in nine cases (11%), all of which were pancreatitis. Difficult biliary cannulation was strongly associated with postoperative anatomic factors. In these situations, early introduction of NKPP should be recommended if the conventional biliary cannulation promises to be difficult.

Precut Papillotomy is Effective and Safe Only “When” Clinically Indicated and “in” Expert Hands

Precut papillotomy is often employed as a rescue technique when conventional methods fail to establish biliary access at endoscopic retrograde cholangiopancreatography (ERCP). This can be performed using either the needle-knife or pull-papillotome. Varying rates of technical success and complication have been reported for this technique in the medical literature.1–4 These reports are mainly from large-volume ERCP centers where ERCPs are performed by dedicated endoscopists. In this issue of Journal of Clinical Gastroenterology, Jukka et al5 from Finland report their experience with 1044 consecutive ERCPs performed over a 4-year period. The authors evaluated the safety and effectiveness of Erlangen precut papillotomy in achieving biliary access. The Erlangen papillotome is a covex plastic catheter with a cutting wire designed to establish contact only with roof of the papilla. When the papillotome is bent, the cutting wire orients itself to the 11o' clock position of the common bile duct and with electrocautery an incision at the papillary orifice would facilitate biliary access. The authors resorted to use of this technique in 20% (121 of 602 patients) of their patients and report a deep cannulation rate of 98.2%. Indication for ERCP was biliary obstruction in 80% of the study cohort; 20% of patients underwent ERCP for reasons other than biliary obstruction. Precut papillotomy was performed in only 17 cases in the cohort of patients who underwent ERCP for reasons other than biliary obstruction. The rates of complication between the precut and standard papillotomy techniques were not significantly different (8.3% vs. 7.1%). Being retrospective, it is unclear when exactly during ERCP the authors resorted to use of precut techniques. Twenty percent, at first glance, appears to be a high number. However, most of the patients had biliary obstruction, the most valid indication for undergoing an ERCP. The authors have subjected the “correct” cohort of patients for undergoing precut papillotomy. Not surprisingly, their rates of success and complications are enviable. The authors seem to be very comfortable with use of this technique as evident by the numbers: 20% of the entire cohort was subjected to precut papillotomy with a success rate of 98.2%. They appear to resort to use of precut early during the procedure when conventional techniques fail. All procedures were performed in a large-volume ERCP center (>200 cases/y) by the 2 dedicated endoscopists. The institutional and individual provider volumes support these favorable outcomes. Most therapeutic endoscopists attempt precut as a last resort when conventional methods fail. This usually happens after multiple cannulation attempts when the papilla is “red and angry” and the endoscopist is “burnt-out” and almost “ready to quit.” Not surprisingly, the rates of failure and complications are higher. Reasons for reluctance to undertake precut papillotomy are multifactorial: Lack of adequate training in fellowship, inadequate procedural volume to maintain competence in advanced techniques, not feeling comfortable to deal with procedural complications, and inherent risk for potential law suits. All 4 reasons are valid and justifiable. Proficiency in precut papillotomy involves a learning curve that can be completed only with adequate training and procedural exposure.4 In a recent study, only 35% of graduating GI fellows in the United States met ASGE requirements for procedural competence in ERCP.6 It is very likely that a majority of these graduates were not trained in advanced techniques such as precut papillotomy. Even if exposed, they may not have the adequate procedural volume to maintain proficiency. This is evident from a recent analysis of the National Inpatient Sample (NIS) database. Only 5% of community hospitals in the United States performed >200 ERCP/y. Only patients who underwent ERCP at high-volume centers had better outcomes: shorter length of hospital stay and lower procedural failure rates.7 ERCP is technically challenging. It is a matter of great satisfaction when the outcomes are successful. However, the desire to achieve this satisfaction should not drive one to desperation. If not proficient, when the papilla turns red and angry, the wise physician will know that it is “time to quit” and to refer the patient to someone more apt to getting the “job done.” Such referral does not exhibit incompetence but rather demonstrates genuineness on the part of the endoscopist in doing what is correct for the patient. Techniques such as precut papillotomy yield good results only when performed in the right patient for the right reason by the right person.

