Biliary cannulation in endoscopic retrograde cholangiography: How to tackle the difficult papilla

Background: In the setting of a naïve papilla, biliary cannulation is a key step in successfully performing endoscopic retrograde cholangiography (ERC). Difficult biliary cannulation (DBC) is associated with an increased risk of post-ERCP-pancreatitis and failure of the whole procedure. Summary: Recommendations for biliary cannulation can be divided in (a) measures to reduce the likelihood of a difficult papilla-situation a priori and (b) rescue techniques in case the endoscopist is actually facing DBC. (a): careful inspection of the papillary anatomy and optimizing its accessibility by scope-positioning is fundamental. A sphincterotome in combination with a soft-tip hydrophilic guide-wire rather than a standard catheter with a standard guide-wire should be used. (b): The most important rescue techniques are needle-knife precut, double-guidewire technique and transpancreatic sphincterotomy. In few cases, anterograde techniques are needed. To this regard, the EUS-guided biliary drainage (EUS-BD) followed by rendezvous is increasingly used as an alternative to percutaneous-transhepatic biliary drainage. Key Messages: Biliary cannulation can be accomplished with alternative retrograde or less frequently by salvage-anterograde techniques, once conventional direct cannulation attempts have failed. Considering recent favorable data for the early use of transpancreatic sphincterotomy, an adopted version of the 2016 European-Society-for-Gastrointestinal-Endoscopy (ESGE)-algorithm on biliary cannulation is proposed.

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Difficult Biliary Cannulation in Endoscopic Retrograde Cholangiopancreatography: Definitions, Risk Factors, and Implications

EMJ Hepatology ◽

10.33590/emjhepatol/20-00283 ◽

2021 ◽

pp. 64-72

Author(s):

Brian M. Fung ◽

Teodor C. Pitea ◽

James H. Tabibian

Keyword(s):

Risk Factors ◽

Endoscopic Retrograde Cholangiopancreatography ◽

Significant Progress ◽

Endoscopic Retrograde ◽

Biliary Cannulation ◽

Vast Array ◽

The Past ◽

Increased Risk ◽

Invasive Method ◽

Difficult Biliary Cannulation

Over the past 50 years, endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred minimally invasive method of treating a vast array of pancreatobiliary diseases. An initial sine qua non for ERCP success is selective ductal cannulation. Despite significant progress in the optimisation of ERCP methods and accessories, selective biliary cannulation using conventional techniques remains unsuccessful in approximately 15% of native papilla cases. Furthermore, difficult biliary cannulation has been associated with an increased risk of post-ERCP pancreatitis, among other adverse events. Here, in the first of a two-part series, the authors provide a primer on standard biliary cannulation techniques and discuss the definition, risk factors, and implications of difficult biliary cannulation. The second part of the series will provide an overview of the existing advanced techniques used in cases of difficult biliary cannulation as well as the approach to their selection.

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Su1631 Needle-knife Sphincterotomy vs. Guidewire-Assisted Transpancreatic Sphincterotomy for Difficult Biliary Cannulation

Gastrointestinal Endoscopy ◽

10.1016/j.gie.2015.03.593 ◽

2015 ◽

Vol 81 (5) ◽

pp. AB359

Author(s):

Yoshiaki Kawaguchi ◽

Tetsuya Mine

Keyword(s):

Biliary Cannulation ◽

Difficult Biliary Cannulation ◽

Needle Knife ◽

Transpancreatic Sphincterotomy

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Salvage Techniques for Difficult Biliary Cannulation: A Retrospective Study of 1021 Endoscopic Retrograde Cholangiopancreatography Cases in a Tertiary Referral Center

10.21203/rs.3.rs-1149043/v1 ◽

2021 ◽

Author(s):

Shikiko Maruta ◽

Harutoshi Sugiyama ◽

Sadahisa Ogasawara ◽

Chihei Sugihara ◽

Mayu Ouchi ◽

...

Keyword(s):

Success Rate ◽

Endoscopic Retrograde Cholangiopancreatography ◽

Success Rates ◽

Endoscopic Retrograde ◽

Biliary Cannulation ◽

Tertiary Referral Center ◽

Treatment Processes ◽

Difficult Biliary Cannulation ◽

Needle Knife ◽

Event Rates

Abstract Although some salvage techniques have been developed to overcome difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP), few reports analyzed the choice of techniques and their clinical outcomes in large cohorts. This study aimed to evaluate the outcomes of biliary cannulation in patients with initial treatment papillae. We retrospectively identified 1021 patients who underwent initial ERCP from January 2013 to March 2020. We investigated background factors, treatment details, success rates, and adverse event rates. Then we analyzed a series of treatment processes, including salvage techniques such as double guidewire technique (DGT), needle knife pre-cutting (NKP), and transpancreatic pre-cut papillotomy (TPPP). The initial ERCP success rate was 94.3%, and the eventual success rate was 98.3%. Salvage techniques were required in 380 of 1021 patients (37.2%), associated with long oral protrusion (OR, 2.38; 95% CI, 1.80–3.15; p < 0.001). A total of 503 cases (49.3%) had long oral protrusions, 47.5% of which required the salvage techniques, much higher than 27.5% of not-long cases. Patients with long oral protrusions had a higher frequency of NKP. In conclusion, patients with long oral protrusions frequently required salvage techniques. Appropriate strategies and salvage techniques may help to overcome many difficult biliary cannulation cases.

