Selective Cannulation Of Common Bile Duct Research Articles

S1257 Selective Common Bile Duct Cannulation Time During Endoscopic Retrograde Cholangiopancreatography: Effects of Dexamethasone

S1257 Selective Common Bile Duct Cannulation Time During Endoscopic Retrograde Cholangiopancreatography: Effects of Dexamethasone

Papilla of Vater morphology as an influencing factor in successful cannulation during resident training in advanced endoscopy. A prospective clinical study

Introduction and aimEndoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure. Clinical guidelines assess competence in ERCP through a defined number of procedures, but multiple factors are involved. Our aim was to analyze the morphology of the papilla of Vater as an independent factor in selective common bile duct cannulation during resident training. Material and methodsPatients that underwent ERCP were studied consecutively. All ERCPs were begun by a resident in training. The type of papilla was classified according to Haraldsson, including those with previous sphincterotomy. Cannulation difficulty and success and their relation to the type of papilla were documented. The analysis was divided into three 4-month periods. ResultsOf the 429 patients, cannulation was difficult in 101 (23.5%). The residents achieved selective cannulation of the common bile duct in 276 (64.3%) and the cannulation success rate at the end of their training was 81.7%. Cannulation was performed with the least difficulty in papillae with previous sphincterotomy (2.8%), unlike the type 4 papilla, which was difficult to cannulate in 50% of the cases. The lowest overall cannulation success was in the type 2 papilla (81.8%). ConclusionPapilla type can influence cannulation success, but it is not the only related factor. Patients that underwent previous sphincterotomy appear to be the cases in whom ERCP training can be started.

Morfología de la papila de Vater como factor que influye en el éxito en canulación durante el entrenamiento del Residente en Endoscopia Avanzada. Estudio clínico prospectivo

Introduction and aimEndoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure. Clinical guidelines assess competence in ERCP through a defined number of procedures, but multiple factors are involved. Our aim was to analyze the morphology of the papilla of Vater as an independent factor in selective common bile duct cannulation during resident training. Material and methodsPatients that underwent ERCP were studied consecutively. All ERCPs were begun by a resident in training. The type of papilla was classified according to Haraldsson, including those with previous sphincterotomy. Cannulation difficulty and success and their relation to the type of papilla were documented. The analysis was divided into three 4-month periods. ResultsOf the 429 patients, cannulation was difficult in 101 (23.5%). The residents achieved selective cannulation of the common bile duct in 276 (64.3%) and the cannulation success rate at the end of their training was 81.7%. Cannulation was performed with the least difficulty in papillae with previous sphincterotomy (2.8%), unlike the type 4 papilla, which was difficult to cannulate in 50% of the cases. The lowest overall cannulation success was in the type 2 papilla (81.8%). ConclusiónPapilla type can influence cannulation success, but it is not the only related factor. Patients that underwent previous sphincterotomy appear to be the cases in whom ERCP training can be started.

Endoscopic Extraction of CBD Stone: single centre experience in tertiary care centre

Background and Aims: Introduction: Endoscopic Retrograde Cholangiopancreatography(ERCP) has become the first line treatment for patients with common bile duct (CBD) stones. This technique may fail, however, due to presence of a large stone, multiple stones, periampullary diverticula or CBD stricture. The aim of this study was to evaluate the success of CBD cannulation, Endoscopic Sphincterotomy(EST) and CBD clearance in initial attempt, identify the failures of stone extraction and assess the post-ERCP complications.
 Methods: A prospective study was carried out over the period of January 2019 to January 2020 on 100 consecutive patients with CBD stones. ERCP was done and the stone size and number recorded. EST was performed using a diathermy unit with a cutting current and stones were extracted using a Balloon catheter or a Dormia basket.
 Results: Of the 100 patients, 44 were male and 56 were female with mean age of 52}17years. Selective CBD cannulation and cholangiogram was achieved in 90%, EST was successful in 90% and complete stone clearance was achieved in first attempt in 46 patients (59%). 52 patients had difficult CBD stone. There were nine complications, most of which rapidly resolved on conservative treatment (four post-ERCP pancreatitis, three bleeding and one retroperitoneal perforation) and one mortality in an old lady due to PSVT that couldn’t be directly attributed to ERCP. Among patients with Stone less than 15 mm in diameter(n=58), stone was removed successfully in 45 patients(78%) whereas in patients with stones over 15 mm (n=20) only one was removed successfully (5%) at initial attempt. Of these 32 patients with residual stones, 13 were referred for surgery and 19 had insertion of biliary stent to be followed by repeat ERCP.
 Conclusion: Endoscopic therapy is a simple, effective and safe method of treatment in patients with CBD stone.

