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Choudhury A, Samanta J, Muktesh G, Dhar J, Kumar A, Shah J, Spadaccini M, Gupta P, Fugazza A, Gupta V, Yadav TD, Kochhar R, Hassan C, Repici A, Facciorusso A. Endoscopic Ultrasound-Guided Rendezvous Technique Versus Precut Sphincterotomy as Salvage Technique in Patients With Benign Biliary Disease and Difficult Biliary Cannulation : A Randomized Controlled Trial. Ann Intern Med 2024; 177:1361-1369. [PMID: 39186789 DOI: 10.7326/m24-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND The standard salvage technique used for difficult bile duct cannulation is precut sphincterotomy, whereas endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a relatively newer method. Prospective comparative data between these 2 techniques as salvage for biliary access in patients with benign biliary disease and difficult bile duct cannulation is lacking. OBJECTIVE To compare EUS-RV and precut sphincterotomy as salvage technique for difficult bile duct cannulation in benign biliary obstruction. DESIGN Participant-masked, parallel-group, superiority, randomized controlled trial. (Clinical Trials Registry of India: CTRI/2020/07/026613). SETTING Tertiary care academic institute from July 2020 to May 2021. PARTICIPANTS All patients with benign biliary disease and difficult bile duct cannulation requiring salvage strategy. INTERVENTION Patients were randomly assigned by computer-generated randomized blocks sequence in 1:1 fashion to either EUS-RV or precut sphincterotomy. Patients with failure in EUS-RV were crossed over to precut sphincterotomy and vice versa. MEASUREMENTS The primary outcome measure was technical success. The other outcome measures included procedure time, radiation dose, and adverse events. RESULTS In total, 100 patients were randomly assigned to EUS-RV (n = 50) and precut sphincterotomy (n = 50). The technical success rate (92% vs. 90%; P = 1.00; relative risk, 1.02 [95% CI, 0.90 to 1.16]), median procedure time (10.1 vs. 9.75 minutes), and overall complication rate (12% vs. 10%; relative risk, 1.20 [CI, 0.39 to 3.68]) were similar between the 2 groups. Five patients (10%) in the EUS-RV group and 5 patients (10%) in the precut sphincterotomy group had developed post-endoscopic retrograde cholangiopancreatography pancreatitis. All failed cases in either salvage group could be successfully cannulated when crossed over to the other group. LIMITATION Single center study done by experts. CONCLUSION Endoscopic ultrasound-guided rendezvous technique and precut sphincterotomy have similar success rates as salvage techniques in the technically challenging cohort of difficult bile duct cannulation for benign biliary disease, with acceptable complications rates. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Arup Choudhury
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India (A.C., J.Samanta, G.M., J.D., A.K., J.Shah, R.K.)
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India (A.C., J.Samanta, G.M., J.D., A.K., J.Shah, R.K.)
| | - Gaurav Muktesh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India (A.C., J.Samanta, G.M., J.D., A.K., J.Shah, R.K.)
| | - Jahnvi Dhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India (A.C., J.Samanta, G.M., J.D., A.K., J.Shah, R.K.)
| | - Antriksh Kumar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India (A.C., J.Samanta, G.M., J.D., A.K., J.Shah, R.K.)
| | - Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India (A.C., J.Samanta, G.M., J.D., A.K., J.Shah, R.K.)
| | - Marco Spadaccini
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy (M.S., A.Fugazza, C.H., A.R.)
| | - Pankaj Gupta
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India (P.G.)
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy (M.S., A.Fugazza, C.H., A.R.)
| | - Vikas Gupta
- Department of GI Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India (V.G., T.D.Y.)
| | - Thakur Deen Yadav
- Department of GI Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India (V.G., T.D.Y.)
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India (A.C., J.Samanta, G.M., J.D., A.K., J.Shah, R.K.)
| | - Cesare Hassan
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy (M.S., A.Fugazza, C.H., A.R.)
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy (M.S., A.Fugazza, C.H., A.R.)
| | - Antonio Facciorusso
- Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Foggia, Foggia, Italy (A.Facciorusso)
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Steerable catheter based on wire-driven seamless artificial blood vessel tube for endoscopic retrograde transpapillary interventions. Int J Comput Assist Radiol Surg 2023; 18:433-447. [PMID: 36477583 DOI: 10.1007/s11548-022-02805-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE Current steerable catheters (SCs) for endoscopic retrograde cholangiopancreatography (ERCP) have performance limitations caused by an asymmetric multiple-slit tube design with a small maximum bend angle, lesser curvatures, and insufficient durability. We propose a wire-driven SC for balanced bidirectional bending using artificial blood vessel material to overcome these limitations. We assess the SC prototype's steerability using phantom and animal models. METHODS The SC prototype employed a slit-less and multiple-lumen seamless tube with a polytetrafluoroethylene (PTFE) body with stretch-retractable porous expanded PTFE at the distal end, and loop-formed control wires. We evaluated the wire routing design using a static model. The bending performance was compared with conventional SCs. Feasibility studies were performed, including major duodenal papilla insertions and ductal branch selections in desktop phantoms and a mini-pig model. RESULTS The proposed design reduced the wire contact force by 48% compared to the single wire configuration. The maximum bend angle was 162°, almost twofold larger than that for conventional SCs. The lateral tip position in the bent shape was maximally 56% smaller. The tip flexibility was comparable to conventional SCs, and the insertion resistance was similar to the passive catheters. Phantom studies showed that the SC prototype could perform the large and protuberant papilla insertions and fine ductal branch selections without breaking; the animal study was completed successfully. CONCLUSION We propose a wire-driven SC design for ERCP using a multi-lumen seamless tube and two loop-formed control wires, different from the conventional SC design with a multiple-slit tube and single control wire. The SC prototype records balanced bidirectional bending with a maximum bending angle of ± 162° without breakage risk. The phantom and animal studies show that the prototype performance potentially facilitates papilla cannulations and intrahepatic ductal branch seeking.
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Fang Y, Jiang G, Huo C, Xiong Z, Li F, Wang X, Qin X, Huang J. The success rate of cannulation of needle-knife precut is superior to continuing wire-guided after difficult biliary cannulation with pancreatic stent placement. Surg Endosc 2023; 37:3253-3259. [PMID: 36645482 DOI: 10.1007/s00464-023-09877-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/06/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND Difficult biliary cannulation and unintended pancreatic cannulation exist in biliary interventions during endoscopic retrograde cholangiopancreatography. Wire-guided cannulation over a pancreatic stent (PS-WGC) and needle-knife precut over a pancreatic stent (PS-NKP) may facilitate biliary cannulation. This study aimed to compare the outcomes of PS-NKP and PS-WGC following guidewire passage into the pancreatic duct. METHODS A total of 304 patients who inserted a pancreatic stent and continued cannulation using wire-guided (PS-WGC) or needle-knife precut (PS-NKP) from October 2018 to November 2021 in three centers were ultimately enrolled in this study. The success rate of cannulation and incidence of complications were compared between the two groups. RESULTS Results of the success rate of cannulation in the PS-NKP (n = 98) group were significantly higher compared with the PS-WGC (n = 206) group (96.9% vs. 89.8%; P < 0.05). The overall adverse events were 10.2% (31/304), and PS-NKP had lower (PEP) rates compared with the PS-WGC (3.1% vs. 10.7%, P < 0.05). CONCLUSION The PS-NKP group is superior to the PS-WGC group in terms of the effectiveness and safety of continued cannulation. Using needle-knife precut, especially early use, over the pancreatic stent to continue cannulation reduced PEP compared with PS-WGC.
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Affiliation(s)
- Ying Fang
- Graduate School of Dalian Medical University, Dalian, China.,Department of Gastroenterology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, 213000, China
| | - Guobin Jiang
- Department of Gastroenterology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chunyan Huo
- Department of Gastroenterology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, 213000, China
| | - Zhe Xiong
- Graduate School of Dalian Medical University, Dalian, China.,Department of Gastroenterology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, 213000, China
| | - Fengdong Li
- Department of Gastroenterology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, 213000, China
| | - Xiang Wang
- Endoscopy Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiangrong Qin
- Department of Gastroenterology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, 213000, China
| | - Jin Huang
- Department of Gastroenterology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, 213000, China.
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Fernandes J, Canena J, Alexandrino G, Figueiredo L, Rafael M, Moreira M, Araújo T, Lourenço L, Horta D, Familiari P, Dinis-Ribeiro M, Lopes L. Outcomes of single-endoscopist-performed needle-knife fistulotomy for selective biliary access in 842 consecutive patients: learning curve and changes over a 14-year period in a retrospective study. Scand J Gastroenterol 2021; 56:1363-1370. [PMID: 34355615 DOI: 10.1080/00365521.2021.1958369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Needle-knife fistulotomy (NKF) has emerged as the preferred precut technique. From a late strategy, NKF has shifted to an early rescue technique and has been used recently as a primary method for biliary access. It is unknown how these changes have affected NKF outcomes. We analyzed the outcomes of NKF over time in a large cohort of patients. METHODS Multicenter retrospective cohort study of 842 patients who underwent NKF for biliary access between 2006 and 2019. Patients were divided into four study periods according to a late or early cannulation strategy and to the use of post-ERCP pancreatitis prophylaxis (Period 1-Period 4). We assessed outcomes of NKF, learning curves and shifts over time. RESULTS Bile duct access was obtained in 88.0% of the patients. The initial cannulation rate increased significantly from 77.5% in P1 to 92.0% in P4 (p < .001). An endoscopist can obtain 80% success rate after performing 100 NKF procedures (95% CI: 0.79-0.86) and a 95% success rate after 830 procedures (95% CI: 0.92-0.98). Adverse events and pancreatitis were observed in 6.5% and 4.9% of patients respectively. The rate of pancreatitis was not significantly different during the 4 periods (p = .190). A decline in the pancreatitis rate was observed from 2006 until 2016 (no trainees) and then an increase until 2019 (trainees involved). The presence of trainees increased the rate of pancreatitis in the last period by 9.9%. CONCLUSIONS The success of NKF has increased significantly over the years, initially in a rapid manner and then more slowly. It is associated with a low rate of complications, which tend to decrease with experience. The involvement of trainees is associated with an increased rate of pancreatitis.
