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Sequential double-guidewire technique and transpancreatic precut sphincterotomy for difficult biliary cannulation.

Kim CW, Chang JH, Kim TH, Han SW - Saudi J Gastroenterol (2015 Jan-Feb)

Bottom Line: When standard techniques were unsuccessful, DGT or NK was performed.Of the sequential DGT-TPS patients, the incidence of PEP was significantly reduced in patients with a pancreatic duct (PD) stent compared with patients without a PD stent (24% vs. 62%, P = 0.023).In the sequential DGT-TPS patients, the incidence of PEP was significantly reduced with the use of a PD stent.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.

ABSTRACT

Background/aims: The double-guidewire technique (DGT) and transpancreatic precut sphincterotomy (TPS) are introduced as alternative biliary cannulation techniques for difficult biliary cannulation. This study aimed to evaluate the sequential use of DGT and TPS compared with a needle-knife precut papillotomy (NK).

Patients and methods: Six hundred and thirty-five consecutive patients with naοve papilla and who underwent endoscopic retrograde cholangiopancreatography (ERCP) for biliary cannulation from March 2010 to April 2014 in a single institute were analyzed. When standard techniques were unsuccessful, DGT or NK was performed. TPS was sequentially performed if DGT failed.

Results: DGT and NK were attempted in 65 and 58 patients, respectively. A sequential DGT-TPS was performed in 38 patients after a failed DGT. Biliary cannulations were successful in 42%, 74%, and 66% of the DGT, sequential DGT-TPS, and NK patients, respectively (P = 0.002). The cannulation rate was higher in the DGT ± TPS patients (85%) than in the NK patients (P = 0.014). Post-ERCP pancreatitis (PEP) developed in 26% of the successful DGT patients, 37% of the sequential DGT-TPS patients, and 10% of the NK patients (P = 0.008). Of the sequential DGT-TPS patients, the incidence of PEP was significantly reduced in patients with a pancreatic duct (PD) stent compared with patients without a PD stent (24% vs. 62%, P = 0.023).

Conclusions: Sequential DGT-TPS is a useful alternative method compared with NK for patients in whom biliary cannulation is difficult. In the sequential DGT-TPS patients, the incidence of PEP was significantly reduced with the use of a PD stent.

No MeSH data available.


Related in: MedlinePlus

Transpancreatic precut sphincterotomy. (a) Fluoroscopy image showed opacification of the pancreatic duct. (b) The endoscopic transpancreatic precut sphincterotomy was performed with a sphincterotome. (c) A small cut of approximately 5 mm was created with a guidewire in the pancreatic duct. (d) A sphincterotome that was preloaded with another guidewire was introduced at the small cut, while the first guidewire remained in the pancreatic duct. (e) Biliary cannulation was successfully performed. (f) A stent was placed in the pancreatic duct
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Figure 3: Transpancreatic precut sphincterotomy. (a) Fluoroscopy image showed opacification of the pancreatic duct. (b) The endoscopic transpancreatic precut sphincterotomy was performed with a sphincterotome. (c) A small cut of approximately 5 mm was created with a guidewire in the pancreatic duct. (d) A sphincterotome that was preloaded with another guidewire was introduced at the small cut, while the first guidewire remained in the pancreatic duct. (e) Biliary cannulation was successfully performed. (f) A stent was placed in the pancreatic duct

Mentions: ERCPs were initially performed with standard techniques that utilized various ERCP catheters, sphincterotomes, or guidewires. After 10 unsuccessful attempts to selectively cannulate the bile duct using ERCP catheters or sphincterotomes with a guidewire, DGT or NK was performed according to guidewire passage through the PD. If a guidewire (0.025 in., Tracer Metro, Cook Endoscopy, Winston-Salem, NC, USA) was placed in the PD, DGT was performed. If a guidewire was not placed in the PD, NK was performed. DGT was initiated by placing a guidewire in the PD through the papilla. Next, biliary cannulation was attempted at the papilla orifice with a sphincterotome (Clever Cut, Olympus Corporation, Tokyo, Japan) preloaded with a second guidewire while the first guidewire remained in the PD [Figure 2]. If DGT failed, TPS was then performed [Figure 3]. The sphincterotome was placed with the pancreatic guidewire, and then, the septum was cut toward an 11 o'clock position using an electrosurgical unit (VIO 300D with endocut I mode, Erbe Elektromedizin, Tübingen, Germany). TPS created an approximately 5 mm cut. Biliary cannulation was re-attempted with a sphincterotome through the TPS site. After 2012, a PD stent was placed in the sequential DGT-TPS patients. We used a PD stent that was 5 Fr/5 cm and straight or single pigtail. The PD stent was removed 1 month after ERCP in the outpatient clinic. Contrast injection into more than 50% of the PD was performed in the DGT or TPS patients when the guidewire did not easily insert into the deep portion of the PD. NK was performed via infundibular fistulotomy or a precut from the papillary orifice with a needle-knife (Triple lumen needle-knife, Olympus Corporation, Tokyo, Japan). In the NK patients, contrast injection into the PD was performed by chance during the procedure to cannulate the bile duct before NK. As a rule, the DGT and NK patients did not receive a PD stent. If biliary cannulation failed after the use of all of these techniques, percutaneous transhepatic biliary drainage (PTBD), surgery, or continued observation of the patients was performed. All procedures were performed by two endoscopists who had performed over 1000 ERCPs. The levels of experience of the two endoscopists were similar.