Impact of nitroglycerin and glucagon administration on selective common bile duct cannulation and prevention of post-ERCP pancreatitis

Objective: Easy common bile duct (CBD) cannulation is associated with low complication rate. This study aimed to investigate the potential impact of nitroglycerin and glucagon administration on selective CBD cannulation and prevention of post-ERCP pancreatitis.Methods: A prospective single center, double–blind randomized study in which a total of 455 patients were randomly assigned to CBD cannulation by receiving 6 puffs (2.4 mg) sublingual nitroglycerin and glucagon 1 mg intravenously (n = 227, group A) or 6 puffs sterile water and 20 mg hyoscine-n-butyl bromide intravenously (n = 228, group B). After ERCP, patients were followed for the development of drugs’ side-effects and post-ERCP complications.Results: There were no statistically significant differences between the two groups regarding demographic data and ERCP findings. Success rate of selective CΒD cannulation was 95.15% in group A versus 82.29% in group B (p < .001). Time required for CBD cannulation was 2.82 ± 2.31 min in group A versus 4.27 ± 3.84 min in group B (p = .021). Needle-knife papillotomy was used in 11 (4.85%) patients of group A and 39 (17.11%) patients of group B (p = .001). The frequency of post-ERCP pancreatitis was significantly lower in group A than in group B (3.08% versus 7.46%, p = .037). No difference was observed between the two groups with regard to the occurrence of post-procedure hemorrhage. There was no procedure-related mortality; no adverse event related to the combination regimen was observed.Conclusions: Combined nitroglycerin and glucagon administration achieves a high selective CBC cannulation rates with concomitant reduction of post-ERCP pancreatitis incidence. However, further relative large-scale studies are needed to confirm our findings before definite conclusions can be drawn (Clinical trial registration number: NT: 4321).

Randomised study on single stage laparo-endoscopic rendezvous (intra-operative ERCP) procedure versus two stage approach (Pre-operative ERCP followed by laparoscopic cholecystectomy) for the management of cholelithiasis with choledocholithiasis.

INTRODUCTION:The ‘Rendezvous’ technique consists of laparoscopic cholecystectomy (LC) standards with intra-operative cholangiography followed by endoscopic sphincterotomy. The sphincterotome is driven across the papilla through a guidewire inserted by the transcystic route. In this study, we intended to compare the two methods in a prospective randomised trial.MATERIALS AND METHODS:From 2005 to 2012, we enrolled 83 patients with a diagnosis of cholecysto-choledocolithiasis. They were randomised into two groups. In ‘group-A’,41 patients were treated with two stages management, first by pre-operative endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct (CBD) clearance and second by LC. In ‘group-B’, 42 patients were treated with LC and intra-operative cholangiography; and when diagnosis of choledocholithiasis was confirmed, patients had undergone one stage management of by Laparo-endoscopic Rendezvous technique.RESULTS:In arm-A and arm-B groups, complete CBD clearance was achieved in 29 and 38 patients, respectively. Failure of the treatment in arm-A was 29% and in arm-B was 9.5%. In arm-A, selective CBD cannulation was achieved in 33 cases (80.5%) and in arm-B in 39 cases (93%). In arm-Agroup, post-ERCP hyperamylasia was presented in nine patients (22%) and severe pancreatitis in five patients (12%) versus none of the patients (0%) in arm-B group, respectively. Mean post-operative hospital stay in arm-A and arm-B groups are 10.9 and 6.8 days, respectively.CONCLUSION:One stage laparo-endoscopic rendezvous approach increases selective cannulation of CBD, reduces post-ERCP pancreatitis, reduces days of hospital stay, increases patient's compliance and prevents unnecessary intervention to CBD.

