Wire-guided Biliary Cannulation Research Articles

A novel concept of passive loop-forming wire-guided biliary cannulation using an ultra-deep angled tip guidewire (with video).

Background and study aims Wire-guided biliary cannulation (WGBC) is a standard technique during endoscopic retrograde cholangiopancreatography-related interventions. However, no dedicated guidewire is available. We investigated a novel "passive loop-forming WGBC" concept using a 0.035-inch ultra-deep angled tip guidewire. Patients and methods This single-arm, single-center, retrospective study included consecutive 111 patients who underwent passive loop-forming WGBC as the first biliary intervention between October 2021 and December 2022. Results WGBCs were completed within 5 minutes and overall were performed at a median papillary negotiation time of 81 seconds (interquartile range [IQR], 39-170) and 114 seconds (IQR, 49-303) in 83 (74.8%) and 106 (95.5%) cases, respectively. Logistic regression analysis identified age ≥ 80 years (odds ratio [OR]: 3.56, 95% confidence interval [CI]: 1.12-11.31) and unintentional pancreatic guidewire insertion (OR: 17.67, 95% CI: 5.75-54.31) as significant risk factors for failed WGBC within 5 minutes. Among the 106 obtained cannulations, the guidewire leading part formed a small-looped tip and wide-looped body in 83 (78.3%) and 23 (21.7%) cases, respectively. Adverse events included post-procedure pancreatitis (2/111 [1.8%]) and guidewire penetration (3/111 [2.7%]). Conclusions Passive loop-forming WGBC using an ultra-deep angled tip guidewire is a feasible procedure.

Wire-guided biliary cannulation: a comprehensive approach to a set of techniques.

Biliary cannulation represent a challenge for the endoscopists that approach to endoscopic retrograde cholangiopancreatography, with non-negligible rate of failure even in expert hands. In order to achieve the biliary tree, two main technique are nowadays mainly used, namely the contrast-assisted cannulation and the wire-guided cannulation (WGC) techniques. The WGC technique is widely used because it seems to be related to higher success rate of cannulation of the common bile duct and, at the same time, to lower rates of complications. Particularly, this approach is associated with lower risk of post endoscopic retrograde cholangiopancreatography pancreatitis, although the pathogenesis of this adverse event is still not completely understood. The outspread of this technique among endoscopists promoted the development of different methods of performing WGC-assisted endoscopic retrograde cholangiopancreatography, such as the touch technique, the no-touch technique and the double guide-wire cannulation. Furthermore, the variety of guide wires and accessories, with their different characteristics, contribute to make the scenario extremely heterogeneous. To date, the published studies did not highlight which is the best strategy that maximizes the rate of success and minimizes the percentage of complications, even because the experience of the operator represents an important variable that conditions the outcomes. The aim of this review is to define state of the art in WGC technique, in order to better understand the possible advantages in using this approach and to bring to light the possible area that may be object of further studies.

The impact of wire caliber on ERCP outcomes: a multicenter randomized controlled trial of 0.025-inch and 0.035-inch guidewires

Wire-guided biliary cannulation has been demonstrated to improve cannulation rates and reduce post-ERCP pancreatitis (PEP), but the impact of wire caliber has not been studied. This study compares successful cannulation rates and ERCP adverse events by using a 0.025-inch and 0.035-inch guidewire. A randomized, single blinded, prospective, multicenter trial at 9 high-volume tertiary-care referral centers in the Asia-Pacific region was performed. Patients with an intact papilla and conventional anatomy who did not have malignancy in the head of the pancreas or ampulla and were undergoing ERCP were recruited. ERCP was performed by using a standardized cannulation algorithm, and patients were randomized to either a 0.025-inch or 0.035-inch guidewire. The primary outcomes of the study were successful wire-guided cannulation and the incidence of PEP. Overall successful cannulation and ERCP adverse events also were studied. A total of 710 patients were enrolled in the study. The primary wire-guided biliary cannulation rate was similar in 0.025-inch and 0.035-inch wire groups (80.7% vs 80.3%; P= .90). The rate of PEP between the 0.025-inch and the 0.035-inch wire groups did not differ significantly (7.8% vs 9.3%; P= .51). No differences were noted in secondary outcomes. Similar rates of successful cannulation and PEP were demonstrated in the use of 0.025-inch and 0.035-inch guidewires. (Clinical trial registration number: NCT01408264.).