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Affiliation(s)
- João Fernandes
- Department of Gastroenterology, Santa Luzia Hospital, Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Jorge Canena
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal.,Department of Gastroenterology, Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal.,Cintesis, Center for Health Technology and Services Research, Porto, Portugal
| | - Gonçalo Alexandrino
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - Luísa Figueiredo
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - Maria Rafael
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - Marta Moreira
- Department of Gastroenterology, Santa Luzia Hospital, Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal
| | - Tarcísio Araújo
- Department of Gastroenterology, Santa Luzia Hospital, Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal
| | - Luís Lourenço
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
| | - David Horta
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal.,Department of Gastroenterology, Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal
| | - Pietro Familiari
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy
| | - Mário Dinis-Ribeiro
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy.,Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Luís Lopes
- Department of Gastroenterology, Santa Luzia Hospital, Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
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Efficacy and safety of primary, early and late needle-knife fistulotomy for biliary access. Sci Rep 2021; 11:16658. [PMID: 34404873 PMCID: PMC8371017 DOI: 10.1038/s41598-021-96142-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/02/2021] [Indexed: 11/08/2022] Open
Abstract
European Society of Gastrointestinal Endoscopy recommends needle-knife fistulotomy (NKF) as the preferred precut technique. However, there is little information on whether NKF performed at different times is associated with different success and adverse event rates. We compared the outcomes of 3 different timings of NKF. This was an observational study conducted at 4 institutions and this was a retrospective analysis of prospectively collected data. We included 330 consecutive patients submitted to NKF attempt for biliary access. Patients were divided into three groups: NKF as an initial procedure for biliary access (group A, n = 121); early NKF defined as after 5 min, 5 attempts, or 2 pancreatic passages (group B, n = 99); and late NKF: after at least 10 min of unsuccessful standard biliary cannulation (group C, n = 110). We assessed the success rate of biliary cannulation at initial ERCP, time to perform NKF until biliary cannulation, overall biliary cannulation rate (second ERCP when initial failure), adverse event rate, and predictors of post-ERCP pancreatitis (PEP). The initial cannulation rate was 98%, 91% and 94% for groups A, B and C respectively, p = 0.08, whereas overall biliary cannulation rate was 100%, 95% and 98%, p = 0.115. The adverse event rate/PEP was 4.1%/2.5%, 7.1%/4% and 10.9%/8.2%, for groups A, B and C respectively, (p = 0.197 and p = 0.190). Median time for creating the fistula was A = 4.0 min, B = 3.2 min, and C = 5.6 min, p < 000.1. Each additional minute spent attempting cannulation increased the odds ratio (OR) for PEP by 1.072, and patients with 3 or more risk factors for pancreatitis had a higher chance of PEP. In conclusion, the timing of NFK does not appear to influence success rates but late NFK is associated with a higher time to create a fistula and an increased risk of pancreatitis. Primary NFK is associated with a high rate of success and a low rate of PEP and deserves additional investigation.
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Sakr C, Harb M, Makhoul E. The role of double-guidewire technique in preventing postendoscopic retrograde cholangiopancreatography pancreatitis. Arab J Gastroenterol 2021; 22:133-136. [PMID: 34120852 DOI: 10.1016/j.ajg.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND STUDY AIMS Postendoscopic retrograde cholangiopancreatography (ERCP) complications increase with repeated cannulation attempts. We evaluated several advanced biliary cannulation techniques, which have been used when the standard approach fails, to increase the success rate and decrease post-ERCP complications. We aimed to evaluate the use of double-wire technique in terms of success rates and effects on post-ERCP pancreatitis (PEP) and to assess the value of pancreatic duct stenting following needle-knife sphincterotomy in difficult biliary cannulation. PATIENTS AND METHODS A single-center, retrospective, randomized study was conducted on patients who underwent ERCP in Notre Dame De Secours University Hospital at Byblos, Lebanon, after obtaining the hospital's ethics committee approval. Patients were divided into three groups. The first group consisted of patients who had an ERCP and was divided into two subgroups, namely, one usingdouble-guidewire technique (DGT) only and another using an extra technique of precut with double-guidewire and pancreatic plastic stent placement. The second group of patients who had only ERCP was the control group. Finally, the third group endured the precut technique alone. RESULTS We could not prove any significant association between the intervention and the occurrence of pancreatitis when comparing double-wire technique plus ERCP to ERCP alone. When DGT with a pancreatic plastic stent was used, the incidence of PEP was significantly lower than that in other techniques. CONCLUSION DGT has a neutral effect on the reduction of PEP compared with the classic ERCP, but the technique can decrease the time of examination and increase success in difficult cases. ERCP using the double-guidewire with placement of a pancreatic plastic stent can contribute to decreasing PEP.
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Affiliation(s)
- Charlyne Sakr
- Hepato Biliary and Pancreas Division, Notre dame des secours University Hospital and the School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Byblos, Lebanon
| | - Marc Harb
- Hepato Biliary and Pancreas Division, Notre dame des secours University Hospital and the School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Byblos, Lebanon
| | - Elias Makhoul
- Hepato Biliary and Pancreas Division, Notre dame des secours University Hospital and the School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Byblos, Lebanon.
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Canena J, Lopes L, Fernandes J, Costa P, Arvanitakis M, Koch AD, Poley JW, Jimenez J, Dominguez-Munõz E, Familiari P, Bruno MJ, Dinis-Ribeiro M. Influence of a novel classification of the papilla of Vater on the outcome of needle-knife fistulotomy for biliary cannulation. BMC Gastroenterol 2021; 21:147. [PMID: 33794778 PMCID: PMC8017832 DOI: 10.1186/s12876-021-01735-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/23/2021] [Indexed: 02/03/2023] Open
Abstract
Background Existing proposed classification systems for the Papilla of Vater (PV) suboptimally account for all relevant, encountered PV appearances, are too complex or have not been assessed for intra- or interobserver variability. We proposed a novel endoscopic classification system for PV, determined its inter- and intraobserver rates and used the classification system to assess whether the success and complications of needle-knife fistulotomy (NKF) are influenced by the morphology of the PV. Methods The classification system was developed by expert endoscopists. To evaluate the inter- and intraobserver agreement, an online questionnaire was sent to 20 endoscopists from several countries (10 experts and 10 nonexperts) that included 50 images of papillae of Vater divided among various categories. Four weeks later, a second survey, with the images from the first questionnaire randomly reordered, was sent to the same endoscopists. The inter- and intraobserver agreements among the experts and nonexperts was calculated. Using the proposed classification system, all 361 consecutive patients who underwent NKF for biliary access to a naïve papilla were prospectively enrolled in the study. Results The novel classification system comprises 7 categories: type I, flat type, lacking an oral protrusion; type IIA, prominent tubular nonpleated type, with an oral protrusion and < 1 transverse fold over the oral protrusion; type IIB, prominent tubular pleated type, with an oral protrusion and > 2 transverse folds over the oral protrusion; type IIC: prominent bulging type, with an enlarged and bulging oral protrusion; type IIIA, diverticular-intradiverticular type, with a papillary orifice inside the diverticulum; type IIIB: diverticular-diverticular border type, with a papillary orifice less than 2 cm from the diverticular border; type IV: unclassified papilla, with no morphology classified in the other categories. The interobserver agreement between experts was substantial (K = 0.611, 95% CI 0.498–0.709) and was higher than that between nonexperts (K = 0.516; 95% CI 0.410–0.636). The intraobserver agreement was substantial among both experts (K = 0,651; 95% CI 0.586–0.715) and nonexperts (K = 0.646, 95% CI 0.615–0.677). In a multivariate model, type IIIA and IIIB were the only independent risk factors for difficult rescue NKF biliary cannulation (P = 0.003 and P = 0.019, respectively), and type I and type IIB were the only independent risk factors for a prolonged cannulation time using NKF (P < 0.001 and P = 0.005, respectively). Conclusions The novel endoscopic classification system for PV is highly reproducible among experienced ERCPists according to the substantial level of agreement between experts. However, nonexperts require further training in its use. Using the novel classification system, we identified different types of papillae significantly associated with a lower efficacy of NKF and a prolonged time to obtain successful biliary cannulation using NKF.