The Wandering Stent

Purpose: A 43-year-old Caucasian woman with a medical history significant for obesity was evaluated for intermittent right upper quadrant abdominal pain for several months. Abdominal ultrasound showed gallstones and a dilated common bile duct of 9 mm. Laboratory studies showed elevated transaminases. An initial endoscopic retrograde cholangiopancreatogram (ERCP) was performed for suspected choledocholithiasis. Selective common bile duct cannulation was unsuccessful, and due to several pancreatograms, a prophylactic 5 Fr x 3 cm non-flanged single pigtail pancreatic duct stent was placed. However, upon deployment, the stent migrated proximally into the pancreatic duct. She developed post-ERCP pancreatitis without complications. A repeat ERCP was performed 1 month later but retrieval of the stent was unsuccessful despite multiple balloon catheter sweeps with an 8.5-mm balloon. Subsequently, another ERCP was performed with the same difficulty in retrieving the pancreatic duct stent, despite use of additional accessories. A repeat ERCP was performed 1 month later, during which the pancreatic duct stent was found to be lodged between genu and proximal body of pancreas (Figure 1). Retrieval was once again unsuccessful. The patient was referred to a pancreatobiliary surgeon and underwent a laparoscopic central pancreatectomy with stent removal and pancreaticogastrostomy. Proximally migrated pancreatic duct stents are a rare complication of ERCP and have an incidence of about 2-5%. Risk factors include chronic pancreatitis, sphincter of Oddi dysfunction, use of long pancreatic stents, and probably most importantly, operator-dependent factors such as lack of experience. Management of these proximally migrated stents is generally anecdotal but includes use of endoscopic retrieval devices, including interventional cardiology accessories. When these measures fail, surgical management is warranted. Surgical operations described include distal pancreatectomy, central pancreatectomy, and pancreatotomy with reconstruction. Good communication between the endoscopist and surgeon should be established after the first or second failed ERCP. The patient had an unremarkable post-operative course without further symptoms.Figure: Proximally migrated pancreatic duct stent as seen on endoscopic retrograde pancreatogram.

The impact of sphincterotome design on selective cannulation of the common bile duct

There is a paucity of data regarding the impact of sphincterotome design on cannulation success. We aimed to compare the 5.5 F standard sphincterotomes of two different manufacturers (sphincterotome 1: Endo-flex 5.5F [ENDO-FLEX GmbH, Voerde, Düsseldorf, Germany] vs sphincterotome 2: Ultratome 5.5F [Boston Scientific, Spencer, IN, USA]). Adult patients undergoing their first endoscopic retrograde cholangiopancreatography were included in two study groups. The sphincterotome preloaded with a guidewire was used for selective common bile duct cannulation in each group. Precut methods were applied in failed cases without crossover. Successful biliary cannulation in 10 attempts was the primary outcome. Baseline features and indications were similar between groups (n = 100, group I, sphincterotome 1, vs n = 100, group II, sphincterotome 2). A higher success in initial cannulation was obtained in group II compared to group I (92% vs 81%, P = 0.03). Moreover, number of cannulation attempts and time to cannulation differed. No statistical significance was noted in group I (8%) versus group II (3%) regarding pancreatitis rate. The overall cannulation success after precut in failed cases was 95% (group I) and 97% (group II). There was a significant difference in cannulation success between the two different sphincterotome. 5.5F Ultratome with guidewire was superior to 5.5F Endo-flex sphincterotome with guidewire in initial selective cannulation of common bile duct. The results may show the importance of sphincterotome features to overcome the obstacles during cannulation such as complex intrapapillary mucosal features.