A prospective randomized study of loop-tip versus straight-tip guidewire in wire-guided biliary cannulation.

Wire-guided cannulation has been widely accepted as a useful technique for achieving selective biliary access because it has significantly increased the success rate of biliary cannulation compared with conventional contrast-assisted cannulation. Unlike conventional guidewires with a straight tip, a loop-tip guidewire (LGW) has a closed distal loop that may facilitate less traumatic access through the epithelial folds of the intra-duodenal biliary segments. The aim of this study was to compare the performance of a LGW with a straight-tip guidewire (SGW) in achieving successful selective biliary cannulation. From December 2014 to December 2015, we performed 192 wire-guided biliary cannulations for a naïve papilla in a randomized controlled trial. Patients were randomly assigned to the LGW group (n=96) or the SGW group (n=96). Our study protocol did not include crossover to the other guidewire arm if randomized wire-guided cannulation proved unsuccessful within the first 10min. There was no significant difference in primary successful biliary cannulation between the two groups (LGW group: 86.5%; SGW group: 77.1%; p=0.134). The rate and the mean number of unintentional pancreatic duct cannulations during wire-guided biliary cannulation were significantly lower in the LGW group than in the SGW group (LGW group: 14.6%; SGW group: 28.1%; p=0.034; LGW group: 0.2±0.5; SGW group: 0.6±1.3; p=0.007). Post-ERCP pancreatitis developed in 5.2% of patients in the LGW group and 8.3% of patients in the SGW group (p=0.567). The biliary cannulation rate of the LGW was not significantly different from those of conventional guidewires. Use of the LGW was associated with a lower rate of unintentional pancreatic duct cannulation during wire-guided biliary cannulation than use of the SGW.

The efficiency of different biliary cannulation in endoscopic retrograde cholangiopancreatography: a meta-analysis

Objective: To compare the success rates of wire-guided biliary cannulation (WGC) and conventional cannulation (CC) and their effect on the outcome of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Methods: All randomized controlled trials (RCTs) were collected by searching CNKI, WanFang Data, CBM, PubMed, Embase and Cochrane Library.The assessment of methodological quality and data extraction of the included studies were performed independently by two reviewers. Meta-analysis was conducted with RevMan 5.2 software. Results: Ten RCTs, with a total of 3 262 patients enrolled, were retrieved.Meta-analysis demonstrated that WGC had a higher success rate(RR=1.04, 95%CI 1.01-1.06, P<0.01)and a lower risk of PEP after cannulation (RR=0.54, 95%CI 0.41-0.71, P<0.01). The main reason for the lower risk of PEP was due to lower proportion of mild PEP patients after WGC(RR=0.52, 95%CI 0.36-0.73, P<0.01), while the incidence of modest and severe PEP was comparable in the two groups(modest group: RR=0.84, 95%CI 0.43-1.64, P=0.61; severe group: RR=0.53, 95%CI 0.22-1.31, P=0.17). Conclusion: WGC may increase the success rate of cannulation and reduce the incidence of PEP because of less complications of mild PEP.

A modern approach to ERCP: maintaining efficacy while optimising safety.

Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging and complications such as post-ERCP pancreatitis (PEP) remain a concern. Modern ERCP techniques aim to maintain efficacy and improve safety. There are limited data regarding efficacy and safety of ERCP carried out by a newly qualified practitioner using modern techniques. The aim of the present study was to conduct an ERCP practice audit and compare it with an Australian national survey in order to review the evidence base underlying modern ERCP practice. All ERCP carried out by a newly qualified practitioner, using prospectively collected data, from September 2011 to May 2015, were audited. Outcomes were compared to an Australia-wide survey of ERCP practice. A literature review was carried out regarding recent developments in ERCP practice. Audit results correlated well with national data. All 478 ERCP were therapeutic and had pre-procedure imaging. Wire-guided biliary cannulation was used. Success rate was 97%. Overall adverse-event rate was 0.8%. Choledocholithiasis was the predominant indication (72%). Biliary cannulation was successful in 338 of 348 naiive papillae. Of these, there were 53 (16%) difficult cannulations but the needle-knife sphincterotomy (NKS) rate was low compared to national data (13% vs 33%). Rate of dual-wire cannulation technique was higher (87% vs 30%). Pancreatic duct stenting (done in 32 cases [70% of dual-wire cannulation cases]) and rectal indomethacin (25%) were used to reduce PEP risk. A newly qualified ERCP proceduralist achieved high success rates with minimal adverse events using modern techniques. Practice was consistent with national data, although dual-wire cannulation technique was preferred to NKS. Evidence base for modern ERCP techniques was reviewed. ERCP efficacy and safety should be monitored by practice audit.

Comparison between loop-tip guidewire-assisted and conventional endoscopic cannulation in high risk patients.

Background: The guidewire biliary cannulation (GWC) technique may increase the cannulation rate and decrease the risk for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. The aim of our multicenter prospective randomized controlled trial was to determine if the use of an atraumatic loop-tip guidewire reduces the rate of post-ERCP pancreatitis (PEP) compared with the standard contrast-assisted cannulation (CC) technique. Methods: From June 2012 to December 2013, a total of 320 patients who had a naïve papilla and were referred for ERCP were randomly assigned to the GWC group (n = 160) or the CC group (n = 160). GWC or CC was randomly used. In cases of failed cannulation in both arms after crossover, biliary access was attempted with alternative techniques (e. g., dual-wire technique, pancreatic duct stenting, precut). Results: The biliary cannulation rates were 81 % in the GWC group and 73 % in the CC group (P = n. s.). Following crossover, cannulation was successful in 8 % and 11 % of patients in the GWC and CC groups, respectively. With use of an alternative technique, the cannulation rates were 98 % in the GWC group and 96 % in the CC group, respectively. The rates of PEP were 5 % in the GWC group and 12 % in the CC group (P = 0.027). The post-interventional complication rates did not differ between the two groups. Conclusion: GWC with the new wire guide is associated with a lower rate of PEP in comparison with the CC technique.Clinical trial reference number: NCT01771419

Early 'shallow' needle-knife papillotomy and guidewire cannulation: an effective and safe approach to difficult papilla.

Needle-knife sphincterotomy (NKS), known as 'precut', is used worldwide to facilitate access to the common bile duct when standard cannulation has failed. This procedure is considered hazardous because it is burdened with high procedural related complications (bleeding and perforation). Its right timing is still debated. In this study we report our results using a modified precut approach, early shallow needle-knife papillotomy (eSNKP) coupled with guidewire cannulation in case of difficult papilla. We evaluated its safety and effectiveness. From 2012 to 2014, 1034 patients underwent therapeutic ERCP. A total of 138 of them presented difficult papilla and were treated with eSNKP performed after 5 failed attempts of standard guidewire cannulation. Deep biliary cannulation rate was recorded, as well as intraoperative and postoperative complication rate. Successful biliary deep cannulation was achieved in 132/138 patients (95.7%) by means of eSNKP. In 6 patients (4.3%), cannulation failed even after eSNKP. ERCP was newly performed 72 hours later with successful and immediate guidewire biliary cannulation. Overall morbidity was 10.1% (14/138). No perforation occurred. Minor bleeding occurred in 4/138 cases (2.9%) and 10/138 patients (7.2%) developed mild pancreatitis. In case of difficult papilla, eSNKP followed by guidewire cannulation increases the successful deep biliary cannulation with low rate of complications.