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Affiliation(s)
- Jorge Canena
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, IC 19, 2720276, Amadora, Portugal. .,Department of Gastroenterology, Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal. .,University Center of Gastroenterology, Hospital Cuf Tejo, Lisbon, Portugal. .,Cintesis - Center for Health Technology and Services Research, Porto, Portugal.
| | - Luís Lopes
- Department of Gastroenterology, Santa Luzia Hospital - Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - João Fernandes
- Department of Gastroenterology, Santa Luzia Hospital - Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal
| | - Patrício Costa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatology and Digestive Oncology, Erasme University Hospital Université Libre de Bruxelles, Brussels, Belgium
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Javier Jimenez
- Endoscopy Unit. Hospital Marques de Valdecilla, Santander, Spain
| | - Enrique Dominguez-Munõz
- Gastroenterology Department, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Pietro Familiari
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Mário Dinis-Ribeiro
- Cintesis - Center for Health Technology and Services Research, Porto, Portugal.,Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
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Shinoura S, Tokushige A, Chinen K, Mori H, Kato S, Ueda S. Endosonographic finding of the simultaneous depiction of bile and pancreatic ducts can predict difficult biliary cannulation on endoscopic retrograde cholangiopancreatography. PLoS One 2020; 15:e0235757. [PMID: 32645076 PMCID: PMC7347092 DOI: 10.1371/journal.pone.0235757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 06/23/2020] [Indexed: 12/24/2022] Open
Abstract
Thus far, no curved linear array endoscopic ultrasound (CLAEUS) findings were established as predictors of difficult selective bile duct cannulation (SBDC). This study aimed to identify CLAEUS findings to predict endoscopic retrograde cholangiopancreatography (ERCP) cases with difficult SBDC. This single-center, retrospective cohort study was conducted between July 2014 and June 2017. This study included all consecutive patients who underwent CLAEUS prior to naïve ERCP. A CLAEUS finding of the simultaneous depiction of bile and pancreatic ducts at the second portion of the duodenum (D2) (simultaneous depiction) was selected as a possible predictor of difficult SBDC, and the κ values in the evaluation of inter- and intra-observer variabilities for “simultaneous depiction” were 0.65 and 0.77, respectively, with substantial correlation. Among the 986 patients who underwent ERCP, 80 patients were relevant for evaluation. Logistic regression analysis revealed strong association between “simultaneous depiction” and difficult SBDC (odds ratio 15.4, 95% confidence interval 4.2–56.0; p<0.001). Among patients who underwent CLAEUS prior to naïve ERCP, a strong correlation was observed between “simultaneous depiction” and the risk of difficult SBDC. An endoscopist can prepare for difficult SBDC by “simultaneous depiction.” The finding enables pertinent planning when performing ERCP, such as setting time limits and selecting alternative devices, techniques, and skilled endoscopists, for difficult SBDC with minimal complications including post-ERCP pancreatitis. However, a future prospective study is necessary to establish the procedure algorithm for suspected difficult SBDC cases based on CLAEUS.
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Affiliation(s)
- Susumu Shinoura
- Department of Healthcare Management, School of Psychology and Healthcare Management at Akasaka, International University of Health and Welfare, Minato, Tokyo, Japan
- Department of Prevention and Analysis of Cardiovascular Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
- Department of Clinical Research and Quality Management, Center of Clinical Research and Quality Management, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Akihiro Tokushige
- Department of Prevention and Analysis of Cardiovascular Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
- Department of Digestive Diseases, Okinawa Chubu Hospital, Uruma, Okinawa, Japan
| | - Kenji Chinen
- Department of Clinical Research and Quality Management, Center of Clinical Research and Quality Management, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Hideki Mori
- Department of Clinical Research and Quality Management, Center of Clinical Research and Quality Management, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Shin Kato
- Department of Gastroenterology and Hepatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Shinichiro Ueda
- Department of Prevention and Analysis of Cardiovascular Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
- * E-mail:
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Should we use papilla morphology to estimate the size of the terminal common bile duct during endoscopic retrograde cholangiopancreatography? Eur J Gastroenterol Hepatol 2020; 32:181-186. [PMID: 31834048 DOI: 10.1097/meg.0000000000001623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE A small common bile duct (CBD) diameter has been associated with complications and with a difficult biliary cannulation. Previous studies suggested that this diameter can be predicted during the endoscopic retrograde cholangiopancreatography (ERCP) simply by observing the papillary morphology. Despite this published suggestion there is no study addressing this topic. This study evaluated a possible association between the morphology of the major papilla and the diameter of the terminal CBD (t-CBD). METHODS Observational cross-sectional study including consecutive patients with naïve papillae was referred for ERCP in two affiliated university hospitals. The transverse (p-transv) and longitudinal measures (p-long) of the papilla were obtained using a visual method. Papillae were classified into nonprominent, prominent, bulging or other. The t-CBD was measured 1 cm from the papilla using fluoroscopic images in prone/supine. Measurements were performed by two senior endoscopists and outcomes were evaluated using correlation and linear regression model. RESULTS We included 245 patients with a median age of 76 years. The median p-transv for each type of papillae was as follows: nonprominent = 6 mm, prominent = 9 mm, bulging = 15 mm and other = 6 mm; P < 0.001. The median t-CBD for nonprominent = 7.62 mm, prominent = 8.34 mm, bulging = 8.60 mm and other = 8.52 mm; P = 0.40. The correlation between the transverse and longitudinal measures of papilla and the t-CBD were 0.0092 and 0.0614, respectively. In the regression model, the t-CBD diameter was not explained by papilla's size or morphology (R = 1.70%; P = 0.80). CONCLUSION The morphology of the papilla must not be used as a predictor of the diameter of the CBD as there is no correlation between these two items.
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Hatamaru K, Kitano M. EUS-guided biliary drainage for difficult cannulation. Endosc Ultrasound 2020; 8:S67-S71. [PMID: 31897382 PMCID: PMC6896436 DOI: 10.4103/eus.eus_60_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/29/2019] [Indexed: 12/15/2022] Open
Abstract
EUS-guided biliary drainage (EUS-BD) has been recognized as a new alternative to failed ERCP. The alternatives for failed/impossible ERCP in cases of difficult and selective bile duct cannulation include percutaneous transhepatic BD (PTBD) with precut papillotomy. EUS-BD is reportedly more convenient than PTBD and more successful than precut papillotomy, suggesting that EUS-BD is the next step following failed/impossible ERCP.
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Affiliation(s)
- Keiichi Hatamaru
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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Abstract
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.
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Zhang D, Cheng Y, Xu G, Yin Z, Chen J, Liang F. Evidence for miniscalpel-needle/needle knife in the management of chronic pain related conditions: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e16474. [PMID: 31305481 PMCID: PMC6641680 DOI: 10.1097/md.0000000000016474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/24/2019] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The aim of this systematic review with meta-analysis is to determine the effect of miniscalpel-needle/needle-knife in treatment of chronic pain symptoms. METHODS The following electronic databases will be searched by 2 independent reviewers: PubMed, Cochrane Library, EMBASE, Springer, China National Knowledge Infrastructure (CNKI), Wanfang, and Chinese Biomedical Literature Database (CBM). All randomized controlled trials on miniscalpel-needle/need-knife for chronic pain published in electronic databases from inception to August 1, 2019 with language restricted in Chinses and English will be included in the study.Methodologic quality is assessed by 2 blinded reviewers independently screen and score the articles using the Physiotherapy Evidence Database (PEDro) scale and the Cochrane Collaboration risk of bias tool. A meta-analysis was performed when there is sufficient clinical homogeneity in at least 2 studies. The Grading of Recommendations Assessment, Development and Evaluation approach is used to rate the body of evidence in each meta-analysis. When the quantitive evaluation is not available, a qualitative description of the results of single study is provided. RESULTS A high-quality synthesis of current evidence of miniscapel-needle/needle-knife treating chronic pain will be illustrated using subjective reports and objective measures of performance. The primary outcomes consisted of pain intensity improvement rate clinically meaningful improvements in pain and disability are also noted. Secondary outcomes involve the short form of McGill Pain Questionnaire score (SF-MPQ) and the side effects. CONCLUSION This protocol will present the evidence of whether miniscalpel-needle/needle-knife is an effective intervention for chronic pain. PROSPERO REGISTRATION NUMBER CRD42019129076.
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Lopes L, Canena J. ERCP in Portugal: A Wide Survey on the Prevention of Post-ERCP Pancreatitis and Papillary Cannulation Techniques. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:14-23. [PMID: 30675500 DOI: 10.1159/000487150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/18/2018] [Indexed: 01/05/2023]
Abstract
Background/Aims Recently the European Society of Gastrointestinal Endoscopy delivered guidelines on the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and on the papillary cannulation and sphincterotomy techniques at endoscopic retrograde cholangiopancreatography (ERCP). There are no data concerning current practices in Portugal. The aim of this study was to capture practice patterns of Portuguese pancreaticobiliary endoscopists with special interest in the prevention of PEP and cannulation techniques. Methods A written survey was distributed to all pancreaticobiliary endoscopists attending the first Portuguese meeting dedicated to ERCP in November 2016. The main outcome measures were: technique used for standard biliary cannulation, use of nonsteroidal anti-inflammatory drugs (NSAIDs) in PEP, attempting prophylactic pancreatic stenting after using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation was difficult, and use of precut as the first rescue technique when biliary cannulation was difficult. Results Completed surveys were collected from 28 of the 32 pancreatobiliary endoscopists attending the meeting (answer rate 87.5%). Biliary cannulation was performed using a guidewire access technique by the majority (77%), usually with a sphincterotome. When cannulation was unsuccessful, precut was the first choice for 70%. NSAIDs were administered routinely for PEP by only 54%; PGW-assisted biliary cannulation was the first choice after failed standard cannulation for a minority of them, and only 27% reported to routinely attempt insertion of a pancreatic stent. High-volume endoscopists (> 150/year) tended to use NSAIDs and to insert a stent in PGW-assisted cannulation less often than low-volume-endoscopists (50 vs. 83.3%, p < 0.01, and 40 vs. 100%, p < 0.01, respectively). Precut was started without prior formal training by more than half of the endoscopists. Conclusions There is a pronounced discrepancy between evidence-based guidelines and current clinical practice. This discrepancy is more pronounced in PEP prophylaxis, especially among high-volume endoscopists. Some advanced techniques in ERCP are initiated unsupervised, without any previous formal training. Key Message There is a significant gap between guidelines and routine clinical practice.