Safety of Erlangen Precut Papillotomy

There is controversy about the ideal utilization of precut papillotomy in endoscopic retrograde cholangiopancreatography examinations. Almost all reports in the literature concentrate on needle knife precut papillotomy, reporting a wide range of complications. We have used Erlangen precut papillotomy in our institution and our aim was to compare the safety of Erlangen precut papillotomy to standard free cannulation technique. The influence of precutting on the deep biliary cannulation rate was also recorded. Over a period of 48 months a total of 602 out of 1044 consecutive endoscopic retrograde cholangiopancreatography examinations fulfilled the inclusion criteria. Patients with an intact papilla who required biliary cannulation were screened. The cohort was divided into a nonprecut group (n=481) and a precut group (n=121). The standard technique included free biliary cannulation with a tapered-tip cannula. An Erlangen type papillotome was used for precutting. Complications, success rate of cannulation, and hyperamylasemia were recorded. Complication rates were similar in the 2 groups (nonprecut 7.1% vs. precut 8.3%, P=0.7). Hyperamylasemia was more common in the precut group (13.3% vs. 31.3%, P<0.001). The final deep biliary cannulation rate after precut papillotomy in cases with problematic cannulation was 98.2%. Erlangen precut papillotomy results in a high deep biliary cannulation rate with no increased risk of complications when compared to cannulation using standard techniques.

Clinical Usefulness of the Mucosa-Tracking-Technique (MTT) with the Iso-Tome in Precut Papillotomy

Background/Aims: This study was done to evaluate the clinical usefulness of MTT in precut papillotomy using the Iso-Tome, an isolated-tip needle-knife papillotome (which was firstly introduced in Gastrointest Endosc 2005;62:588-591). Methods: From September 2004 to June 2006, there were 59 patients (35 choledocholithiasis, 10 malignancies, 7 pancreatitis, 7 others) who underwent precut papillotomy with the Iso-Tome consecutively when biliary cannulation failed by the conventional method. The intrapapillary (common channel, bile and pancreatic duct) mucosa of the ampulla of Vater (AV) contacted with the isolated-tip of the Iso-Tome was scathelessly preserved on precut papillotomy starting from the orifice of the AV. The intactly exposed intrapapillary mucosa was carefully tracked and classified into four groups; fully exposed and oriented toward the direction of the bile duct (group A) or the pancreatic duct (group B), partially exposed (group C), and submucosa only exposed (group D). Initial success rates of bile duct cannulation (ISRBC), time (minutes) required for bile duct cannulation from placing the Iso-Tome into the orifice of the AV (TBC), and complications were compared between four groups. Results: see table. Summary; (1) ISRBC was 86.4% (51/59) in total and higher in the mucosa-exposed groups (group A, B, C) than in group D, (2) ISRBC was 100% in group B even though primary incision was incorrectly oriented toward the direction of the pancreatic duct, (3) TBC was the shortest in the group A, (4) Complications occurred totally in 6.8% (4/59) and consisted of 4 pancreatitis (3 mild; 1 moderate). There was no difference of complication rates between four groups and all 4 patients with complications were managed medically. Conclusion: It is critical for successful precut papillotomy to expose the intrapapillary mucosa of the AV intactly and sufficiently as possible and then to track the orientation of the exposed intrapapillary mucosa carefully. MTT with the Iso-Tome is a useful method to improve the efficiency of precut papillotomy. Tabled 1 Group A (n = 29) Group B (n = 4) Group C (n = 19) Group D (n = 7) p value Gender (female/male) 8/21 3/1 9/10 5/2 0.07 Age (yrs; mean ± SD) 63.5 ± 16.2 69.8 ± 11.9 67.8 ± 12.1 62.4 ± 14.8 0.65 ISRBC (%) 96.6%(28/29) 100% (4/4) 84.2% (16/19) 42.9% (3/7) 0.002 TBC (minutes;mean ± SD) 4.3 ± 2.8 23.9 ± 10.6 12.4 ± 13.6 16.3 ± 14.4 0.0003 Complications (%) 0% 25% (1/4;1 moderate pancreatitis) 10.5% (2/19; 2 mild pancreatitis) 14.3% (1/7; 1 mild pancreatitis) 0.15 Open table in a new tab

