Outcome of precut sphincterotomy compared to standard cannulation techniques in ERCP with difficult cannulation

An assessment of the learning curve for precut biliary sphincterotomy

It is unclear which is the best strategy for difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP). We compared the different techniques, through a network meta-analysis combining direct and indirect comparisons. We identified 12 randomized controlled trials (1605 patients) comparing different techniques for difficult biliary cannulation (early and late needle knife techniques, pancreatic guidewire- and stent-assisted techniques, transpancreatic sphincterotomy, and endoscopic ultrasound rendez-vous [EUS-RV]) either with each other or with persistence with the standard cannulation techniques. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) were the primary outcomes. Only transpancreatic sphincterotomy significantly outperformed pancreatic stent assisted cannulation (risk ratio [RR] 1.33, 1.00-1.55), whereas no difference was observed among the other techniques in terms of cannulation success. SUCRA ranking suggested EUS-RV and early needle knife techniques as the best performing approaches (SUCRA 0.78 and 0.68, respectively). In terms of PEP rate, only EUS-RV significantly outperformed pancreatic guidewire-assisted techniques (RR 0.21, 0.04-0.98). Based on low quality of evidence, the several techniques for difficult biliary cannulation show similar results although a trend in favour of needle knife techniques and EUS-RV was observed. EUS-RV seems to decrease the risk of PEP.

Needle Knife Sphincterotomy Does Not Increase the Risk of Pancreatitis in Patients With Difficult Biliary Cannulation

Introduction: In 6-10% of endoscopic retrograde cholangiopancreatographies (ERCPs), biliary cannulation (BC) is unsuccessful. In these cases with difficult BC, other cannulation techniques, such as the double guidewire technique (DGT), may be required. In the DGT, a guidewire is placed deep into the pancreatic duct, then alongside this guidewire a sphincterotome loaded with another guidewire is used for BC. The aim of the present study was to evaluate the usefulness of DGT for difficult biliary cannulation after unsuccessful biliary cannulation, using a cannula/sphincterotome under guidance of injected contrast with P-GW. Methods: A total of 652 ERCP were studied at three centers in Guayaquil, Ecuador from October 2013 to May 2017. In total, 143 patients with difficult biliary cannulation who underwent SGT were included in this retrospective study. DGT was carried out if SGT was unsuccessful. Pancreatic duct (PD) stenting was attempted to prevent post-ERCP pancreatitis (PEP) in all patients. The success rate of cannulation and the risk factors for PEP were investigated. Results: Biliary cannulation with SGT was achieved in 70%. DGT was carried out in 143 patients with unsuccessful SGT, biliary cannulation being successful in 72 %( 103 patients). Of the 11 patients who underwent precut sphincterotomy, biliary cannulation was achieved in 52%. The incidence of PEP in patients who had undergone SGT, DGT, and precut sphincterotomy was 8% (12: mild, 8; moderate, 3; severe, 1), 4% (mild, 1), and 0%, respectively. PD stenting was successfully carried out in 86%. Multivariate analysis revealed unsuccessful PD stenting to be the only risk factor for PEP (OR 8.3, 95% CI 2.3-30). Conclusion: The DGT can be used as an alternative to other cannulation techniques in difficult BC with similar success rates. However, the higher risk of PEP with the DGT may prohibit its widespread use. Further studies on whether this higher risk is due to the technique itself or other factors such as a pancreatic duct stent are required.

GoalsOur study aims to define success and complication rates of precut sphincterotomy with the needle-knife and transpancreatic papillary septotomy (TPS) techniques as experienced at a single, high-volume endoscopy centre.BackgroundComplication rates...

The interval between extracorporeal shock-wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) may cause differences in cannulation and stone removal. This study was to investigate the optimal timing of ERCP after ESWL. Patients with chronic calcified pancreatitis, who underwent ESWL and subsequent ERCP in Changhai Hospital from February 2012 to February 2015, were retrospectively analyzed. The interval between ESWL and ERCP was used to divide patients into groups A (<12 hours), B (12-36 hours), and C (>36 hours). Cannulation success, stone clearance, and post-ESWL/ERCP complications were compared. A total of 507 patients were enrolled. There were no significant differences regarding the successful cannulation and stone removal rates between the 3 groups. In patients without prior ERCP, the successful cannulation rates were 71.4%, 81.9%, and 90.9% (P = 0.004), and the successful clearance rates were 76.2%, 85.1%, and 90.9% (P = 0.031) for these 3 groups, respectively, showing significant differences. There were no differences in the successful cannulation and stone extraction rates for patients with prior ERCP. The interval between ESWL and ERCP in chronic calcified pancreatitis patients with prior ERCP is not relevant, while delaying endoscopic intervention is recommended in those with native papilla.