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Affiliation(s)
- Luís Lopes
- Department of Gastroenterology, Hospital de Santa Luzia, ULS Alto Minho, Viana do Castelo, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Jorge Canena
- Gastroenterology Center, Hospital Cuf Infante Santo - Nova Medical School/Faculdade de Ciências Médicas da UNL, Lisbon, Portugal.,Department of Gastroenterology, Hospital Amadora-Sintra, Amadora, Portugal.,Department of Gastroenterology, Hospital de Santo António dos Capuchos - CHLC, Lisbon, Portugal.,Cintesis - Center for Health Technology and Services Research, Porto, Portugal
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Nagai K, Katanuma A, Takahashi K, Yane K, Kin T, Maguchi H. A simple and novel marking method for correctly identifying the precutting direction to achieve safe and efficacious precut sphincterotomy (with video). Endosc Int Open 2019; 7:E3-E8. [PMID: 30648133 PMCID: PMC6327752 DOI: 10.1055/a-0752-9755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 05/09/2018] [Indexed: 01/17/2023] Open
Abstract
Background and study aims Failure to recognize the right direction and precise incision length during precutting has been reported. To address these concerns, we developed a marking method that places a marking on the cutting endpoint before starting precutting. This preliminary study aimed to assess the effectiveness and safety of precut sphincterotomy using our new marking method. Patients and methods Between April 2015 and May 2017, 21 patients from our tertiary referral center were included in this study. Precut sphincterotomy using our marking method was employed for difficult common bile duct cannulation cases. Before starting precutting, a marking was placed slightly before the upper margin of the bulge of the papilla in the 11- to 12-o'clock direction as a cutting endpoint by cauterization with a needle knife. Results Technical success was obtained in all 21 procedures. There were no post-endoscopic retrograde cholangiopancreatography (ERCP) complications except for one mild case of post-ERCP pancreatitis. Conclusion Our new marking method before precutting enabled precise incision and quick bile duct cannulation without causing severe complications.
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Affiliation(s)
- Kazumasa Nagai
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan,Corresponding author Kazumasa Nagai, MD Center for GastroenterologyTeine Keijinkai Hospital1-40, 1-jo 12-chome, MaedaTeine-ku, Sapporo 006-8555Japan+81-11-681-8111+81-11-685-2967
| | - Akio Katanuma
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan
| | | | - Kei Yane
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan
| | - Toshifumi Kin
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan
| | - Hiroyuki Maguchi
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan
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Tang Z, Yang Y, Yang Z, Meng W, Li X. Early precut sphincterotomy does not increase the risk of adverse events for patients with difficult biliary access: A systematic review of randomized clinical trials with meta-analysis and trial sequential analysis. Medicine (Baltimore) 2018; 97:e12213. [PMID: 30200135 PMCID: PMC6133433 DOI: 10.1097/md.0000000000012213] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The present study was conducted to investigate whether early precut sphincterotomy (EPS) itself increases the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), bleeding, and perforation, or improves the overall success rates of biliary cannulation. METHODS Four electronical databases were searched systematically for randomized controlled trials (RCTs) reporting the incidence of adverse events for difficult biliary access (DBA) between EPS groups and persistent cannulation attempts (PCA). The primary endpoint was the incidence of PEP. Secondary outcomes were the incidence of bleeding and perforation, and the overall success rates of biliary cannulation. The Mantel-Haenszel method was used to pool data on the outcomes into random-effect models. Heterogeneity, sensitivity, and stratified analyses were performed with Review Manager 5.3. Furthermore, we performed trial sequential analysis (TSA) to evaluate the reliability of the primary endpoint and secondary outcomes. RESULTS Seven RCTs (999 patients with DBA of 10450, 9.5%) were included. The incidence of PEP was significantly lower in EPS groups than PCA (risk ratio [RR] = 0.57, 95% confidence interval [CI] 0.36, 0.92, P = .02). Furthermore, TSA (TSA-adjusted 95% CI 0.30-0.82, P = .0061) and subgroup analysis stratified by the fellow involvement in initial cannulation before randomization, technique of precut, and the definition of DBA confirmed this finding. Success rates of overall cannulation (RR = 1.00, P = .94), bleeding (RR = 1.22, P = .58), and perforation (RR = 1.59, P = .32) were similar in both groups; however, the results of TSA could not confirm these findings. CONCLUSION Both the quality and the quantity of evidence supporting, compared with PCA, EPS itself do not increase the risk of PEP for DBA patients. Moreover, subgroup analysis demonstrated that EPS can significantly decrease the risk of PEP when it is performed by qualified staff endoscopists with using needle-knife fistulutomy earlier for patients with DBA.
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Affiliation(s)
- Zengwei Tang
- The First Clinical Medical School of Lanzhou University
| | - Yuan Yang
- The First Clinical Medical School of Lanzhou University
| | - Zhangfu Yang
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital,Fudan University, and Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Shanghai
| | - Wenbo Meng
- The First Clinical Medical School of Lanzhou University
- Department of Special Minimally Invasive Surgery, The first Hospital of Lanzhou University, Lanzhou
| | - Xun Li
- The First Clinical Medical School of Lanzhou University
- The second department of General Surgery, The first Hospital of Lanzhou University, Lanzhou, China
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Zheng M, Liu X, Li N, Li WZ. Emergency endoscopic needle-knife precut papillotomy in acute severe cholangitis resulting from impacted common bile duct stones at duodenal papilla. Dig Liver Dis 2018; 50:267-270. [PMID: 29361439 DOI: 10.1016/j.dld.2017.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 11/21/2017] [Accepted: 11/21/2017] [Indexed: 12/11/2022]
Abstract
AIM To evaluate the efficacy and safety of emergency endoscopic needle-knife precut papillotomy in acute severe cholangitis resulting from impacted common bile duct stones at duodenal papilla. METHODS Between January 2010 and January 2015, 118 cases of acute severe cholangitis with impacted common bile duct stones at the native papilla underwent emergency endoscopic retrograde cholangiopancreatography (ERCP) and early needle-knife precut papillotomy in a tertiary referral center. Precut techniques were performed according to the different locations of stones in the duodenal papilla. Clinical data about therapy and recovery of the 118 patients were recorded and analyzed. RESULTS One hundred and eighteen patients underwent emergency ERCP within 24 h after hospitalization, with a total success rate of 100%. The mean operating time was 6.4 ± 4.1 min. Postoperative acute physiology and chronic health evaluation (APACHE) II scores, white blood cell count and liver function improved significantly. The complication rate was 4.2% (5/118); two with hemorrhage and three with acute pancreatitis. There was no procedure-related mortality. CONCLUSION Emergency endoscopic needle-knife precut papillotomy is effective and safe for acute severe cholangitis resulting from impacted common bile duct stones at the duodenal papilla.
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Affiliation(s)
- Mingwei Zheng
- Department of Surgery, Tianjin Nankai Hospital, Tianjin, China; Tianjin Medical University, Tianjin, China.
| | - Xufeng Liu
- Department of Surgery, Tianjin Dagang Oilfield General Hospital, Tianjin, China
| | - Ning Li
- Department of Surgery, Tianjin Nankai Hospital, Tianjin, China
| | - Wei-Zhi Li
- Department of Surgery, Tianjin Nankai Hospital, Tianjin, China
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Ryozawa S, Itoi T, Katanuma A, Okabe Y, Kato H, Horaguchi J, Fujita N, Yasuda K, Tsuyuguchi T, Fujimoto K. Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy. Dig Endosc 2018; 30:149-173. [PMID: 29247546 DOI: 10.1111/den.13001] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/10/2017] [Indexed: 02/06/2023]
Abstract
The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.
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Affiliation(s)
- Shomei Ryozawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takao Itoi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akio Katanuma
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hironari Kato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Jun Horaguchi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naotaka Fujita
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kenjiro Yasuda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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de la Morena Madrigal EJ, Rodríguez García MªI, Galera Ródenas AB, Pérez Arellano E. Biliary cannulation effectiveness and pancreatitis risk using two early precut techniques. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 110:74-81. [PMID: 29271219 DOI: 10.17235/reed.2017.5175/2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Precut techniques allow for successful biliary cannulation rates approaching 100% but there may be an associated increase in the risk of complications. Recently, early needle-knife precut has been shown to be a safe procedure and is now used as a pancreatitis prevention resource for difficult cannulation cases. The goal of the present study was to assess cannulation and pancreatitis rates using two early precut techniques. PATIENTS AND METHODS This was a retrospective study of endoscopic retrograde cholangio-pancreatography (ERCP) procedures performed from 2013 to 2016. The efficacy and safety of simple cannulation, needle-knife precut and transpancreatic precut were assessed. RESULTS Simple cannulation was achieved in 369 (73.4%) of 503 evaluable ERCP procedures. Needle-knife precut was successful in 51 (96.2%) of 53 attempts and transpancreatic precut was successful in 75 (96.2%) of 78 attempts. The overall cannulation rate was 98.4%. There were eleven (2.4%) pancreatitis events, six (1.8%) with simple cannulation (two severe, one fatal), five (6.3%) with transpancreatic precut (two severe) and zero events with the needle-knife precut procedure. Among the patients undergoing the precut procedure, seven experienced perforations (two severe) and there were seven bleeding events. The overall complication rate was 14.4%. CONCLUSIONS The complementary use of either precut technique provides a satisfactory biliary cannulation rate. However, the rates of pancreatitis and other severe complications are higher for transpancreatic versus needle-knife precut, therefore the indications for both techniques should be modified.
