Successful Bile Duct Cannulation Research Articles

Factors affecting complete stone removal and bile duct stone recurrence in patients with surgically altered anatomy treated by double-balloon endoscopy-assisted endoscopic retrograde cholangiography.

This study assessed factors influencing the complete removal and recurrence of bile duct stones in patients with surgically altered anatomy (SAA) undergoing double-balloon endoscopy-assisted endoscopic retrograde cholangiography (DBERC). A retrospective analysis of 289 patients with SAA treated for biliary stones with DBERC at Jichi Medical University Hospital (January 2007 to December 2022) was conducted. Evaluation of factors impacting complete stone removal was performed in 257 patients with successful bile duct cannulation. Logistic and Cox proportional hazards regression models were used to compute the odds ratios (ORs) and hazard ratios (HRs) at 95% confidence intervals (CIs). Of 257 patients, 139 (54.0%) and 209 (81.3%) achieved initial and complete removal, respectively. Recurrence occurred in 55 (21.4%) patients. Factors associated with initial complete stone removal included cholangitis (P < 0.01, OR 0.48, 95% CI 0.27-0.83), number of stones (P < 0.01, OR 0.31, 95% CI 0.18-0.54), and largest stone diameter (P < 0.01, OR 0.37, 95% CI 0.20-0.67). The size of the largest stone was associated with complete removal (P = 0.01, OR 0.24, 95% CI 0.13-0.76). Recurrence was associated with cholangitis (P = 0.046, HR 0.54, 95% CI 0.29-0.99), congenital biliary dilatation (P = 0.01, HR 2.65, 95% CI 1.21-5.80), and number of stones (P = 0.02, HR 1.96, 95% CI 1.12-3.41). Successful complete bile stone removal in patients with SAA depends on the stone diameter and number. Stone recurrence is influenced by the number of stones and history of congenital biliary dilatation.

Obesity and Risk for Incomplete Stone Clearance in Patients with Bile Duct Stones Undergoing ERCP.

Obesity degrades fluoroscopic image quality and could impact on the endoscopic retrograde cholangiopancreatography (ERCP) outcomes. Our study aimed to compare the clinical outcomes and adverse events (AEs) between obese and non-obese patients undergoing ERCP for biliary stone-related conditions. Patients who underwent ERCP for biliary-stone related conditions were included. The analyzed outcomes included the rates of successful bile duct cannulation, incomplete bile duct stone clearance, recurrent bile duct stones, and AEs. A total of 229 patients (116 obese patients and 113 non-obese patients) were included. All patients had successful bile duct cannulation. The rates of incomplete bile duct stone clearance (11.3% vs. 9.0%, P = 0.51), recurrent bile duct stones (1.9% vs. 4.2%, P = 0.24), and AEs (1.8% vs. 0.7%, P = 0.43) were not significantly different between the two groups, respectively. Our study demonstrates no associations between obesity and the rates of incomplete stone clearance, recurrent stones, successful cannulation, or AEs in patients undergoing ERCP for biliary stone-related disease.

DIFFICULT BILIARY CANNULATION: SHOULD WE ALWAYS TRY A SECOND ERCP AFTER A FAILED NEEDLE-KNIFE FISTULOTOMY?

A successful bile duct cannulation is a prerequisite for the realization of endoscopic retrograde cholangiopancreatography (ERCP). When biliary cannulation is not possible, needle-knife fistulotomy (NKF) can be performed. However, when biliary access is not successfully achieved even after performing NKF, it is possible to interrupt the procedure, and repeat the ERCP after a short interval. The aim of this study is to analyze if repeating an ERCP after a short interval of 48 hours is effective in achieving biliary access after an initial NKF was unsuccessfully performed. A total of 1024 patients with a naive papilla, that underwent ERCP between the years of 2009-2019, were retrospectively reviewed. Difficult biliary cannulation was identified in 238 of these cases and NKF was performed. Success of biliary cannulation, NKF success at the first and second ERCPs, the associations between the type of the papilla, biliary dilatation, and overall success of NKF and adverse events rates were evaluated. Biliary access was initially achieved in 183 (76.8%) cases. Of the 55 (23.1%) remaining cases a second attempt was performed after 48 hours, and biliary access was successfully achieved in 46 (83.6%) of them. The overall success of NKF after the first and second ERCP, the success rate was 96.2%. Papilla located out of its normal position was related to a minor chance of success at NKF (P<0.05). We conclude that when biliary access is not achieved after the performance of a NKF, a second attempt is safe and effective and should be attempted.