Selective biliary cannulation is a difficult part of endoscopic retrograde cholangiopancreatography (ERCP). Therefore, endoscopists have focused on how to improve the cannulation success rate and reduce the postoperative complication rate. This study aims to provide practical advice on safe operation for endoscopists. Data from the ERCP database of our medical center from January 2008 to December 2017 were retrospectively reviewed. All patients underwent ERCP for the first time. Data pertaining to diseases, anatomic factors, difficult cannulation rates, cannulation success rates, and postoperative complication rates for various assistive cannulation techniques were analyzed by using the Pearson χ2 tests and Fisher exact tests. The difficult cannulation rate was 8.1%. The main influencing factors were benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy. The postoperative complication rates and overall cannulation success rates of 7 assistive techniques were not statistically different (P>0.05), but the overall complication rates were statistically different (P<0.05). Needle-knife precut sphincterotomy had the highest rate of complications. Benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy were the main factors of difficult selective biliary cannulation. The overall incidence of needle-knife precut sphincterotomy complications was higher than that of other techniques, but various assistive techniques were safe and effective in our single center.

Background and study aims Difficult cannulation is a risk factor for pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). The double-guidewire technique (DGT) may improve cannulation success and reduce the risk of post-ERCP pancreatitis (PEP) in patients with difficult cannulation. This systematic review compared the DGT with persistent conventional cannulation or other advanced techniques in patients with difficult cannulation. Patients and Methods CENTRAL, MEDLINE, EMBASE, and CINAHL databases and DDW and UEGW abstracts up to March 2016 were searched for randomized controlled trials (RCTs) comparing DGT with persistent conventional cannulation or other advanced techniques (precut, pancreatic duct [PD] stenting). The primary outcome was PEP. Secondary outcomes included severity of PEP, successful cannulation of the common bile duct (CBD) with the randomized technique, overall CBD cannulation success, and ERCP-related complications. Results 7 RCTs (577 patients) were included. Use of the DGT significantly increased PEP compared to other endoscopic techniques (risk ratio [RR] 1.98, 95 % confidence interval [95 %CI] 1.14 - 3.42). There was no significant difference in CBD cannulation success with the randomized technique (RR 1.04, 95 %CI 0.87 - 1.24) or in overall cannulation success (RR 1.04, 95 %CI 0.91 - 1.18) between DGT and other techniques. There was also no significant difference in the risk of other ERCP-related complications (bleeding, perforation, cholangitis, and mortality). The results were robust in sensitivity analyses. Conclusions In patients with difficult cannulation, sole use of the DGT appears to increase the risk of PEP without any superiority in achieving biliary cannulation compared to other techniques. PD stenting may reduce the risk of PEP when the DGT is used. The influence of co-intervention in the form of per-procedural nonsteroidal anti-inflammatory drug (NSAID) administration is unclear.

Precut sphincterotomy is a technique usually employed for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of bile duct disease. It is a validated risk factor for post-ERCP pancreatitis (PEP), but it is not clear whether the risk is related to the technique itself or to the repeated biliary cannulation attempts preceding it. The primary aim of the study was to assess the incidence of PEP in early precut compared with the standard technique in patients with difficult biliary cannulation. Secondary aims were to compare complications and cannulation success. In this prospective, multicenter, randomized, clinical trial, patients who were referred for therapeutic biliary ERCP and difficult biliary cannulation were randomized to early precut (Group A) or repeated papillary cannulation attempts followed, in cases of failure, by late precut (Group B). PEP was defined as the onset of upper abdominal pain associated with an elevation in serum pancreatic enzymes of at least three times the normal level at more than 24 hours after the procedure. No rectal indomethacin or diclofenac was used for prevention of PEP. A total of 375 patients were enrolled. PEP developed in 10 of the 185 patients (5.4 %) in Group A and 23 of the 190 (12.1 %) in Group B (odds ratio [OR] 0.35; 95 % confidence interval [CI] 0.16 - 0.78). The incidence of PEP was significantly lower in the early precut group (10/185, 5.4 %) than in the delayed precut subgroup (19/135 [14.1 %]; OR 0.42, 95 %CI 0.17 - 1.07). There were no differences in biliary cannulation success rates, bleeding, perforation, and cholangitis. In patients with difficult biliary cannulation, early precut is an effective technique and can significantly reduce the incidence of PEP. Repeated biliary cannulation attempts are a real risk factor for this complication.