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Colan-Hernandez J, Aldana A, Concepción M, Chavez K, Gómez C, Mendez-bocanegra A, Martínez-Guillen M, Sendino O, Villanueva C, Llach J, Guarner-Argente C, Cárdenas A, Guarner C. Optimal timing for a second ERCP after failure of initial biliary cannulation following precut sphincterotomy: an analysis of experience at two tertiary centers. Surg Endosc 2017; 31:3711-3717. [DOI: 10.1007/s00464-016-5410-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 12/30/2016] [Indexed: 02/05/2023]
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Chafic AE, Romero RV, Shah JN. Interventional endoscopic ultrasound and advanced endoscopic retrograde cholangiopancreatography access techniques. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017; 19:143-150. [DOI: 10.1016/j.tgie.2017.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Abstract
Gallstone disease is a common and frequently occurring disease in human, and it is the main disease among the digestive system diseases. The incidence of gallstone disease in western countries is about 5%-22%, and common bile duct stones (CBDS) accounts for 8%-20%. CBDS easily lead to biliary obstruction, secondary cholangitis, pancreatitis, and obstructive jaundice, even endanger life. Therefore, it needs timely treatment once diagnosed. The recurrence of choledocholithiasis after bile duct stones clearance involves complicated factors and cannot be completely elaborated by a single factor. The risk factors for recurrence of choledocholithiasis include bacteria, biliary structure, endoscopic and surgical treatment, and inflammation. The modalities for management of choledocholithiasis are endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic or open common bile duct exploration, dissolving solutions, extracorporeal shockwave lithotripsy (ESWL), percutaneous radiological interventions, electrohydraulic lithotripsy (EHL) and laser lithotripsy. We compare the different benefits between surgery and ERCP. And finally, we make a summary of the current strategy for reducing the recurrence of CBDS and future perspectives for CBDS management.
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Affiliation(s)
| | - Sun Qiang
- b Department of General Surgery , Jing'an District Center Hospital of Shanghai (Huashan Hospital Fudan University Jing'an Branch) , Shanghai , PR China
| | - Yin Bao-Bing
- c Department of General Surgery , Huashan Hospital, Fudan University , Shanghai , PR China
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Lee TH, Park SH. Optimal Use of Wire-Assisted Techniques and Precut Sphincterotomy. Clin Endosc 2016; 49:467-474. [PMID: 27642848 PMCID: PMC5066416 DOI: 10.5946/ce.2016.103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/19/2016] [Accepted: 08/19/2016] [Indexed: 12/12/2022] Open
Abstract
Various endoscopic techniques have been developed to overcome the difficulties in biliary or pancreatic access during endoscopic retrograde cholangiopancreatography, according to the preference of the endoscopist or the aim of the procedures. In terms of endoscopic methods, guidewire-assisted cannulation is a commonly used and well-known initial cannulation technique, or an alternative in cases of difficult cannulation. In addition, precut sphincterotomy encompasses a range of available rescue techniques, including conventional precut, precut fistulotomy, transpancreatic septotomy, and precut after insertion of pancreatic stent or pancreatic duct guidewire-guided septal precut. We present a literature review of guidewire-assisted cannulation as a primary endoscopic method and the precut technique for the facilitation of selective biliary access.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital, Soon Chun Hyang University College of Medicine, Cheonan, Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital, Soon Chun Hyang University College of Medicine, Cheonan, Korea
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Singla V, Arora A, Tyagi P, Sharma P, Bansal N, Kumar A. Failed common bile duct cannulation during pregnancy: Rescue with endoscopic ultrasound guided rendezvous procedure. Endosc Ultrasound 2016; 5:201-5. [PMID: 27386479 PMCID: PMC4918305 DOI: 10.4103/2303-9027.183977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Common bile duct (CBD) stones can lead to serious complications and require intervention with either endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic techniques for urgent relief. On an average 10%-20% of the patients with gall bladder stones can have associated CBD stones. CBD stones during pregnancy can be associated with hazardous complications for both the mother and the fetus. Failed cannulation while performing ERCP during pregnancy is a technically demanding situation, which requires immediate rescue with special techniques. Conventional rescue techniques may not be feasible and can be associated with hazardous consequences. Endoscopic ultrasound (EUS) guided rendezvous technique has now emerged as a safe alternative, and in one of our patients, this technique was successfully attempted. To the best of our knowledge, this is the first case report in the literature on EUS-guided rendezvous procedure during pregnancy.
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Affiliation(s)
- Vikas Singla
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Pankaj Tyagi
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Praveen Sharma
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Naresh Bansal
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India
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Lopes L, Dinis-Ribeiro M, Rolanda C. Gaining competence in needle-knife fistulotomy - can I begin on my own? Endosc Int Open 2016; 4:E383-8. [PMID: 27092315 PMCID: PMC4831920 DOI: 10.1055/s-0041-109399] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 11/04/2015] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND While there are guidelines for appropriate training in ERCP, these are non-existent for needle-knife precut. The aim of this study was: (1) evaluate the experience curve of three endoscopists in needle-knife fistulotomy (NKF); (2) propose a minimum number of NKF procedures to attest proficiency. METHODS Between November 1997 and March 2011, the first 120 consecutive NKF performed by three endoscopists (A, B, and C) were selected (360 patients) from three centers. Each group of 120 patients was chronologically ordered into three subgroups of 40. The main outcomes were: NKF use, NKF success, and post-ERCP adverse events. RESULTS The need for NKF did not decrease over time. The NKF success rate in the first attempt for endoscopist A and C in each of the three subgroups was 85 %/85 %, 87.5 %/87.5 %, and 87.5 %/90 %, respectively. Furthermore, both demonstrated a high NKF success in their initial 20 NKFs (85 % and 80 %, respectively). Endoscopist B however presented a different pattern as the success rate initiated at 60 %, then rose to 82.5 % and 85 % for the last group (P = 0.03). Adverse events were mild (28 of the 32 occurrences) with no clear reduction with increased experience. CONCLUSIONS A skillful endoscopist may expect to master NKF easily with few adverse events. While some endoscopists could begin on their own because of their innate skills, a minimal training is needed for all, as we cannot predict skills in advance. We propose a minimum of 20 NKF precuts to attest a trainee's competence in this procedure.
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Affiliation(s)
- Luís Lopes
- Department of Gastroenterology, Hospital of Santa Luzia, Viana do Castelo, Portugal,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal,ICVS/3B’s, PT Government Associate Laboratory, Guimarães/Braga, Portugal,Corresponding author Luís Lopes, MD PhD Hospital de Santa Luzia, Department of GastroenterologyUnidade Local de Saúde do Alto MinhoEstrada de Santa Luzia4901-858Viana do CasteloPortugal+351-252-802577
| | - Mário Dinis-Ribeiro
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal,Department of Gastroenterology, IPO Porto, Portugal
| | - Carla Rolanda
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal,ICVS/3B’s, PT Government Associate Laboratory, Guimarães/Braga, Portugal,Department of Gastroenterology, Hospital Braga, Braga, Portugal
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Mammen A, Haber G. Difficult Biliary Access: Advanced Cannulation and Sphincterotomy Technique. Gastrointest Endosc Clin N Am 2015; 25:619-30. [PMID: 26431594 DOI: 10.1016/j.giec.2015.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Many devices and techniques have been developed to assist in cases of difficult biliary cannulation. Guidewire-assisted cannulation has become the first-line technique for biliary cannulation. Precut sphincterotomy can be safe and effective if used soon after encountering difficulty. Pancreatic duct stents are an important adjunct to reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis in difficult access. Ultimately, cannulation success of greater than 95% and complication rates of less than 5% is the standard that endoscopists doing ERCP should achieve.
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Affiliation(s)
- Anish Mammen
- Lenox Hill Hospital, 100 East 77th St., New York, NY 10075, USA
| | - Gregory Haber
- Division of Gastroenterology, The Center for Advanced Therapeutic Endoscopy, Lenox Hill Hospital, 100 East 77th St., New York, NY 10075, USA.
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Abstract
The precut sphincterotomy is used to facilitate selective biliary access in cases of difficult biliary cannulation. Needle-knife precut papillotomy is the standard of care but is associated with a high rate of complications such as pancreatitis, duodenal perforation, bleeding, etc. Sometimes during bowing of the sphincterotome/cannula and the use of guide wire to facilitate biliary cannulation, inadvertent formation of a false passage occurs in the 10 to 11 o'clock direction. Use of this step to access the bile duct by the intramucosal incision technique was first described by Burdick et al., and since then two more studies have also substantiated the safety and efficacy of this non-needle type of precut sphincterotomy. In this review, we discuss this non-needle technique of precut sphincterotomy and also share our experience using this "Burdick's technique."
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Affiliation(s)
| | - Vijay Kumar Rai
- Institute of Gastro Sciences, Apollo Gleneagles Hospitals, Kolkata, India
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Lee TH, Park DH. Endoscopic prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. World J Gastroenterol 2014; 20:16582-16595. [PMID: 25469026 PMCID: PMC4248201 DOI: 10.3748/wjg.v20.i44.16582] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/11/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is not an uncommon adverse event but may be an avoidable complication. Although pancreatitis of severe grade is reported in 0.1%-0.5% of ERCP patients, a serious clinical course may be lethal. For prevention of severe PEP, patient risk stratification, appropriate selection of patients using noninvasive diagnostic imaging methods such as magnetic resonance cholangiopancreatography or endoscopic ultrasonography (EUS), and avoidance of unnecessary invasive procedures, are important measures to be taken before any procedure. Pharmacological prevention is also commonly attempted but is usually ineffective. No ideal agent has not yet been found and the available data conflict. Currently, rectal non-steroidal anti-inflammatory drugs are used to prevent PEP in high-risk patients, but additional studies using larger numbers of subjects are necessary to confirm any prophylactic effect. In this review, we focus on endoscopic procedures seeking to prevent or decrease the severity of PEP. Among various cannulation methods, wire-guided cannulation, precut fistulotomy, and transpancreatic septostomy are reviewed. Prophylactic pancreatic stent placement, which is the best-known prophylactic method, is reviewed with reference to the ideal stent type, adequate duration of stent placement, and stent-related complications. Finally, we comment on other treatment alternatives, and make the point that further advances in EUS-guided techniques may afford useful PEP prophylaxis.