Quality in Endoscopic Retrograde Cholangiopancreatography—Incidence and Predictive Factors of Adverse Events

Background and AimsIncidence of endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events varies between endoscopy units. We aimed to identify factors related to successful bile duct (BD) cannulation and to determine the incidence and predictive factors of post-ERCP adverse events. MethodsAbout 1103 ERCPs were evaluated from a prospective database over a 4-year period and 57 were excluded: age <18 years; incomplete procedure; surgically altered small bowel anatomy and refusal of informed consent. Factors associated with successful BD cannulation and predictive of post-ERCP adverse events were evaluated. ResultsOut of 1046 ERCPs analyzed, successful cannulation rate of native papilla of Vater was 91.3% (n = 639). Guidewire-assisted BD cannulation and choledocholithiasis were associated with higher native papilla cannulation rates (P = 0.02 and P < 0.001). Malignant biliary stricture and acute gallstone pancreatitis were associated with lower native papilla cannulation rates (P < 0.001 and P = 0.024). The incidence of post-ERCP adverse events was: Pancreatitis (PEP) 2.7% (n = 28), bleeding 0.8% (n = 8), cholangitis 0.7% (n = 7) and perforation 0.5% (n = 5). PEP risk was significantly higher in patients with native papilla compared with non-native papilla (rate of 3.6% and 0.6%, respectively, P = 0.005). In patients with native papilla, ≥2 unintentional pancreatic duct cannulations was the only independent predictive factor associated with PEP (odds ratio 2.371, 95% confidence interval: 1.003-5.605, P = 0.049). ConclusionCholedocholithiasis is associated with a higher cannulation rate while malignant biliary stricture and acute gallstone pancreatitis are associated with a lower BD cannulation rate. Patients with native papilla have a significantly higher risk of PEP with the only factor associated with PEP being 2 or more unintentional pancreatic duct cannulations.

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

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

Complications of Endoscopic Retrograde Cholangiopancreatography in children with Chronic Pancreatitis

A new papillotome has been developed, an isolated-tip needle-knife papillotome (Iso-Tome) that has a semi-oval-shaped tip of epoxide adhesive to prevent electric leakage from the tip of the incising needle. The coated tip aids in keeping the papillotome tightly in the orifice of the ampulla of Vater and is believed to prevent unintentional deep cuts or perforations. This study was done to evaluate the clinical usefulness of the new papillotome for pre-cut papillotomy.From June 2003 to November 2003, 115 patients underwent attempted ERCP. If biliary cannulation failed by the conventional method, pre-cut papillotomy was performed by using the Iso-Tome in the direction of the bile duct. After successful bile-duct cannulation, papillotomy was extended for therapeutic procedures, such as stone removal or stent insertion, in the majority of the cases. Post-ERCP complications were classified according to consensus guidelines.Pre-cut papillotomy with the Iso-Tome was done in 25 patients (21.7% of cases). Protective pancreatic stents were not used. Of these patients, 11 had common bile duct stones, 7 had pancreatitis, 5 had malignancies, one had sphincter of Oddi dysfunction, and one had bile-duct leak. After pre-cut papillotomy with the Iso-Tome, bile-duct cannulation was successfully achieved in 23 of 25 (92%) patients. Complications occurred in 7 of 25 patients (28%) and consisted of mild pancreatitis in 5 (20%), moderate bleeding in one (4%), and biliary pain in one (4%). All 7 patients with complications were managed medically, and there was no death.In this pilot study, the isolated-tip needle knife was found to be a clinically useful papillotome for pre-cut papillotomy. Further large comparative studies (with and without pancreatic protective stents) are needed to determine improved efficacy and safety compared with standard techniques.