A prospective randomized controlled study of selective common bile duct cannulation guided by loach guide wire and zebra guide wire in ERCP

Objective To compare curve-tip angiography guide wire （loach guide wire） and ultrasmooth hydrophilic guide wire （ zebra guide wire） in selective common bile duct （CBD） cannulation of endoscopic retrograde cholangiopanereatography （ERCP）. Methods A total of 196 patients were randomly assigned to loach guide wire group to receive cannulation guided by loach guide wire first （ n = 98 ） and zebra guide wire group to use zebra guide wire first （n = 98 ）. If cannulation was not successful after 10 minutes, a further attempt was made for an additional 10 minutes using the alternative guide wire. If still not successful after 10 minutes, other cannulation accessories would be used. The primary and overall selective cannulation time, success rate, and post-procedure abdominal pain and serum amylase were assessed. Results The primary success rate of selective CBD cannulation was higher in the loach guide wire group （93.9%） than that in zebra guide wire group （86. 7%, P 〈0. 05）, while there was no significant difference in cannulation time between 2 groups （ P 〉 0. 05 ）. The cannulation success rate after crossover was higher in loach guide wire group （76.9%） than that in zebra guide wire group （0. 0% , P 〈0. 05）. There was no significant difference in post-procedure serum amylase or occurrence rate of post ERCP pancreatitis between 2 groups （ P 〉 0. 05 ）. Conclusion Loach guide wire is superior to zebra guide wire in ERCP selective CBD cannulation, which can replace zebra guide wire in difficult cannulation. Key words: Cholangiopanereatography, endoscopic retrograde ; Loach guide wire ; Zebra guide wire

Mo1443 A Single Session of Supervised ERCP Mechanical Simulator (EMS) Practice Prepares Novice Trainees for Superior Clinical Performance

Trainees with one session of supervised EMS practice had significantly higher success rate in cannulating the common bile duct (CBD) during early training (AJG 2010, in press). The impact of additional unsupervised practice is unknown. To evaluate the effects of multiple vs single-session practice on clinical outcomes. 8 ERCP-naive trainees per year were randomized to study (n=4) and control (n=4) groups in 2007 and 2009, respectively. All trainees received 4 hours of ERCP didactic discussions. The study groups underwent one session of supervised EMS practice. In 2009, the study group continued biweekly unsupervised EMS practice over 3 months. All trainees received routine clinical ERCP training; success of selective CBD cannulation and performance score (1=poor, 2=fair, 3=neutral, 4=good, 5=excellent, rated by trainers blinded to the randomization) were recorded. The group-averaged effects of single and multiple practices were estimated and compared by generalized estimation equation (GEE) with pooled data from 2007 and 2009, adjusting for number of ERCPs before each ERCP, difficulty of papilla (prior papillotomy and multiple stenting as easy) and year of study. Baseline characteristics of the procedures were comparable between study and control groups in both years (not shown). Clinical performance was superior in study groups compared to control groups in all outcome measures (all p<0.05) (Table 1). The adjusted odds ratio (OR) by GEE analysis further confirmed both single and multiple sessions practice conferred significant benefits with no difference between the 2 study groups (Table 2).Table 1Factors associated with success of deep CBD cannulation by traineesYear 2007Year 2009Clinical performanceSingle EMSControlMultiple EMSControlCBD cannulation success, n(%)31/40 (77.5)20/39 (51.3)40/58 (69.0)23/53 (43.4)Steps⁎Steps: selective CBD cannulation, ampullary/biliary dilation, biliary stenting. accomplished (%), mean (SD)75 (35)53 (45)80 (32)53 (41)Performance score, mean (SD)3.8 (0.9)3.2 (0.7)4.0 (0.7)3.2 (0.7) Steps: selective CBD cannulation, ampullary/biliary dilation, biliary stenting. Open table in a new tab Table 2Effects of single/multiple EMS practices on clinical performance: pooled analysisCannulation successPerformance scoreGEE analysisOR95% CIPOR95% CIPSingle EMS3.80⁎P=.83;2.07-6.96<.0013.82⁎⁎P=.74.1.60-9.10.003Multiple EMS3.33⁎P=.83;1.27-8.76.0156.19⁎⁎P=.74.2.98-12.86<.001Per 1 ERCP1.010.99-1.03.2451.031.00-1.06.022Easy papilla4.012.66-6.05<.0011.160.85-1.58.3412009 vs 20070.580.27-1.24.1600.730.31-1.74.483 P=.83; P=.74. Open table in a new tab As an educational tool a single supervised practice session with the EMS appears to augment the novice trainees' understanding sufficiently to significantly enhance clinical performance (success of CBD cannulation) in the first three months of training. The superior performance was unmistakable to blinded clinical trainers.