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Abstract
OBJECTIVE. Although precut is considered an useful alternative when standard methods of biliary access have failed, there is some controversy about it's safety. The study aim was to evaluate the effectiveness of needle-knife fistulotomy (NKF) after a difficult biliary cannulation and whether common bile duct (CBD) diameter influenced complications. MATERIAL AND METHODS. Between November 2006 and December 2010, a total of 1087 consecutive patients with naive papilla were submitted to endoscopic retrograde cholangiopancreatography (ERCP) for biliary access, in an affiliated university hospital. If the biliary cannulation was unsuccessful after 12-15 min, a NKF was performed. The main outcomes were biliary cannulation rate, NKF success and post-ERCP complications. RESULTS. Biliary cannulation by standard methods was successful in 883 patients (81%). In the remaining 204 patients, NKF was performed and allowed CBD access in 166 (81%), leading to a 96% cannulation rate. A second ERCP was performed in 25 patients, with an NKF success of 90% and an overall biliary cannulation rate of 98%. The post-ERCP complication rate was 7.9% (n = 16) with a 6.4% pancreatitis rate and no deaths. The complication for patients with a CBD ≤ to 4 mm was 13.9% compared with 4.5% in the remaining patients (OR = 3.39, p = 0.024). CONCLUSIONS. NKF is a safe and highly useful method of accessing the CBD in the setting of a difficult biliary cannulation. Despite its safety profile, extra caution is needed when applying NKF to patients with thin bile ducts.
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Affiliation(s)
- Luís Lopes
- Department of Gastroenterology, Hospital of Santa Luzia , Viana do Castelo , Portugal
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Navaneethan U, Konjeti R, Venkatesh PGK, Sanaka MR, Parsi MA. Early precut sphincterotomy and the risk of endoscopic retrograde cholangiopancreatography related complications: An updated meta-analysis. World J Gastrointest Endosc 2014; 6:200-208. [PMID: 24891933 PMCID: PMC4024493 DOI: 10.4253/wjge.v6.i5.200] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 03/12/2014] [Accepted: 04/25/2014] [Indexed: 02/05/2023] Open
Abstract
AIM To study the cannulation and complication rates of early pre-cut sphincterotomy vs persistent attempts at cannulation by standard approach. METHODS Systematic search of PubMed, EMBASE, Web of Science, and the Cochrane Library for relevant studies published up to February 2013. The main outcome measurements were cannulation rates and post-endoscopic retrograde cholangiopancreatography (ERCP) complications. A comprehensive systematic search of the Cochrane library, PubMed, Google scholar, Scopus, National Institutes of Health, meta-register of controlled trials and published proceedings from major Gastroenterology journals and meetings until February 2013 was conducted using keywords. All Prospective randomized controlled trials (RCT) studies which met our inclusion criteria were included in the analysis. Prospective non-randomized studies and retrospective studies were excluded from our meta-analysis. The main outcomes of interest were post-ERCP pancreatitis, overall complication rates including cholangitis, ERCP-related bleeding, perforation and cannulation success rates. RESULTS Seven RCTs with a total of 1039 patients were included in the meta-analysis based on selection criteria. The overall cannulation rate was 90% in the pre-cut sphincterotomy vs 86.3% in the persistent attempts group (OR = 1.98; 95%CI: 0.70-5.65). The risk of post-ERCP pancreatitis (PEP) was not different between the two groups (3.9% in the pre-cut sphincterotomy vs 6.1% in the persistent attempts group, OR = 0.58, 95%CI: 0.32-1.05). Similarly, there was no statistically significant difference between the groups for overall complication rate including PEP, cholangitis, bleeding, and perforation (6.2% vs 6.9%, OR = 0.85, 95%CI: 0.51-1.41). CONCLUSION This meta-analysis suggests that pre-cut sphincterotomy and persistent attempts at cannulation are comparable in terms of overall complication rates. Early pre-cut implementation does not increase PEP complications.
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Baek DH, Song GA, Kim DU, Kim GH, Lee BE, Jeon HK, Jhi JH, Bae JH, Lee HJ. [A single institution's experience of infundibulotomy in patients taking antiplatelet agents: outcomes, safety and complications]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2014; 63:216-222. [PMID: 24755746 DOI: 10.4166/kjg.2014.63.4.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS The diagnostic and therapeutic utility of endoscopic retrograde cholangiopancreatography (ERCP) has been well demonstrated for biliary and pancreatic diseases. Biliary access can be allowed by infundibulotomy if failed by using the standard cannulation methods. However, no data are available regarding ERCP-related complications in patients taking antiplatelet agents who are undergoing infundibulotomy. Therefore, we aimed to assess the frequency of ERCP-related complications after infundibulotomy in patients taking antiplatelet agents. METHODS We performed a retrospective study, and enrolled 835 patients who underwent ERCP at Pusan National University Hospital from January 2011 to December 2012. Seventy-two patients had been taking antiplatelet agents prior to the procedure. Patients were classified into two groups according to the utilization of infundibulotomy: 20 patients underwent infundibulotomy (group 1), and 52 patients did not undergo infundibulotomy (group 2). Complications after ERCP were defined as bleeding, post-ERCP pancreatitis, and perforation according to Cotton's criteria. RESULTS Between group 1 and 2, there were no significant differences in baseline characteristics. ERCP was successfully performed in all cases. Clinically significant bleeding was observed in one patient in group 1 (5%, 1/20) versus none in group 2. Post-ERCP pancreatitis was observed in 2 patients (10.0%, 2/20) in group 1, and 7 patients (13.5%, 7/52) in group 2 (p=0.691). However, none of these differences were statistically significant. No perforation occurred in both groups. CONCLUSIONS Considering the low incidence of bleeding after infundibulotomy in patients taking antiplatelet agents, infundibulotomy may be safely performed in this group of patients.
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Affiliation(s)
- Dong Hoon Baek
- Department of Internal Medicine, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 602-739, Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 602-739, Korea
| | - Dong Uk Kim
- Department of Internal Medicine, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 602-739, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 602-739, Korea
| | - Bong Eun Lee
- Department of Internal Medicine, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 602-739, Korea
| | - Hye Kyung Jeon
- Department of Internal Medicine, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 602-739, Korea
| | - Joon Hyung Jhi
- Department of Internal Medicine, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 602-739, Korea
| | - Jung Ho Bae
- Department of Internal Medicine, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 602-739, Korea
| | - Hyun Jeong Lee
- Department of Internal Medicine, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 602-739, Korea
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Lee TH, Hwang SO, Choi HJ, Jung Y, Cha SW, Chung IK, Moon JH, Cho YD, Park SH, Kim SJ. Sequential algorithm analysis to facilitate selective biliary access for difficult biliary cannulation in ERCP: a prospective clinical study. BMC Gastroenterol 2014; 14:30. [PMID: 24529239 PMCID: PMC3929560 DOI: 10.1186/1471-230x-14-30] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 02/10/2014] [Indexed: 01/17/2023] Open
Abstract
Background Numerous clinical trials to improve the success rate of biliary access in difficult biliary cannulation (DBC) during ERCP have been reported. However, standard guidelines or sequential protocol analysis according to different methods are limited in place. We planned to investigate a sequential protocol to facilitate selective biliary access for DBC during ERCP. Methods This prospective clinical study enrolled 711 patients with naïve papillae at a tertiary referral center. If wire-guided cannulation was deemed to have failed due to the DBC criteria, then according to the cannulation algorithm early precut fistulotomy (EPF; cannulation time > 5 min, papillary contacts > 5 times, or hook-nose-shaped papilla), double-guidewire cannulation (DGC; unintentional pancreatic duct cannulation ≥ 3 times), and precut after placement of a pancreatic stent (PPS; if DGC was difficult or failed) were performed sequentially. The main outcome measurements were the technical success, procedure outcomes, and complications. Results Initially, a total of 140 (19.7%) patients with DBC underwent EPF (n = 71) and DGC (n = 69). Then, in DGC group 36 patients switched to PPS due to difficulty criteria. The successful biliary cannulation rate was 97.1% (136/140; 94.4% [67/71] with EPF, 47.8% [33/69] with DGC, and 100% [36/36] with PPS; P < 0.001). The mean successful cannulation time (standard deviation) was 559.4 (412.8) seconds in EPF, 314.8 (65.2) seconds in DGC, and 706.0 (469.4) seconds in PPS (P < 0.05). The DGC group had a relatively low successful cannulation rate (47.8%) but had a shorter cannulation time compared to the other groups due to early switching to the PPS method in difficult or failed DGC. Post-ERCP pancreatitis developed in 14 (10%) patients (9 mild, 1 moderate), which did not differ significantly among the groups (P = 0.870) or compared with the conventional group (P = 0.125). Conclusions Based on the sequential protocol analysis, EPF, DGC, and PPS may be safe and feasible for DBC. The use of EPF in selected DBC criteria, DGC in unintentional pancreatic duct cannulations, and PPS in failed or difficult DGC may facilitate successful biliary cannulation.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan Hospital, 23-20 Bongmyung-dong, Cheonan, South Korea.
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Zhu JH, Liu Q, Zhang DQ, Feng H, Chen WC. Evaluation of early precut with needle-knife in difficult biliary cannulation during ERCP. Dig Dis Sci 2013; 58:3606-10. [PMID: 23975343 DOI: 10.1007/s10620-013-2834-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 07/31/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is scarce information on whether performing the precut procedure early rather than after several cannulation attempts is associated with different success and complication rates. OBJECTIVE The aim of this retrospective study was is to compare the early precut technique with the standard one in terms of the results and complications. METHODS The contemporary success rate and postoperative complications in 792 endoscopic retrograde cholangiopancreatography cases were frequently observed during the period from June 2007 to May 2011, and 56 of these cases were carried out with precut biliary sphincterotomy after the standard sphincterotomy had failed. RESULTS The success rate for standard sphincterotomy was 89.8%: 51 out of 56 cases were carried out with precut biliary sphincterotomy and succeeded. The total success rate was 96.3%. The difference was significant (χ2=25.62, p<0.01) compared to the success rate of first cannulation, while the difference in complication rates between precut and standard sphincterotomy was minor (9.9 vs. 12.5%, p>0.05). CONCLUSION Early precut with a needle-knife in a difficult biliary cannulation was safe and effective if performed by experienced endoscopists.