PTH-036 Single Centre Experience of The Use of Needle Knife Papillotomy During Difficult ERCP: Is It Safe and Should It Be Used By, and Taught to Trainees

Introduction Despite previous concerns regarding the safety of needle knife papillotomy (NKP) there is data to support its efficacy and safety in the context of increasing bile duct cannulation at ERCP.1 This data predominantly originates from high volume tertiary centres outside the UK. We audited our experiences of using NKP in a secondary care centre where wire-guided cannulation is the standard method for accessing the bile duct and the overall ERCP complication rate is Methods Electronic databases and medical records were interrogated to retrieve data for analysis on all ERCP cases using NKP between 2010–2015. The following data was collected: patient (pt) demographics, indications for ERCP and subsequent complications. Results 1843 ERCP were performed on 1362 pts (817 female (F), 545 male (M), age range (AR) 16–103). NKP was performed in 69 cases (3.7% 37F 32 M, AR 21–98). In the papillotomy cohort indications for ERCP were stone disease (40); stricturing disease (22); others including unexplained pancreatitis (4), bile leak (2), sphincter of Oddi dysfunction (1). Successful bile duct cannulation was achieved during the index procedure in 50 cases (25M 25 F). Of the remaining 19 cases, 11 (5M 6 F) had bile duct cannulation achieved during a repeat procedure via the papillotomy: global success rate 88%. The remaining 6 cases (4F 2 M) were managed with alternative interventions (5 PTC, 1 surgical). NKP was more successful for stone disease: an initial procedure success rate of 73% vs. 64% for non-stone disease, increasing to 95% with repeat procedure. 5/6 (83%) cases requiring alternative interventions had non-stone disease. Complications: 4/69 (5.8%) cases were complicated by pancreatitis; all were managed conservatively with no associated mortality. 3/4 (75%) required hospitalisation for 10 days. There were 4 cases of bleeding (5.8%) with 2/4 (50%) requiring blood transfusion and endoscopic therapy to achieve haemostasis. Perforation occurred in 2 cases (2.8%); both were managed conservatively, 1 case died. Conclusion The global success rate for bile duct cannulation after pre-cut NKP was 88% which supports its efficacy for obtaining bile duct access in otherwise difficult ERCP cases. The overall complication rate of 13% associated with the technique is high, though comparable to other published data. Acknowledgement that NKP may be less fruitful in cases of non-stone related disease may help to guide our practice further, particularly by helping identify cases that may be more appropriate for trainees to tackle. Reference 1 Baillie J. GIE79(5): 2014. Disclosure of Interest None Declared

Precut Papillotomy with Isolated-Tip Needle-Knife Papillotome

In spite of the risk of precutting-related pancreatitis, precut papillotomy is a feasible and valuable technique for enhancing bile duct cannulation when conventional methods using a standard catheter or guidewire failed. The pink intrapapillary mucosa (PIPM) of the ampulla of Vater, which consists of the mucosa of the common channel, bile duct, and pancreatic duct, is an important endoscopic landmark helpful in guiding a successful bile duct cannulation. When precut papillotomy is performed, it is recommended that the PIPM should be exposed as intact as possible and then tracked carefully, instead of hastily performing a blind incision and unintentional attempts at bile duct cannulation. This article is part of an expert video encyclopedia.

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

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

PTU-247 ERCP—can a small volume unit provide a satisfactory service?

IntroductionIn recent years, systems grading ERCP technical difficulty have been introduced in UK clinical practice. According to these, small volume units are advised to refer complex cases to specialised centres....

Contemporary use of endoscopic retrograde cholangiopancreatography (ERCP): A Norwegian prospective, multicenter study