Anatomical Factors Predictive of Difficult Biliary Cannulation During ERCP

Background: Limited data are available in the literature in regard to the anatomical factors that might be related to difficult biliary cannulation during ERCP. Aim: The aim of this study was to elucidate the anatomical factors predictive of difficult biliary cannulation during ERCP. Patients and Methods: Three hundred seventy-two consecutive patients(212 men, 160 women; mean age, 64.7 years; age range, 16-96 years) who underwent ERCP at the Yokohama city university hospital from April 2005 to October 2006 for various biliary or pancreatic disorders were enrolled in this study. Difficult biliary cannulation was defined as failure biliary cannulation after a 20-minute attempt. The characteristics of the group needing precut papillotomy using a needle knife (NKPP) (n = 40, 12%) were compared with those of a group in which only standard maneuvers were performed (n = 332, 88%). Various factors (patient age, gender, presence of periampullary diverticulum, length of the narrow distal segment, diameter of the common bile duct, cholangiographic angulation of the common bile duct, location of the cystic duct, presence of benign biliary stricture, presence of malignant biliary stricture, and the presence of choledochlithiasis were retrospectively analyzed in the two groups to identify any relationship of these factors to difficult biliary cannulation in patients undergoing ERCP. Results:The success rate of biliary cannulation facilitated by NKPP in patients with difficult biliary cannulation was 92% (37/40), yielding a total success rate of 99% (364/372). Univariate analysis revealed that a long narrow distal segment, sharp cholangiographic angulation of the common bile duct, presence of malignant biliary stricture, and a lower location of the cystic duct were significantly associated with difficult biliary cannulation during ERCP (p < 0.05). Multivariate logistic regression analysis showed that sharp cholangiographic angulation of the common bile duct(OR = 1.021, 95% CI 1.002-1.041, p = 0.0333), presence of malignant biliary stricture (OR = 2.896, 95% CI 1.236-6.786, p = 0.0144)and a lower location of the cystic duct(OR = 5.263, 95% CI 1.556-17.805, p = 0.0076) were independent risk factors associated with difficult biliary cannulation. Conclusions: In conclusion, a long narrow distal segment, sharp cholangiographic angulation of the common bile duct, presence of malignant biliary stricture, and a lower location of the cystic duct are risk factors for difficult biliary cannulation during ERCP. However, NKPP is a useful and promising method for deep biliary cannulation in such difficult cases.

Endoscopic retrograde cholangiopancreatography in the elderly: a prospective and comparative study

In this study we aimed to compare the utility and safety of endoscopic retrograde cholangiopancreatography (ERCP) in elderly and younger groups of people. The study involved 299 patients who underwent ERCP for the first time between March 2002 and January 2003. Group A consisted of 202 patients who were 69 years of age or younger and group B involved 97 patients who were 70 years of age or older. The patients were prospectively identified and data were gathered on them prospectively. Clinical and biochemical features, ERCP procedures, ERCP diagnosis, complications and length of hospital stay were compared between the two groups. Group B patients presented with more specific symptoms compared with group A. Laboratory findings were similar in both groups other than mean bilirubin levels, which were higher in the elderly group. Selective biliary cannulation was technically successful in 99% of both groups. Pre-cut papillotomy was performed in 49.5% of group A patients and 56.7% of group B patients. Choledocholithiasis was the most frequent diagnosis in both groups. Benign biliary stenosis was more frequent in group A and malignant biliary stenosis in group B. Among the malignant aetiologies, pancreatic carcinoma was the most common cancer in both groups. Post-procedural complications developed in 27 (9%) patients. There were 16 (7.9%) complications (six bleeding, five pancreatitis, three perforation and two cholangitis) in the 202 patients aged under 70 years. In comparison, 11 (11.3%) of the 97 patients aged over 70 years developed a complication (bleeding in six, pancreatitis in one, perforation in one, cholangitis in two and ileus in one). Twelve (nine group A and three group B) patients died within 5-30 days of the procedure. Length of hospital stay was comparable for both groups (15.53+/-12.43 days in group A and 14.84+/-11.56 days in group B). Diagnostic and therapeutic ERCP has similar outcomes in both elderly and younger patients. ERCP is effective and safe in elderly patients with naive papilla. The more invasive procedures like pre-cut papillotomy may be performed safely in the elderly.