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

Even in experienced hands, a common problem with endoscopic retrograde cholangiopancreatography (ERCP) is difficulty reaching a deep biliary cannulation. The most recent alternative method for difficult biliary cannulation is the double-guidewire technique. The current prospective study aimed to clarify the feasibility and safety of the double-guidewire-assisted biliary cannulation at the authors' institution. All consecutive patients (n=284) admitted for biliary ERCP during 2009 who had unhindered access to a native papilla were included in the study. The application and success rates of the double-guidewire method for deep biliary cannulation and the complications of ERCP procedures using the double-guidewire technique were determined. The overall success rate for biliary cannulation in these cases also was determined, and the times from the first touch to the papilla to deep biliary cannulation and for the entire ERCP procedure were recorded. The double-guidewire-assisted cannulation technique was applied in 18% (50/284) of ERCPs with a success rate of 66% (33/50). In these 50 cases, the overall success rate for biliary cannulation was 98% (49/50). The median cannulation time was 8 min, and the median duration of the entire ERCP procedure was 20 min. The rate of post-ERCP pancreatitis was 2% (1/50). The double-guidewire technique is a feasible and safe method for difficult biliary cannulation with low rate of post-ERCP pancreatitis. However, it seems important to proceed to alternative cannulation techniques if the double-guidewire technique appears troublesome.

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the standard treatment for bile duct stones (BDS). While reported success rates often exceed 80%, the literature rarely distinguishes between success at the index ERCP and cumulative success across multiple procedures. Moreover, definitions of ERCP success vary significantly. This study evaluates the index ERCP's success rates according to pre-defined criteria. A retrospective review of all ERCPs performed for BDS before cholecystectomy at University Hospitals Plymouth (2009-2023). Primary outcomes included bile duct clearance at index ERCP, post-procedural complications, stone recurrence, and mortality. A total of 1,436 patients, median age 72years (20-94), underwent 1853 ERCPs for BDS. The bile duct cannulation and clearance rates were 93.5% and 70.9%, respectively. The main reasons for procedure failure were incomplete stone removal (12.3%) and anatomical challenges (7.1%). Among the cohort, 22.8% required repeat ERCPs. The complication rate was 4.8% (pancreatitis = 1.7%, biliary sepsis = 1.5%, bleeding = 1.3% and perforation = 0.4%). The BDS recurrence rate was 9.8% and the median time to recurrence was 7months (1-112). On multivariate analysis, male sex was the only risk factor for stone recurrence (OR:2.242,95%CI:1.304-3.853, P = 0.003). All patients with post-ERCP complications were admitted to the hospital, and their median hospital stay was seven days (1-306). The 90-day mortality rate was 2.1%. In our study, index ERCP achieved stone clearance in 70.9% of cases, with a quarter of patients needing a repeat procedure. Patients should be appropriately consented to and informed of the success rate of ERCP and alternative treatment options, such as intraoperative imaging followed by bile duct exploration and cholecystectomy for surgically fit patients.

Several variables have been studied to predict difficult cannulation during endoscopic retrograde cholangiopancreatography (ERCP), but none have been identified that can effectively predict this difficulty and help make decisions to prevent complications. To determine whether endoscopic variables of the duodenal papilla, as well as the sign of bile aspiration, are associated with difficult cannulation during ERCP. A prospective and analytical study that included 203 patients who underwent ERCP, establishing an association between the type of duodenal papilla, location, presence of periampullary diverticulum and the sign of bile aspiration, and difficult cannulation. 140 (69.97%) women and 63 (31.03%) men were included, with an average age of 54.35 years. Difficult cannulation criteria were present in 32.51% of patients. Type 1 duodenal papilla had a lower rate of difficult cannulation, while types 3 and 4 had a higher cannulation difficulty (OR=1.89, 95% CI: 1.01-3.54 and OR=4.37, 95% CI: 1.54-12.4 respectively). The distal location of the duodenal papilla had an OR=1.32 for difficult cannulation, while the presence of a periampullary diverticulum had an OR=0.54 and the endoscopic sign of bile aspiration OR=0.9, without being statistically significant. Types 3 and 4 duodenal papilla are significantly associated with difficult cannulation. The location of the papilla, as well as the presence of a periampullary diverticulum and bile aspiration, are not significantly associated with difficult cannulation.