Objective. Novel imaging modalities have supplanted endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of hepatobiliary pancreatic diseases, but the use of ERCP as a diagnostic and therapeutic tool in current clinical practice is not well known. The main objective of this study was to describe and evaluate contemporary use of ERCP in Norway. Material and methods. Prospective and consecutive data were collected between January 2007 and December 2009 from voluntary institutional reports of ERCP activity at participating hospitals in the Gastronet database. Results. A total of 3840 procedures at 14 hospitals were registered during the study period. Data from 3809 procedures (53% females) were available for evaluation. Patients were ≥60 years of age in 2567 (67%) procedures. High co-morbidity (ASA score ≥3) was present in 32% of patients. The main indication for ERCP was evaluation and therapy of bile duct-related disorders. Successful bile duct cannulation was achieved in 93%. Pre-cut sphincterotomy was performed in 5% of procedures, and a guide wire to facilitate duct access was employed in 63%. Sphincterotomy, treatment for common bile duct stones (CBDS), and an insertion or change of bile duct stents were the most commonly employed procedures. Complications occurred in 10% of the patients, with a procedure-related mortality of 1%. Conclusions. In Norway, ERCP is predominantly performed for CBDS and biliary strictures in elderly patients with associated co-morbidity. Patient selection, indications, and procedures are in concert with international guidelines and recommendations. Disease patterns in Norway differ slightly from those observed in central Europe and North America.

Nationwide, population-based data from 11,074 ERCP procedures from the Swedish Registry for Gallstone Surgery and ERCP

The Swedish Registry for Gallstone Surgery and ERCP (GallRiks) is the first nationwide Web-based quality registry for gallstone surgery and ERCP in the world. In this article we report data from 11,074 ERCPs performed in 2007 and 2008. The aim of this study is to present outcomes, safety data, and success rates of ERCPs performed in Sweden. Data gathering from a medical record database. This study reviewed 11,074 ERCPs performed in 2007 and 2008. In GallRiks, data concerning surgery performed for gallstone disease as well as all ERCPs are recorded. The registry is approved by the Swedish Surgical Society and is based on an Internet platform with online data registration. The online program includes 30-day follow-up information as well as the opportunity to retrieve electronic reports on demand. The present data represent 76% of all ERCPs performed in Sweden in 2007 and 95% of those performed in 2008. The database also has been validated, indicating a complete match between the medical records and the database in 97.3% of ERCP cases. Cannulation success and perioperative and postoperative complications. A successful bile duct cannulation was achieved in 92% of the ERCPs performed. The presence of common bile duct stones was the predominant finding and was seen in 36.8% of examinations. Perioperative and postoperative complication rates were 2.5% and 9.8%, respectively. The rate of ERCP-induced pancreatitis was 2.7%, and the total 30-day mortality rate in the database was 5.9% but varied significantly among the different diagnostic groups. The indications for ERCP differed between high-volume and low-volume centers, indicating an adequate referral pattern of complex cases in Sweden. GallRiks registration is voluntary and thus not 100%. This makes selection bias a possibility. ERCP is widely used at Swedish hospitals, with acceptable cannulation success rates and perioperative and postoperative complication rates similar to established standards. GallRiks is a population-based nationwide registry with good data validity and high inclusion rates regarding ERCPs.

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.

Difficult biliary cannulation: use of physician-controlled wire-guided cannulation over a pancreatic duct stent to reduce the rate of precut sphincterotomy (with video)

Successful cannulation of the common bile duct (CBD) remains the benchmark for ERCP. Use of a pancreatic duct (PD) stent to facilitate biliary cannulation has been described, although the majority of patients require precut sphincterotomy to achieve CBD cannulation. To report the performance characteristics of using a PD stent in conjunction with physician-controlled wire-guided cannulation (WGC) to facilitate bile duct cannulation. Retrospective cohort. Two tertiary care, academic medical centers. All undergoing ERCP with native papillae. In cases of difficult biliary access in which the PD is cannulated, a pancreatic stent is placed. After this, physician-controlled WGC is attempted by using the PD stent to direct the sphincterotome into the biliary orifice. If cannulation is unsuccessful after several minutes, a precut sphincterotomy is performed over the PD stent or the procedure is terminated. Frequency of successful bile duct cannulation and precut sphincterotomy. A total of 2345 ERCPs were identified, 1544 with native papillae. Among these, CBD and PD cannulation failed in 16 (1.0%) patients, whereas 76 (4.9%) patients received a PD stent to facilitate biliary cannulation. Successful cannulation was achieved in 71 (93.4%) of 76 patients, 60 (78.9%) of whom did not require precut sphincterotomy. Complications included mild post-ERCP pancreatitis in 4 (5.3%) and aspiration in 1 (1.3%). Precut sphincterotomy was complicated by hemorrhage, controlled during the procedure in 2 (13.3%) of 15. Physician-controlled WGC over a PD stent facilitates biliary cannulation while maintaining a low rate of precut sphincterotomy.