Su1639 Comparison of the Wire-guided Biliary Cannulation Using J-Tip and Angled-Tip Guidewire: a Prospective Multi-Center Controlled Study, the Jangle Study

Wire-guided cannulation (WGC) has become common as a biliary cannulation technique, and guidewires with various shapes of the tip (such as straight and angled tips) and materials (hardness) have been used for WGC. However, there have been apparently no reports indicating that the biliary cannulation rate changes depending on the type of guidewire used. Recently, the J-tip guidewire (JGW) has become commercially available and the biliary cannulation rate is thus expected to increase. We performed a prospective, multi-center, controlled study, and evaluated the effectiveness of JGW in biliary cannulation.

Wire‐guided biliary cannulation technique does not reduce the risk of post‐ERCP pancreatitis: Multicenter randomized controlled trial

To evaluate the effect of wire-guided biliary cannulation (WGC) on the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). We investigated the impact of the WGC technique on the incidence of PEP by comparing the conventional cannulation (CC) technique in selective bile duct cannulation during ERCP with a cross-over design in a prospective multicenter randomized controlled trial and the potential risk factors for PEP. This involved six tertiary referral centers and three university hospitals. A total of 322 patients with indications for ERCP requiring selective biliary cannulation were enrolled from April 2008 to March 2009. One hundred and sixty-three patients were assigned to the WGC group and 159 to the CC group. The incidence of PEP was the same between the groups (6.1% vs 6.3%, P = 0.95). Primary successful biliary cannulation was achieved in 136 patients (83%) in the WGC group and in 138 (87%) in the CC group (P = 0.40). The mean time required for primary successful biliary cannulation was 7.4 ± 8.3 min and 7.2 ± 7.9 min, respectively (P = 0.83). Multivariate analysis demonstrated that accidental guidewire insertions and unintended injections of contrast into the main pancreatic duct were the only independent risk factors for PEP (P = 0.001, relative risk [RR]: 8.70, 95% confidence interval [CI]: 2.46-30.81). The WGC technique does not reduce the risk of PEP and also does not improve the success rate of selective bile duct cannulation.

Guidewire biliary cannulation does not reduce post-ERCP pancreatitis compared with the contrast injection technique in low-risk and high-risk patients

Guidewire (GW) cannulation can reduce the risk of post-ERCP pancreatitis (PEP) by avoiding the opacification of the main pancreatic duct. To compare the effects of conventional contrast ERCP and GW cannulation of the common bile duct on the rate of PEP in low- and high-risk patients. Prospective, comparative-intervention single-center study. Tertiary referral center. Patients with biliary disease with an intact papilla were prospectively examined by ERCP. Biliary cannulation using a sphincterotome with contrast injection (ConI) or a hydrophilic GW without contrast injection. Pancreatitis rate in the GW group and the contrast injection (ConI) group. PEP occurred in 60 of 1249 patients (4.8%), 35 of 678 (5.2%) in the GW group and 25 of 571 (4.4%) in the ConI group (not significant). The overall rate of PEP was significantly higher in high-risk patients (12.2%) than in low-risk patients (3.5%) (P < .001), but was similar for the 2 techniques within each of these 2 groups. In patients with unintended main pancreatic duct (MPD) cannulation or opacification, the rate of PEP was not significantly different with the GW (15.2%) and ConI (8.4%) techniques but was associated with a significantly higher rate of pancreatitis (11.9%) than in patients in whom the contrast medium or GW did not enter the MPD (3.5%) (P < .001). Multivariate analysis indicated that more than 10 papillary cannulation attempts, MPD cannulation or opacification, suspected sphincter of Oddi dysfunction, and precut methods were significant risk factors independently associated with PEP. Lack of randomization. For selective cannulation of the CBD, the risk of inducing PEP is similar with the ConI and GW techniques in high-risk and low-risk patients. Any manipulation of the MPD must be considered a high-risk factor for PEP, such as multiple attempts on the papilla or use of the precut method.