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Affiliation(s)
- Jian-hong Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
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Tian C, Gamboa A, Chaudhury B, Willingham FF, Keilin S, Cai Q. Cannulation time is a more accurate measure of cannulation difficulty in endoscopic retrograde cholangiopancreatography than the number of attempts. Gastroenterol Rep (Oxf) 2013; 1:193-7. [PMID: 24759965 PMCID: PMC3938000 DOI: 10.1093/gastro/got024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cannulation of the common bile duct (CBD) is the initial and sometime challenging step in endoscopic retrograde cholangiopancreatography (ERCP) procedure. Endoscopists often use cannulation attempts and cannulation time to grade cannulation difficulty, but a standard system has yet to be established. The objective of this study was to compare cannulation times with numbers of cannulation attempts, as measures of cannulation difficulty. METHODS We conducted a prospective study in a tertiary referral center, enrolling 58 patients who were undergoing ERCP for a variety of indications. Cannulation time and the number of cannulation attempts were recorded for each patient. A subset of 14 ERCPs had two observers assessing attempts at cannulation. Cannulation time, number of attempts and inter-observer variability in assessment of attempts were compared and studied. RESULTS The degree of agreement between two the methods (cannulation times and number of cannulation attempts) was unacceptable. There were considerable discrepancies between attempt tallies from two observers but the mean difference was statistically insignificant. CONCLUSION The grade of cannulation difficulty for a given ERCP procedure may differ when different methods are used (total cannulation time vs number of attempts); thus, grading by different methods should not be used interchangeably. Cannulation time is a more objective and more accurate assessment tool for grading cannulation difficulty than the number of attempts to cannulate the papilla.
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Affiliation(s)
- Chenlu Tian
- Division of Digestive Diseases, Emory University, School of Medicine, Atlanta, GA
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Kobayashi G, Fujita N, Imaizumi K, Irisawa A, Suzuki M, Murakami A, Oana S, Makino N, Komatsuda T, Yoneyama K. Wire-guided biliary cannulation technique does not reduce the risk of post-ERCP pancreatitis: multicenter randomized controlled trial. Dig Endosc 2013; 25:295-302. [PMID: 23368891 DOI: 10.1111/j.1443-1661.2012.01372.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 07/20/2012] [Indexed: 12/11/2022]
Abstract
AIM To evaluate the effect of wire-guided biliary cannulation (WGC) on the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). METHODS 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. RESULTS 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). CONCLUSION The WGC technique does not reduce the risk of PEP and also does not improve the success rate of selective bile duct cannulation.
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Affiliation(s)
- Go Kobayashi
- Tohoku Bilio-pancreatic Interventional Endoscopy Group, Tohoku.
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Jamry A. Comparative analysis of endoscopic precut conventional and needle knife sphincterotomy. World J Gastroenterol 2013; 19:2227-2233. [PMID: 23599649 PMCID: PMC3627887 DOI: 10.3748/wjg.v19.i14.2227] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 12/15/2012] [Accepted: 02/08/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the efficacy, complications and post-procedural hyperamylasemia in endoscopic pre-cut conventional and needle knife sphincterotomie.
METHODS: We performed a retrospective analysis of two pre-cut sphincterotomy (PS) techniques, pre-cut conventional sphincterotomy (PCS), and pre-cut needle knife (PNK). The study included 143 patients; the classic technique was used in 59 patients (41.3%), and the needle knife technique was used in 84 patients (58.7%). We analyzed the efficacy of bile duct access, the need for a two-step procedure, the rates of complications and hyperamylasemia 4 h after the procedure, “endoscopic bleeding” and the need for bleeding control. Furthermore, to assess whether the anatomy of the Vater’s papilla, indications for the procedure or the need for additional procedures could inform the choice of the PS method, we evaluated the additive hyperamylasemia risk 4 h after the procedure with respect to the above mentioned variables.
RESULTS: The bile duct access efficacy with PNK and PCS was 100% and 96.6%, respectively, and the difference between the two groups was not significant (P = 0.06). However, the needle knife technique required two-step access significantly more often, in 48.8% vs 8.5% of cases (P < 0.0001). The only complication noted was post-ercp pancreatitis (PEP), which was observed in 4/84 (4.8%) and 2/59 (3.4%) patients submitted to PNK and PSC, respectively; the difference between the two procedures was not significant (P = 0.98). An analysis of other consequences of the techniques yielded the following results in the PNK and PCS groups: hyperamylasemia 4 h after the procedure > 80 U/L, 41/84 vs 23/59 (P = 0.32); hyperamylasemia 4 h after the procedure > 240 U/L, 19/84 vs 11/59 (P = 0.71); pancreatic pain, 13/84 vs 7/59 (P = 0.71); endoscopic bleeding, 10/84 vs 8/59 (P = 0.97); and the need for bleeding control, 10/84 vs 7/59 (P = 0.79). In the next part of the study, we analyzed the influence of the method chosen on the risk of hyperamylasemia with respect to an indication for endoscopic retrograde cholangiopancreatography, papillary anatomy and concomitant procedures performed. We determined that the hyperamylasemia risk was increased by more than threefold [odds ratio (OR) = 3.38; P = 0.027] after PCS in patients with a flat Vater’s papilla and more than fivefold (OR = 5.3; P = 0.049) after the PNK procedure in patients who required endoscopic homeostasis.
CONCLUSION: PCS and PNK do not differ in terms of efficacy or complication rates, but PNK is more often associated with the necessity for a two-step procedure.
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Safety and efficacy of a newly developed baby-sphincterotome for cannulation and precut in cases of failed selective wire-guided bile duct access: a prospective 8-year clinical evaluation. Eur J Gastroenterol Hepatol 2013; 25:195-200. [PMID: 23117469 DOI: 10.1097/meg.0b013e32835a0a84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Precut sphincterotomy (PCS) is a well-established alternative after repeated unsuccessful attempts of common bile duct (CBD) cannulation using standard catheters and/or guide-wire. Commonly used instruments for precutting are the needle-knife and a modified traction-type sphincterotome. In 1996, a so-called 'baby-sphincterotome' with a preshaped, small-caliber 3 Fr tip was developed, which enables cannulation and precutting in one step. OBJECTIVE A clinical evaluation was carried out and the complication rates were determined at a tertiary referral hospital. DESIGN Prospective clinical evaluation. INTERVENTIONS During an 8-year period, a total of 5389 endoscopic retrograde cholangiopancreatographies were performed at our hospital. In total, 1886 patients fulfilled the inclusion criteria for this prospective study. The baby-sphincterotome was used in 345 of 1886 patients (mean age 63.4 ± 16.4 years, 203 women) after five unsuccessful attempts of CBD cannulation using a hydrophilic guide-wire. After two more failed CBD cannulations with the baby-sphincterotome, PCS was performed using the same device. MAIN OUTCOME MEASUREMENTS The success rates of biliary access, postendoscopic retrograde cholangiopancreatography pancreatitis, and bleeding were assessed. RESULTS Initially, the success rate of CBD cannulation on using the baby-sphincterotome was 28% (96/345 patients). Postinterventional pancreatitis occurred in two of 96 patients (2%) and minor bleeding occurred during traction-type sphincterotomy in four of 93 patients (4%). In the remaining 249 patients precut with a baby-sphincterotome, CBD cannulation was achieved in 219 cases (88%), although with pancreatitis and severe bleeding in 4% each. In 30 of 249 patients (12%), a second or a third (n=5) intervention was necessary, with a success rate of 73% (22/30 cases) after PCS. LIMITATIONS This was a single-centre, uncontrolled study. CONCLUSION The newly developed baby-sphincterotome enables bile duct access in a single session in 91% of the patients when guide-wire cannulation has failed. Direct cannulation was possible in about one-quarter of the patients, whereas PCS with the new device showed a high efficacy and a low complication rate.
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Cha SW, Leung WD, Lehman GA, Watkins JL, McHenry L, Fogel EL, Sherman S. Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy-associated pancreatitis? A randomized, prospective study. Gastrointest Endosc 2013; 77:209-16. [PMID: 23084272 DOI: 10.1016/j.gie.2012.08.022] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 08/21/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pancreatitis is the most common major complication of ERCP and precut endoscopic sphincterotomy (ES). Prophylactic pancreatic duct (PD) stent placement has been shown to reduce the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk settings. OBJECTIVE To determine whether leaving a main PD stent in place after precut ES would reduce the incidence and severity of PEP. DESIGN Single-center, randomized, prospective study. SETTING Tertiary care ERCP referral center. PATIENTS Consecutive patients who underwent ERCP with a clear indication for biliary access and standard biliary ES whereby free cannulation of the bile duct was not possible and precut ES was undertaken. INTERVENTIONS When free bile duct cannulation for ES was not possible and selective PD cannulation was achieved, a PD stent was placed. Using the PD stent as a guide, we used a needle-knife sphincterotome to perform precut ES. The patients were then randomized to either leaving the PD stent in place for 7 to 10 days (stent group) or immediate removal after the procedure (stent removed group). The remaining patients who did not undergo selective PD cannulation and stent placement were not randomized (no stent group) and had a free-hand needle-knife ES performed. MAIN OUTCOME MEASUREMENTS Patients were prospectively followed for the development of complications. Standardized criteria were used to diagnose and grade the severity of PEP. RESULTS A total of 151 patients were enrolled. The groups were similar with regard to patient demographics and patient and procedure risk factors for PEP. The overall incidence of PEP was 13.2% (20/151). It occurred in 4.3% (2/46), 21.3% (10/47), and 13.8% (8/58) of patients in the stent, stent removed, and no stent groups, respectively. The stent group had a significantly lower frequency and severity of PEP compared with the stent removed group (4.3% vs 21.3%; P = .027 for frequency and 0% vs 12.8%; P = .026 for moderate and severe pancreatitis). LIMITATIONS Single center. Randomization scheme not optimal. CONCLUSIONS These data suggest that placing and maintaining a PD stent for needle-knife precut ES reduces the frequency and severity of postprocedure pancreatitis.