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.

Modified rendezvous intrahepatic bile duct cannulation technique to pass a PTBD catheter in ERCP

The rendezvous procedure combines an endoscopic technique with percutaneous transhepatic biliary drainage (PTBD). When a selective common bile duct cannulation fails, PTBD allows successful drainage and retrograde access for subsequent rendezvous techniques. Traditionally, rendezvous procedures such as the PTBD-assisted over-the-wire cannulation method, or the parallel cannulation technique, may be available when a bile duct cannot be selectively cannulated. When selective intrahepatic bile duct (IHD) cannulation fails, this modified rendezvous technique may be a feasible alternative. We report the case of a modified rendezvous technique, in which the guidewire was retrogradely passed into the IHD through the C2 catheter after end-to-end contact between the tips of the sphincterotome and the C2 catheter at the ampulla's orifice, in a 39-year-old man who had been diagnosed with gallbladder carcinoma with a metastatic right IHD obstruction. Clinically this procedure may be a feasible and timesaving technique.

ERCP Mechanical Simulator (EMS) Practice Enhances Traineesʼ Success with Common Bile Duct (CBD) Cannulation

Purpose: Background: EMS practice in the early stage of clinical ERCP training has been reported to be beneficial (GIE 2009; 69:AB141). Its role in augmenting performance of trainees with some clinical ERCP experience is unknown. Hypothesis: EMS practice is a predictor of success in CBD cannulation when introduced to EMS naive trainees after 6 months of usual clinical training.Table 1: Success with deep CBD cannulationTable 2: Factors associated with success of selective CBD cannulation by trainees (GEE analysis)Methods: Design: A randomized controlled cross-over study. 8 trainees attended didactic lectures on ERCP. Randomization was stratified based on site (n=2). Study group (SG) trainees participated in a one day handson simulator practice of selective bile duct cannulation supervised by JWL. Control group (CG) trainees did not participate in EMS practice. Subsequent clinical ERCP performance of all trainees was documented objectively. Primary outcome was successful deep CBD cannulation (0=fail, 1=success). After 6 months, CG trainees were crossed over to participate in one session of EMS practice. Performance of all trainees was tracked for another 6 months. The primary outcome was correlated to EMS practice status (with or without), overall clinical ERCP experience (days entered into ERCP training) and level of difficulty (normal papilla, diverticula, prior papillotomy or stenting) for CBD cannulation. Statistical analysis was performed using generalized estimation equations (GEEs) to fit the parameters of a generalized linear model where unknown correlations are present. The equations allow for correlation without explicitly defining a model for the origin of the dependency and are most suitable when the random effects and their variances are not of direct interest. The average response over the population (“population-averaged” effects) is estimated rather than the regression parameters that would enable prediction of the effect of changing one or more components of an unknown factor on a given individual. Results: Deep CBD cannulation was attempted in 153 of 224 and 142 of 225 cases in each of the two consecutive 6 months period, respectively. The table summarizes the odds ratio of trainee success in deep CBD cannulation taking all pre and post crossover data into consideration. EMS practice is a significant factor in predicting success while difficult papilla predicts cannulation failure. Conclusion: A single session of EMS practice enhances the success rate of CBD cannulation regardless of when it is introduced - at the beginning or after 6 months of usual clinical training. The results provide evidence to support the use of mechanical simulator practice, offered at the beginning or midway through clinical ERCP training, to augment the ERCP training experience. Disclosure: Cook Endoscopy - educational grant and equipment support Olympus America - educational grant and equipment support Dr Joseph Leung is supported by Cook Asia (speakers honorarium) during his sabbatical leave to conduct the research study in Taiwan. Partial research funding support from ACG Research Grant. This research was supported by an industry grant from Cook Endoscopy and Olympus Tokyo provided equipment support for simulator practice. The ERCP mechanical simulator is not commercially available and is used for teaching and research purposes.