Introduction Biliary anastomotic strictures (AS) occur in 5%–15% of liver transplant (LT) recipients and cause graft dysfunction and morbidity. The main alternative to surgical reconstruction is stenting at endoscopic retrograde cholangiopancreatography (ERCP), using plastic polyethylene or fully-covered self-expanding metal stents (fcSEMS). We retrospectively reviewed outcomes after ERCP for biliary AS, aiming to assess rates of success and complications. Methods Records for all patients undergoing ERCP post LT between 2013–16 were reviewed. AS were classified as early or late ( Results In total 252 ERCPs were performed (median 4/patient, range 2–10) in 62 patients, 72.6% male, age at LT 54 years (range 20–71). 48 grafts (77.4%) were donations after brain death, 13 (21.0%) after cardiac death and 1 live donor. At first endoscopy 53 (85.4%) had a native papilla. Median time from LT was 28 days (4–75) in early AS (n=29, 46.7%, 9 presenting with bile leak) vs 11.5 mths (3.4–251) in late AS (n=33, 53.2%). Biliary stents were placed in 172 ERCPs (63.4% plastic vs 36.6% fcSEMS) and AS dilated in 68 (27.0%; 60 in conjunction with stenting). Stricture resolution was achieved endoscopically in 47/55 patients with complete outcome data (85.5%). Plastic stents were placed at index ERCP in 23/26 of early AS, in whom sequential plastic ‘upstenting’ was ultimately successful in 9 (39.1%) and 12 (52.2%) proceeded to fcSEMS (stricture remodelled in all). Of late AS, 9/29 were managed with fcSEMS (88.8% successfully), 8 plastic ‘upstenting’ (75% success), 8 fcSEMS after initial plastic stent (all successful) and 2 resolved with dilatation only. The overall rate of post-ERCP pancreatitis (PEP) was 7.1% (none severe by Cotton criteria) and was higher after fcSEMS (15.9%) than plastic stenting (5.5%, p=0.024), despite similar use of NSAID prophylaxis. Compared with plastic stents, fcSEMS were more likely to migrate (36.5% vs 12.8%, p Conclusions Endoscopic management is effective in treating 85% of biliary AS. fcSEMS appear superior to sequential plastic ‘upstenting’ but are associated with higher rates of PEP and migration.

Background and study aim Simulator-based training has been extensively studied in training gastroduodenoscopy and colonoscopy and shown to significantly improve learning curves of novices. Data on simulator-based training in endoscopic retrograde cholangiopancreatography (ERCP) are scarce. We aimed to determine the impact of 2-day intensive hands-on simulator training on the course of the learning curve of novice trainees. Methods We conducted a prospective cohort study using a validated mechanical ERCP simulator (Boškoski-Costamagna ERCP Trainer). Six trainees were allocated to the simulation course program (SG). Each of these trainees were paired with an endoscopy trainee starting regular ERCP training at the same center who had no exposure to a simulation course program (control group; CG). The course included lectures, live ERCP demonstrations, and hands-on ERCP training to educate trainees in basic techniques related to cannulation, stent placement, stone extraction and stricture management. After the course, both the SG and CG started formal ERCP training in their respective centers. The Rotterdam Assessment Form for ERCP was used to register each performed ERCP. Simple moving average was applied to create learning curves based on successful common bile duct (CBD) cannulation. Outcomes were plotted against a historical cohort (HC). Results Thirteen trainees were included, six trainees in the SG and seven trainees in the CG, with a total of 717 ERCPs. Mean successful ERCP cannulation rate was higher for the simulator group at baseline compared to both CG and HC, 64% versus 43% and 42%, respectively. Differences became less explicit after 40 ERCPs, but persisted until a median of 75 ERCPs. Conclusions We demonstrate that 2-day hands-on simulator-based ERCP training course has a positive effect on the learning curves of ERCP trainees and should be considered an integral part of the training curricula for ERCP to develop skills prior to patient-based training.