Sequential double-guidewire technique and transpancreatic precut sphincterotomy for difficult biliary cannulation.

Kim CW, Chang JH, Kim TH, Han SW - Saudi J Gastroenterol (2015 Jan-Feb)

Transpancreatic precut sphincterotomy. (a) Fluoroscopy image showed opacification of the pancreatic duct. (b) The endoscopic transpancreatic precut sphincterotomy was performed with a sphincterotome. (c) A small cut of approximately 5 mm was created with a guidewire in the pancreatic duct. (d) A sphincterotome that was preloaded with another guidewire was introduced at the small cut, while the first guidewire remained in the pancreatic duct. (e) Biliary cannulation was successfully performed. (f) A stent was placed in the pancreatic duct
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4355857&req=5

Figure 3: Transpancreatic precut sphincterotomy. (a) Fluoroscopy image showed opacification of the pancreatic duct. (b) The endoscopic transpancreatic precut sphincterotomy was performed with a sphincterotome. (c) A small cut of approximately 5 mm was created with a guidewire in the pancreatic duct. (d) A sphincterotome that was preloaded with another guidewire was introduced at the small cut, while the first guidewire remained in the pancreatic duct. (e) Biliary cannulation was successfully performed. (f) A stent was placed in the pancreatic duct
Mentions: ERCPs were initially performed with standard techniques that utilized various ERCP catheters, sphincterotomes, or guidewires. After 10 unsuccessful attempts to selectively cannulate the bile duct using ERCP catheters or sphincterotomes with a guidewire, DGT or NK was performed according to guidewire passage through the PD. If a guidewire (0.025 in., Tracer Metro, Cook Endoscopy, Winston-Salem, NC, USA) was placed in the PD, DGT was performed. If a guidewire was not placed in the PD, NK was performed. DGT was initiated by placing a guidewire in the PD through the papilla. Next, biliary cannulation was attempted at the papilla orifice with a sphincterotome (Clever Cut, Olympus Corporation, Tokyo, Japan) preloaded with a second guidewire while the first guidewire remained in the PD [Figure 2]. If DGT failed, TPS was then performed [Figure 3]. The sphincterotome was placed with the pancreatic guidewire, and then, the septum was cut toward an 11 o'clock position using an electrosurgical unit (VIO 300D with endocut I mode, Erbe Elektromedizin, Tübingen, Germany). TPS created an approximately 5 mm cut. Biliary cannulation was re-attempted with a sphincterotome through the TPS site. After 2012, a PD stent was placed in the sequential DGT-TPS patients. We used a PD stent that was 5 Fr/5 cm and straight or single pigtail. The PD stent was removed 1 month after ERCP in the outpatient clinic. Contrast injection into more than 50% of the PD was performed in the DGT or TPS patients when the guidewire did not easily insert into the deep portion of the PD. NK was performed via infundibular fistulotomy or a precut from the papillary orifice with a needle-knife (Triple lumen needle-knife, Olympus Corporation, Tokyo, Japan). In the NK patients, contrast injection into the PD was performed by chance during the procedure to cannulate the bile duct before NK. As a rule, the DGT and NK patients did not receive a PD stent. If biliary cannulation failed after the use of all of these techniques, percutaneous transhepatic biliary drainage (PTBD), surgery, or continued observation of the patients was performed. All procedures were performed by two endoscopists who had performed over 1000 ERCPs. The levels of experience of the two endoscopists were similar.

Bottom Line: When standard techniques were unsuccessful, DGT or NK was performed.Of the sequential DGT-TPS patients, the incidence of PEP was significantly reduced in patients with a pancreatic duct (PD) stent compared with patients without a PD stent (24% vs. 62%, P = 0.023).In the sequential DGT-TPS patients, the incidence of PEP was significantly reduced with the use of a PD stent.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.

ABSTRACT

Background/aims: The double-guidewire technique (DGT) and transpancreatic precut sphincterotomy (TPS) are introduced as alternative biliary cannulation techniques for difficult biliary cannulation. This study aimed to evaluate the sequential use of DGT and TPS compared with a needle-knife precut papillotomy (NK).

Patients and methods: Six hundred and thirty-five consecutive patients with naοve papilla and who underwent endoscopic retrograde cholangiopancreatography (ERCP) for biliary cannulation from March 2010 to April 2014 in a single institute were analyzed. When standard techniques were unsuccessful, DGT or NK was performed. TPS was sequentially performed if DGT failed.

Results: DGT and NK were attempted in 65 and 58 patients, respectively. A sequential DGT-TPS was performed in 38 patients after a failed DGT. Biliary cannulations were successful in 42%, 74%, and 66% of the DGT, sequential DGT-TPS, and NK patients, respectively (P = 0.002). The cannulation rate was higher in the DGT ± TPS patients (85%) than in the NK patients (P = 0.014). Post-ERCP pancreatitis (PEP) developed in 26% of the successful DGT patients, 37% of the sequential DGT-TPS patients, and 10% of the NK patients (P = 0.008). Of the sequential DGT-TPS patients, the incidence of PEP was significantly reduced in patients with a pancreatic duct (PD) stent compared with patients without a PD stent (24% vs. 62%, P = 0.023).

Conclusions: Sequential DGT-TPS is a useful alternative method compared with NK for patients in whom biliary cannulation is difficult. In the sequential DGT-TPS patients, the incidence of PEP was significantly reduced with the use of a PD stent.

No MeSH data available.


Related in: MedlinePlus