PROPHYLACTIC PANCREAS STENTING FOLLOWED BY NEEDLE‐KNIFE FISTULOTOMY IN PATIENTS WITH SPHINCTER OF ODDI DYSFUNCTION AND DIFFICULT CANNULATION: NEW METHOD TO PREVENT POST‐ERCP PANCREATITIS

The aim of the present study was to reduce post-endoscopic retrograde cholangiopancreatography (ERCP) complications with a combination of early needle-knife access fistulotomy and prophylactic pancreatic stenting in selected high-risk sphincter of Oddi dysfunction (SOD) patients with difficult cannulation. Prophylactic pancreatic stent insertion was attempted in 22 consecutive patients with definite SOD and difficult cannulation. After 10 min of failed selective common bile duct cannulation, but repeated (>5x) pancreatic duct contrast filling, a prophylactic small calibre (3-5 Fr) pancreatic stent was inserted, followed by fistulotomy with a standard needle-knife, then a standard complete biliary sphincterotomy followed. The success and complication rates were compared retrospectively with a cohort of 35 patients, in which we persisted with the application of standard methods of cannulation without pre-cutting methods. Prophylactic pancreatic stenting followed by needle-knife fistulotomy was successfully carried out in all 22 consecutive patients, and selective biliary cannulation and complete endoscopic sphincterotomy were achieved in all but two cases. In this group, not a single case of post-ERCP pancreatitis was observed, in contrast with a control group of three mild, 10 moderate and two severe post-ERCP pancreatitis cases. The frequency of post-ERCP pancreatitis was significantly different: 0% versus 43%, as were the post-procedure (24 h mean) amylase levels: 206 U/L versus 1959 U/L, respectively. In selected, high-risk, SOD patients, early, prophylactic pancreas stent insertion followed by needle-knife fistulotomy seems a safe and effective procedure with no or only minimal risk of post-ERCP pancreatitis. However, prospective, randomized studies are awaited to lend to support to our approach.

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.

A comparative study of standard ERCP catheter and hydrophilic guide wire in the selective cannulation of the common bile duct