Biliary access in technically difficult biliary cannulation: the mucosal bridge technique

BackgroundThe use of precut sphincterotomy during endoscopic retrograde cholangiopancreatography (ERCP) facilitates selective bile duct access in difficult procedures. However, it is also associated with high rates of complications. Several techniques for precut sphincterotomy have been described in the literature. This paper reports our experience with a non-needle-knife technique for precut sphincterotomy, namely, the mucosal bridge technique. MethodsWe analysed the experience of a single surgical endoscopist at our centre in performing precut sphincterotomies by retrospectively examining information in the database for January 2002 to February 2008, which had been stored prospectively using Endoscribe. ResultsThe mucosal bridge technique was performed in 16 (3.19%) of 501 patients. Success rates were 75% and 100% after first and second ERCPs, respectively. The failure of initial procedures was caused by bleeding, tissue oedema, poorly visualized papilla or a poorly distensible duodenum and oedematous papilla. There were four cases of complications, which included periductular extravasation of contrast, bleeding, and sepsis in two patients. However, these complications were not a direct consequence of the precut sphincterotomy. ConclusionsThe mucosal bridge technique can be used to increase the likelihood of successful bile duct cannulation, thus preventing the need for a second intervention.

Commitment, confirmation, and clearance: new techniques for nonradiation ERCP during pregnancy (with videos)

Symptomatic choledocholithiasis during pregnancy can be treated with ERCP, but fluoroscopy may pose a risk to the fetus. Nonradiation ERCP may be a safer form of treatment, but its performance has not been optimized. The purpose of this study was to evaluate new methods of nonradiation ERCP during pregnancy, including wire-guided cannulation techniques to achieve bile-duct access without the use of fluoroscopy, and the use of peroral choledochoscopy to confirm ductal clearance. A retrospective review of consecutive ERCPs performed on pregnant women. Urban referral hospital. Pregnant women with symptomatic choledocholithiasis. All patients underwent therapeutic ERCP without any use of fluoroscopy. Endoscopist-controlled wire-guided cannulation was performed to achieve biliary access. The rate of successful biliary cannulation and short-term outcomes. ERCP procedures were performed by a single endoscopist. Successful bile-duct cannulation with sphincterotomy and the removal of biliary stones or sludge was performed without fluoroscopy in 21 pregnant women. There was one case of mild post-ERCP pancreatitis. Choledochoscopy confirmed ductal clearance in 5 cases. Nonradiation ERCP is a safe and effective treatment for symptomatic choledocholithiasis during pregnancy. Wire-guided biliary cannulation and choledochoscopy may enhance the performance of ERCP in this setting.