Wire-guided biliary cannulation should be considered to be standard practice

Wire-guided biliary cannulation should be considered to be standard practice

Difficult Biliary Cannulation: Use of Physician Controlled Wire-Guided Cannulation Over a Pancreatic Duct Stent to Reduce the Rate of Precut Sphincterotomy

Background: Successful cannulation of the common bile duct (CBD) remains the benchmark for endoscopic retrograde cholangiopancreatography (ERCP). Difficult cannulation, particularly with the use of precut sphincterotomy, has been shown to be a risk factor for post-ERCP pancreatitis. While use of a pancreatic duct (PD) stent to facilitate biliary cannulation has been described, the majority of patients required precut sphincterotomy to achieve CBD cannulation. We report the performance characteristics of this technique in conjunction with physician controlled wire-guided biliary cannulation to minimize the need for precut. Methods: We performed a retrospective, cohort analysis of ERCPs performed by two experienced endoscopists at independent medical centers. Both endoscopists routinely use a PD stent to facilitate biliary cannulation prior to resorting to a precut sphincterotomy and to reduce the risk of post ERCP pancreatitis. All patients with native papillae undergoing ERCP between January, 2006 and April, 2008 were included. Routine cannulation and failure to cannulate either the PD or CBD were excluded. In cases of difficult biliary access where the PD is cannulated, a soft, 5Fr pancreatic stent is left in the PD without performing a pancreatic sphincterotomy. Following this, physician controlled wire-guided biliary cannulation is attempted 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. We reviewed medical records to determine rates of PD stent placement to facilitate biliary cannulation as well as rate of precut sphincterotomy. Outcomes included biliary cannulation rate, frequency of precut sphincterotomy, and incidence of procedure-related complications. Results: 2,345 ERCPs were identified, 1,544 with native papillae. Among these, CBD and PD cannulation failed in 16 (1.0%), while 76 (4.9%) patients received a PD stent to facilitate biliary cannulation. Successful cannulation was achieved in 71 of 76 (93.4%) 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 of 16 (12.5%). Conclusions: Physician controlled wire-guided cannulation over a PD stent facilitates biliary cannulation and significantly reduces the rate of precut sphincterotomy. Future studies should compare the use of a PD stent with other noninvasive techniques to promote safe and effective biliary cannulation.

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.

Primary precutting versus conventional over-the-wire sphincterotomy for bile duct access: a prospective randomized study

Precut is a well-known technique that is used if repeated attempts at common bile duct (CBD) cannulation fail. Opinions on the complication rate of precut are conflicting, however. The aim of the present study was to compare the efficacy and complication rate of precut used as a primary method of CBD access with the efficacy and safety of the conventional technique. During the 19-month study period, consecutive patients who were scheduled for first-time endoscopic sphincterotomy (ES) for a variety of biliary disorders were randomized into two groups: patients in group A underwent conventional wire-guided biliary cannulation followed by ES (with precut being performed only when this failed); in patients in group B precut was used as a primary technique to gain biliary access, followed by wire-guided ES. We used a specially designed, modified Erlangen type of sphincterotome for precutting. A total of 291 patients (100 men, 191 women; mean +/- SD age 65 +/- 17.5 years) were recruited: 146 patients were assigned to group A (conventional approach) and 145 to group B (primary precut approach). The indications for ES were comparable in the two groups. In group A, wire-guided cannulation of the CBD failed in 42 patients. Secondary precut was successful in 41 of these patients, leading to an overall success rate of 99.3 %. In group B, the ES success rate using primary precut was 100 % at the first attempt. The mean time to successful deep CBD cannulation was 8.3 +/- 2.1 minutes in group A and 6.9 +/- 1.8 minutes in group B ( P < 0.001). The incidence of mild to moderate pancreatitis was similar in the two groups (2.9 % in group A vs. 2.1 % in group B, P > 0.05). Mild bleeding occurred in only one patient (from group A) and this was controlled by epinephrine injection. None of the study patients developed severe pancreatitis or perforation. In experienced hands, an approach using primary precut appears to be at least as successful and safe as a conventional approach using guide-wire-based CBD cannulation followed by ES, and might also be a quicker method.