Deep cannulation of the common bile duct (CBD) is paramount for the success of endoscopic biliary intervention. The aim of the present study was to compare standard ERCP catheter and hydrophilic guide wire (HGW) in the selective cannulation of the CBD. A total of 332 patients were randomly assigned to cannulation with a standard catheter (n = 165) or a HGW (n = 167). If cannulation had not succeeded after 10 minutes with the technique assigned at randomization, a further attempt was made for an additional 10 minutes using the alternative technique. The following were assessed: primary and overall selective cannulation, time to cholangiography, number of pancreatic opacifications and guide-wire pancreatic duct insertions, and complication rates. The primary success rate of selective CBD cannulation was higher in the HGW (81.4 %) than in the standard catheter group (53.9 %; P < 0.001). The overall cannulation rate after crossover was comparable between the two groups (standard catheter 84 % vs. HGW 83.8 %; P = 0.19). Time required for primary selective CBD cannulation was 3.53 +/- 0.32 minutes in the standard catheter vs. 4.48 +/- 0.32 minutes in the HGW group ( P = 0.04), and the number of insertions of the guide wire into the pancreatic duct was 3.29 +/- 0.47 in the standard catheter vs. 2.7 +/- 0.21 in the HGW group ( P = 0.22). Pancreatic opacifications occurred 3.19 +/- 0.20 times in the standard catheter vs. 1.50 +/- 0.22 times in the HGW group ( P < 0.001). Precut techniques were used in 56 patients (16.9 %) (n = 31 in the standard catheter vs. n = 25 in the HGW group; P = 0.07). The frequency of postinterventional pancreatitis and hemorrhage did not differ between the two groups. A young woman developed post-ERCP hemolytic crisis due to glucose-6-phosphate dehydrogenase deficiency. There was no procedure-related mortality. The use of HGW, as primary technique or as a secondary technique after failure of cannulation with a standard catheter, achieves a high rate of selective CBD cannulation.

A prospective cross-over study using a sphincterotome and a guidewire to increase the success rate of common bile duct cannulation

During endoscopic retrograde cholangiopanc-reatography (ERCP), selective cannulation of the common bile duct (CBD) is required in most of the cases. From June 2001 till December 2002, all patients referred to our unit for ERCP were considered for entry into the study. Selective CBD cannulation was first attempted with a standard catheter with or without the use of a guidewire. In cases, where CBD cannulation was considered unsuccessful, patients were crossed over to a double-lumen sphincterotome and a guidewire. All patients were hospitalized for 24 h after the procedure in order to assess the incidence of post-ERCP complications. The study sample consisted of 158 patients. Selective CBD cannulation using a standard ERCP catheter with or without the assistance of a guidewire, was accomplished in 129 patients (success rate: 81.65%). From the 29 patients who were crossed over to a sphincterotome and a guidewire, selective CBD cannulation was achieved in 24; the overall success rate rising to 96.8%. Meanwhile, the use of this technique did not increase the incidence of post-ERCP complications. The use of a sphincterotome and a guidewire increases the success rate of selective bile duct cannulation in cases that this has not been accomplished with a standard catheter.

Laparoscopic transcystic bile duct stenting in the management of common bile duct stones

The management of patients with common bile duct stones associated with stones in the gall bladder remains controversial. Over the three-year period from 1996 to 1999, patients with cholelithiasis and known choledocholithiasis, or choledocholithiasis found at laparoscopic cholecystectomy, were initially treated by placing a stent across the sphincter of Oddi. The stent was pushed along a guide wire through the cystic duct and then down the common bile duct, before the cystic duct was closed. Subsequently, the stent was used to facilitate performance of a needle knife endoscopic sphincterotomy. The stent was then removed, a cholangiography was performed and the common bile duct was cleared. Patients with persistent jaundice usually had a preoperative endoscopic retrograde cholangio-pancreatography. Transcystic stenting was the 'intention-to-treat' basis of therapy for 56 of the patients. The placement of the stent only failed once when the stent became trapped in the cystic duct. Complications of the operation included: pain and jaundice (n = 2), cholangitis (n = 1), and pulmonary embolus (n = 1). The median postoperative hospitalization was 2 days (range: 1-15). Five further patients had common bile duct stones removed via a choledochotomy; a stent was placed through the choledochotomy before its closure. The selective common bile duct cannulation rate at the first endoscopic retrograde cholangio-pancreatography, was 98%. A second endoscopic retrograde cholangio-pancreatography was required in 15% of patients. The only complication of all the endoscopic procedures was a single case of mild cholangitis; there were no cases of pancreatitis. A treatment option open to all surgeons for non-jaundiced patients with known choledocholithiasis or choledocholithiasis found at operative cholangiogram, is the transcystic stenting of the sphincter of Oddi at the time of laparoscopic cholecystectomy. At a subsequent sitting, the common bile duct can be safely cleared endoscopically using a sphincterotomy facilitated by the stent.