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

Arquivos de Gastroenterologia ◽

10.1590/s0004-2803.202100000-91 ◽

2021 ◽

Vol 58 (4) ◽

pp. 509-513

Author(s):

Victor Kalil FLUMIGNAN ◽

Marina Garcia SEIKE ◽

Victória Soares de SOUZA ◽

Matheus Iguera CIRQUEIRA ◽

Ana Beatriz SILVA ◽

...

Keyword(s):

Bile Duct ◽

Adverse Events ◽

Success Rate ◽

Short Interval ◽

Normal Position ◽

Endoscopic Retrograde ◽

Biliary Cannulation ◽

Difficult Biliary Cannulation ◽

Needle Knife ◽

A Minor

ABSTRACT BACKGROUND: 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. OBJECTIVE: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

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Needle Knife Precut Papillotomy and Fistulotomy for Difficult Biliary Cannulation during Endoscopic Retrograde Cholangiopancreatography

Digestion ◽

10.1159/000352027 ◽

2013 ◽

Vol 88 (2) ◽

pp. 95-100 ◽

Cited By ~ 3

Author(s):

Qisheng Zhang ◽

Bing Han ◽

Jianhua Xu ◽

Wenmin Bao ◽

Jieli Tao ◽

...

Keyword(s):

Endoscopic Retrograde Cholangiopancreatography ◽

Endoscopic Retrograde ◽

Biliary Cannulation ◽

Difficult Biliary Cannulation ◽

Needle Knife

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Transpancreatic precut papillotomy versus double-guidewire technique in difficult biliary cannulation: a systematic review and meta-analysis

Endoscopy International Open ◽

10.1055/a-1534-2388 ◽

2021 ◽

Vol 09 (11) ◽

pp. E1758-E1767 ◽

Cited By ~ 1

Author(s):

Edson Guzmán-Calderón ◽

Belen Martinez-Moreno ◽

Juan A. Casellas ◽

José Ramón Aparicio

Keyword(s):

Systematic Review ◽

Meta Analysis ◽

High Rate ◽

Endoscopic Retrograde ◽

Biliary Cannulation ◽

Successful Cannulation ◽

Ovid Medline ◽

Difficult Biliary Cannulation ◽

The Mean ◽

Transpancreatic Sphincterotomy

Abstract Background and study aims Approximately 11 % of biliary cannulations are considered difficult. The double guidewire (DGW-T) and transpancreatic sphincterotomy (TPS) are two useful techniques when difficult cannulation exists and the main pancreatic duct is unintentionally accessed. We carried out a systematic review and meta-analysis to evaluate the effectiveness and security of both DGW-T and TPS techniques in difficult biliary cannulation. Methods We conducted a systematic review in different databases, such as PubMed, OVID, Medline, and Cochrane Databases. Were included all RCT which showed a comparison between TPS and DGW in difficult biliary cannulation. Endpoints computed were successful cannulation rate, median cannulation time, and adverse events rate. Results Four studies were selected (4 RCTs). These studies included 260 patients. The mean age was 64.79 ± 12.99 years. Of the patients, 53.6 % were men and 46.4 % were women. The rate of successful cannulation was 93.3 % in the TPS group and 79.4 % in the DGW-T group (P = 0.420). The rate of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) was lower in patients who had undergone TPS than DGW-T (TPS: 8.9 % vs DGW-T: 22.2 %, P = 0.02). The mean cannulation time was 14.7 ± 9.4 min in the TPS group and 15.1 ± 7.4 min with DGW-T (P = 0.349). Conclusions TPS and DGW are two useful techniques in patients with difficult cannulation. They both have a high rate of successful cannulation; however, the PEP was higher with DGW-T than with TPS.

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Transpancreatic biliary sphincterotomy versus double guidewire in difficult biliary cannulation: a randomized controlled trial

Endoscopy ◽

10.1055/a-1327-2025 ◽

2021 ◽

Author(s):

Leena Kylänpää ◽

Vilja Koskensalo ◽

Arto Saarela ◽

Per Ejstrud ◽

Marianne Udd ◽

...

Keyword(s):

Pancreatic Duct ◽

Controlled Trial ◽

Good Alternative ◽

Endoscopic Retrograde ◽

Biliary Cannulation ◽

Randomized Controlled ◽

Biliary Sphincterotomy ◽

Difficult Biliary Cannulation ◽

Definition Of ◽

Randomized Method

Abstract Background Difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) increases the risk of post-ERCP pancreatitis (PEP). The purpose of this prospective, randomized, multicenter study was to compare two advanced rescue methods, transpancreatic biliary sphincterotomy (TPBS) and a double-guidewire (DGW) technique, in difficult common bile duct (CBD) cannulation. Methods Patients with native papilla and planned CBD cannulation were recruited at eight Scandinavian hospitals. An experienced endoscopist attempted CBD cannulation with wire-guided cannulation. If the procedure fulfilled the definition of difficult cannulation and a guidewire entered the pancreatic duct, randomization to either TPBS or to DGW was performed. If the randomized method failed, any method available was performed. The primary end point was the frequency of PEP and the secondary end points included successful cannulation with the randomized method. Results In total, 1190 patients were recruited and 203 (17.1 %) were randomized according to the study protocol (TPBS 104 and DGW 99). PEP developed in 14/104 patients (13.5 %) in the TPBS group and 16/99 patients (16.2 %) in the DGW group (P = 0.69). No difference existed in PEP severity between the groups. The rate of successful deep biliary cannulation was significantly higher with TPBS (84.6 % [88/104]) than with DGW (69.7 % [69/99]; P = 0.01). Conclusions In difficult biliary cannulation, there was no difference in PEP rate between TPBS and DGW techniques. TPBS is a good alternative in cases of difficult cannulation when the guidewire is in the pancreatic duct.

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