Prospective Study of Operator-Controlled Guidewire Cannulation of the Bile Duct

Bile duct (BD) access during ERCP is usually achieved by contrast injection (CI) and/or assistant-directed guidewire cannulation (GWC). Short wire biliary catheters now allow the operator to control guidewire manipulations during ERCP. The aim of this prospective study was to evaluate the efficiency and safety of operator-controlled GWC when only BD cannulation is intended. Methods: BD cannulation was attempted in all cases using a hydrophilic tipped guidewire controlled by the endoscopist. Contrast was injected after GWC of the BD or when needed to help achieve BD cannulation. Access sphincterotomy (precut) was usually performed if repeated unintentional PD cannulations occurred. Data collected included ERCP indication, BD GWC success and need for CI, unintentional pancreatic duct (PD) GWC or CI, cannulation difficulty, and complications. Cannulation difficulty was graded as: easy (1-4 attempts & < 5 min), moderate (5-10 attempts & < 10 min), difficult, or precut. Results: From 996 ERCPs performed between 5/2004 and 11/2006, 398 patients without prior endotherapy underwent attempted operator-controlled GWC. GWC of only the BD was intended in 223 patients. Indications for ERCP were: abnormal liver tests (n = 135), abnormal intraoperative cholangiogram (n = 43), pain (n = 23), biliary pancreatitis (n = 12), or other (n = 10). Successful BD cannulation was achieved in 220 (99%) cases. GWC of the BD was achieved before any CI in 114 (51%). CI was needed in 48 and precut was performed in 58. Unintentional PD cannulation occurred in 110 (49%) cases with only GWC of the PD in 28 and PD GWC + PD CI in 82. BD cannulation difficulty and post-procedure complication data according to whether the PD was cannulated are found in Tables 1 & 2. One case of mild post-ERCP pancreatitis occurred after operator-controlled unintentional PD GWC without CI. Conclusions: 1) Operator-controlled GWC of the BD is most often easily obtained but unintentional PD cannulation still occurs about half the time. 2) Attempted GWC of the BD is associated with an acceptable risk for post-ERCP complications but is most safe when PD cannulation is completely avoided. Table 1Operator-controlled biliary GWC difficulty according to PD cannulation Cannulation difficulty Easy Moderate Difficult Precut Failed No PD cannulation (n = 113) 85 17 3 7 1 Unintentional PD (n = 110) 19 27 11 51 2 Total (n = 223) 104 44 14 58 3 Open table in a new tab Table 2Post-procedure complications Pancreatitis Perforation Other complications No PD cannulation (n = 113) 0 0 1 (pain) Unintentional PD (n = 110) 5 (4.5%) 1 (0.9%) 1 (bleed) Total ERCP (n = 996) 20 (2%) 7 (0.7%) 21 Open table in a new tab

Pre-cut papillotomy with a new papillotome

A new papillotome has been developed, an isolated-tip needle-knife papillotome (Iso-Tome) that has a semi-oval-shaped tip of epoxide adhesive to prevent electric leakage from the tip of the incising needle. The coated tip aids in keeping the papillotome tightly in the orifice of the ampulla of Vater and is believed to prevent unintentional deep cuts or perforations. This study was done to evaluate the clinical usefulness of the new papillotome for pre-cut papillotomy. From June 2003 to November 2003, 115 patients underwent attempted ERCP. If biliary cannulation failed by the conventional method, pre-cut papillotomy was performed by using the Iso-Tome in the direction of the bile duct. After successful bile-duct cannulation, papillotomy was extended for therapeutic procedures, such as stone removal or stent insertion, in the majority of the cases. Post-ERCP complications were classified according to consensus guidelines. Pre-cut papillotomy with the Iso-Tome was done in 25 patients (21.7% of cases). Protective pancreatic stents were not used. Of these patients, 11 had common bile duct stones, 7 had pancreatitis, 5 had malignancies, one had sphincter of Oddi dysfunction, and one had bile-duct leak. After pre-cut papillotomy with the Iso-Tome, bile-duct cannulation was successfully achieved in 23 of 25 (92%) patients. Complications occurred in 7 of 25 patients (28%) and consisted of mild pancreatitis in 5 (20%), moderate bleeding in one (4%), and biliary pain in one (4%). All 7 patients with complications were managed medically, and there was no death. In this pilot study, the isolated-tip needle knife was found to be a clinically useful papillotome for pre-cut papillotomy. Further large comparative studies (with and without pancreatic protective stents) are needed to determine improved efficacy and safety compared with standard techniques.

Biliary decompression by nasobiliary catheter or biliary stent in acute suppurative cholangitis: A prospective randomized trial