A sphincterotome-based technique for selective transpapillary common bile duct cannulation

Background: Endoscopic retrograde cholangiopancreatography (ERCP) requires selective cannulation of the common bile duct and pancreatic duct. Selective common bile and pancreatic duct cannulation with standard techniques can be achieved in most but not all cases even in experienced centers. To facilitate selective cannulation, sphincterotomes can be used. Methods: A prospective randomized study aimed at selective deep cannulation of the common bile and pancreatic ducts comparing different ERCP procedures was performed. One hundred patients were randomly assigned to undergo cannulation with a standard catheter or with a guidewire sphincterotome (GS) without guidewire. Results: The primary success rate of selective common bile duct cannulation was significantly higher in the GS group (84%) as compared with the standard catheter group (62%) (p = 0.023). In patients with primary standard catheter failure, selective common bile duct cannulation was possible in 16 patients using a GS which increased the total success rate in the standard catheter group to 94% (p < 0.001). In GS failures selective common bile duct cannulation was possible in two patients using a standard catheter and increased the total success rate from 84% to 88%. The frequency of postinterventional pancreatitis did not differ significantly between the two groups. Conclusions: ERCP using a GS without guidewire has a significantly higher primary success rate for selective common bile duct cannulation then ERCP using a standard catheter. The use of a GS should be considered to optimize selective cannulation of the common bile duct before resorting to precut techniques. (Gastrointest Endosc 2000;52:387–91.)

Selective cannulation of the common bile duct: a prospective randomized trial comparing standard catheters with sphincterotomes

Background: Current recommendations for the use of standard catheters or sphincterotomes for the initial attempt at selective common bile duct cannulation have been made in the absence of prospective comparative data. Methods: A prospective study was carried out in which patients were randomized to undergo cannulation with a standard catheter or a sphincterotome (standard or wire-guided). Multivariate models were constructed to determine significant independent predictors of the success rates of initial and selective cannulation and the number of attempts and time needed to achieve selective cannulation. Results: Eighty-three successive patients were evaluated; 36 were excluded because they had undergone previous therapeutic endoscopic retrograde cholangiopancreatography (ERCP) or a Billroth II operation. Of the 47 patients (28 women, mean age 60.6 ± 14.5 years), indications for ERCP included suspected bile duct stones in 41 patients, pancreatico-biliary malignancies in 4, and biliary leaks in 2. Eighteen patients were randomized to undergo selective common bile duct cannulation with standard catheter and 29 to standard/wire-guided sphincterotome. Initial common bile duct cannulation for the standard catheter and standard/wire-guided sphincterotome groups was successful in 12 (67% [95% CI: 41%, 87%]) and 28 (97% [95% CI: 82%, 100%]) patients, respectively (95% CI for the difference: –0.57 to –0.03, p = 0.009). Using intention to treat analysis, selective common bile duct cannulation was successful for standard catheter and standard/wire-guided sphincterotome patients in 17 (94% [95% CI: 73%, 99%]) and 28 (97% [95% CI: 82%, 100%]) cases, respectively (95% CI for the difference: –0.15 to +0.10, p > 0.05). The mean number of attempts required to achieve selective common bile duct cannulation were 12.4 ± 6.0 and 2.8 ± 3.1 ( p = 0.0001). The mean time taken to achieve selective common bile duct cannulation was 13.5 ± 6.14 and 3.1 ± 5.1 minutes ( p = 0.0001). Multivariate modeling revealed that the initial choice of catheter was the only significant independent predictor of the time taken and the number of attempts performed to achieve selective common bile duct cannulation ( p = 0.0001 for each model). Conclusion: The use of standard/wire-guided sphincterotome was superior to that of standard catheter for the initial attempt at cannulation of the common bile duct. The number of attempts required may bear clinical significance with regard to the development of post-ERCP pancreatitis and warrants further study. (Gastrointest Endosc 1999;50:775-9.)