Background: Endoscopic drainage has replaced emergent surgery for biliary decompression in patients with acute cholangitis. The aim of this study was to prospectively compare the efficacy of the nasobiliary catheter and indwelling stent as temporary measures for biliary decompression in acute suppurative cholangitis caused by bile duct stones. Methods: Over a 60-month period, 79 patients with acute cholangitis who required emergent endoscopic drainage were recruited. Indications for urgent drainage included any one of the following: temperature greater than 39°C, septic shock with systolic blood pressure less than 90 mm Hg, increasing abdominal pain, and impaired level of consciousness. Patients who had previously undergone sphincterotomy or had coexisting intrahepatic duct stones were excluded. After successful bile duct cannulation, patients were randomized to receive either a nasobiliary catheter or indwelling stent without sphincterotomy for biliary decompression. Outcome measures included procedure time, complications, clinical response, and patient discomfort (scored with a 10-cm, unscaled visual analog score). Results: Of the 79 patients, 5 were excluded because of previous sphincterotomy and intrahepatic duct stones, 40 were randomized to receive a nasobiliary catheter (NBC group), and 34 to receive indwelling stent (stent group). Demographic data were similar between the groups. All procedures were successful in the NBC group; there was one failure in the stent group. The mean (SD) procedure time was similar (NBC group 14.0 [9.3] minutes vs. stent group 11.4 [7.2] min). There were 2 ERCP-related complications in the NBC group. Four patients pulled out the nasobiliary catheter and one catheter became kinked. One stent occluded. There was a significantly lower mean (SD) patient discomfort score on day 1 after the procedure in the stent group (stent group 1.8 [2.6] vs. NBC group 3.9 [2.7]; p = 0.02 t test). The overall mortality rate was 6.8% (2.5% NBC group vs. 12% stent group). Conclusion: Endoscopic biliary decompression by nasobiliary catheter or indwelling stent was equally effective for patients with acute suppurative cholangitis caused by bile duct stones. The indwelling stent was associated with less postprocedure discomfort and avoided the potential problem of inadvertent removal of the nasobiliary catheter. (Gastrointest Endosc 2002;56:361-5.)

7243 Endoscopic retrograde cholangiopancreatography (ercp) in roux-en-y anastomosis or whipple surgery patients: eight-year experience from a large tertiary care center.

Reaching major papilla and performing cannulation of the pancreatic and bile duct in the setting of Roux-en-Y anastomosis or Whipple surgery is considered one of the most technically challenging anatomic variants in patients (pts) with symptomatic pancreaticobiliary disease. AIM: To describe eight-year ERCP experience in Roux-en-Y anastomosis or Whipple surgery pts from a large tertiary care center. METHODS: Nineteen consecutive pts (10-male, 9-female, age range 38-79) with Rouxen-Y anastomosis or Whipple surgery presented over a eight-year period had an attempted ERCP. Thirteen (70%) of pts had Roux-en-Y anastomosis while 6 pts had undergone Whipple surgery. Indications for ERCP were obstructive jaundice (n=5), cholangitis (n=3), suspected choledocholithiasis (n=5), abdominal pain (n=3), dilated pancreatic duct (n=2), and chronic pancreatitis (n=1). RESULTS: Successful bile duct cannulation could be achieved in only 8 (47%) of the 17 pts. Six out of 13 (46%) Roux-en-Y anastomosis pts had successful ERCP (5 of 6 with the use of diagnostic duodenoscope),while only 2 out of 6 (33%) Whipple surgery pts had successful ERCP. Major papilla could not be reached in 8 pts (88%) in whom ERCP was unsuccessful. In one patient with Whipple surgery a pancreatogram could not be obtained because of inability to locate enteropancreatic anastomosis. Two Roux-en-Y anastomosis pts who had successful cannulation, common bile duct stones were removed, one patient with Whipple surgery had a plastic stent placed across a choledochojejunostomy stricture, one patient with a Roux-en-Y anastomosis underwent sphincter of Oddi manometry and in one Roux-en-Y anastomosis patient a plastic stent was placed in an occluded wallstent. Diagnostic duodenoscope was the most commonly used instrument (n=11), followed by pediatric colonoscope (n=7). One patient had a small intestinal perforation requiring surgery. All pts with obstructive jaundice and cholangitis (n=5) who had unsuccessful ERCP underwent subsequent successful percutaneous transhepatic biliary drainage. Conclusions: Success rate in performing ERCP in Roux-en-Y anastomosis or Whipple surgery pts is low despite a high level of endoscopic expertise. Both side viewing duodenoscopes and forward viewing colonoscopes can be used in an attempt to reach the major papilla in pts with Roux-en-Y anastomosis, although the instrument of choice remains the former.