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Affiliation(s)
- Sang-Woo Cha
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana 46202, USA
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Comparison of three types of precut technique to achieve common bile duct cannulation: a retrospective analysis of 274 cases. Dig Dis Sci 2012; 57:3286-92. [PMID: 22714730 DOI: 10.1007/s10620-012-2271-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 06/01/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this retrospective study was to evaluate the success rate and complications of three precut techniques of sphincterotomy after failure of conventional techniques of cannulation of common bile duct (CBD). PATIENTS AND METHODS Between January 2003 and October 2011, 2,903 consecutive ERCPs were performed in patients with naïve major papilla. In 283 patients in whom biliary cannulation was not achieved, precut technique was performed and these patients were included in the study. RESULTS A total of 274 patients were included in the final analysis. Needle-knife papillotomy (NKP) was performed in 129 cases (47.1 %), suprapapillary fistulotomy (SPF) in 78 patients (28.5 %), and transpancreatic sphincterotomy (TPS) in 67 cases (24.5 %). No significant difference was observed in the initial and eventual success rate of biliary cannulation between the three groups. Overall, complications occurred in 54 patients (19.7 %), of which 33 (25.6 %) were with NKP, 6 (7.7 %) with SPF and 15 (22.4 %) with TPS, respectively, a difference statistically significant favoring the SPF group (p = 0.006). Post-procedure acute pancreatitis was developed in 27 cases (20.9 %) with NKP, compared to two cases (2.6 %) with SPF and 15 cases (22.4 %) with TPS, a difference statistically significant favoring the SPF group. No difference was observed between the groups with regard to the occurrence of post-procedure hemorrhage and perforation. CONCLUSIONS The three types of precut sphincterotomy have no different overall CBD cannulation rates; SPF reduces post-ERCP pancreatitis risk.
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Ayoubi M, Sansoè G, Leone N, Castellino F. Comparison between needle-knife fistulotomy and standard cannulation in ERCP. World J Gastrointest Endosc 2012; 4:398-404. [PMID: 23125897 PMCID: PMC3487187 DOI: 10.4253/wjge.v4.i9.398] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 07/02/2012] [Accepted: 09/12/2012] [Indexed: 02/05/2023] Open
Abstract
AIM: To compare the rates of success and complications of two different methods of access into the common bile duct (CBD).
METHODS: Between October 2007 and November 2008, 173 consecutive patients (71 men, 102 women, mean age 68.6 years) requiring endoscopic retrograde cannulation of the papilla and endoscopic treatment were studied. In the first 88 patients CBD cannulation was performed through supra-papillary fistulotomy (group F); in the following 85 patients standard cannulation was performed through the Oddi sphincter (group S). Indications for the procedure were: choledocholithiasis, biliary obstruction, postoperative leak, sclerosing cholangitis, and Mirizzi’s syndrome.
RESULTS: Deep CBD cannulation was successful in 85/88 patients (96.5%) in group F vs 60/85 patients (70.6%) in group S (P < 0.0001). The remaining 25 group S patients in whom cannulation failed were shifted to fistulotomy. Fistulotomy was successful in 21/25 patients (84%). As for complications, hyperamilasemia occurred in 7 (7.9%) group F patients vs 7 (8.2%) group S patients (P = NS); mild pancreatitis in 1 (1.1%) group F patient vs 5 (5.8%) group S patients (P = NS); bleeding in 3 (3.4%) group F patients vs 3 (3.5%) group S patients (P = NS).
CONCLUSION: Needle-knife fistulotomy should represent either the first approach to therapeutic cannulation or rescue therapy after unsuccessful standard cannulation.
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Affiliation(s)
- Mohammad Ayoubi
- Mohammad Ayoubi, Gianni Sansoè, Nicola Leone, Francesca Castellino, Endoscopy unit, Gradenigo Hospital, 10153 Torino, Italy
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Lim JU, Joo KR, Cha JM, Shin HP, Lee JI, Park JJ, Jeon JW, Kim BS, Joo S. Early use of needle-knife fistulotomy is safe in situations where difficult biliary cannulation is expected. Dig Dis Sci 2012; 57:1384-1390. [PMID: 22258716 DOI: 10.1007/s10620-012-2030-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Accepted: 01/04/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Difficult cannulation is a well known risk for post-ERCP pancreatitis. This study evaluated the outcomes of needle-knife fistulotomy (NKF) used prior to being faced with difficult biliary cannulation. METHODS Patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for the purpose of biliary endotherapy between January 2007 and December 2008 were eligible for this study; 218 patients were recruited. Biliary cannulation was performed only by a standard catheter or a pull type papillotome, without wire-guided assistance in all patients. If selective cannulation was not achieved within five cannulation attempts, NKF was performed, and the results were compared with the easy cannulation group that succeeded biliary cannulation within five attempts. RESULTS Needle-knife fistulotomy (NKF) was performed in 72 (33.0%) of the 218 patients. The total success rate of the ERCP was 98.2% (214/218), and for the NKF group the success rate was 94.4% (68/72). The rate of complications in patients with NKF did not increase compared to patients in the easy cannulation group (P > 0.05): 4.2% (3/72) versus 3.4% (5/146) for acute pancreatitis, 6.9% (5/72) versus 6.8% (10/146) for bleeding, and 1.4% (1/72) versus 0% (0/146) for perforation, respectively. CONCLUSIONS Our results suggest that the use of NKF for biliary cannulation might be safe and effective. Therefore, in experienced hands, early use of NKF might be recommended.
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Affiliation(s)
- Jun Uk Lim
- Department of Gastroenterology, Kyung Hee University Hospital at Gangdong, 892 dongnam-lo, Gangdong-gu, Seoul 134-727, Korea
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Kim J, Ryu JK, Ahn DW, Park JK, Yoon WJ, Kim YT, Yoon YB. Results of repeat endoscopic retrograde cholangiopancreatography after initial biliary cannulation failure following needle-knife sphincterotomy. J Gastroenterol Hepatol 2012; 27:516-20. [PMID: 21913986 DOI: 10.1111/j.1440-1746.2011.06914.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM After failed biliary cannulation with needle knife sphincterotomy (NKS), endoscopic retrograde cholangiopancreatography (ERCP) is sometimes repeatedly performed in clinically stable patients; however, there are few reports about the results. This study assessed the results of repeated ERCPs after failure with NKS. METHODS After failed NKS, patients who underwent repeated ERCP for the same purpose within 3 days were retrospectively identified. Success was defined as deep placement of a catheter into the common bile duct. RESULTS Sixty-nine patients underwent a second ERCP procedure and, of those, six underwent a third ERCP. Of the 69 patients, cannulation was successful in 76.8% (53/69): 46 of 58 patients without additional NKS and 7 of 11 with additional NKS. Success increased to 79.7% (55/69) after the results of the third ERCP were included. Common causes of failed NKS were biliary deep cannulation failure (78.3%) and blocking of the endoscopic view due to bleeding (13.0%). There was a significant difference in success rates between the one day (65.7%) and the combined 2-3 day (88.2%) cases (P = 0.027). Except for the interval between ERCPs, there were no other factors associated with success rates. Complications occurred in 8, 11, and one patient after initial, second, and third ERCP and there was no difference of complication rates between each ERCPs. CONCLUSIONS In cases with biliary cannulation failure with NKS, it is more worthwhile repeating ERCP 2 or 3 days after such failure than one day after, if the patient's condition permits delay of procedure.
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Affiliation(s)
- Jaihwan Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Dhir V, Bhandari S, Bapat M, Maydeo A. Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access (with videos). Gastrointest Endosc 2012; 75:354-359. [PMID: 22248603 DOI: 10.1016/j.gie.2011.07.075] [Citation(s) in RCA: 156] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 07/04/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Precut papillotomy after failed bile duct cannulation is associated with an increased risk of pancreatitis. EUS-guided rendezvous drainage is a novel alternative technique, but there are no data comparing this approach with precut papillotomy. OBJECTIVE To evaluate the safety and efficacy of EUS-guided rendezvous drainage of the bile duct and compare its outcome with that of precut papillotomy. DESIGN Retrospective study. SETTING Tertiary care referral center. PATIENTS Consecutive patients with distal bile duct obstruction, in whom selective cannulation of the bile duct at ERCP failed after 5 attempts with a guidewire and sphincterotome, underwent an EUS-guided rendezvous procedure. The outcomes were compared with those in a historical cohort of patients who underwent precut papillotomy. INTERVENTIONS Patients in whom selective cannulation failed underwent EUS-guided rendezvous drainage by use of the short wire technique or precut papillotomy by use of the Erlangen papillotome. At EUS, after the extrahepatic bile duct was punctured with a 19-gauge needle, a hydrophilic angled-tip guidewire 260 cm long was passed in an antegrade manner across the papilla into the duodenum. The echoendoscope was then exchanged for a duodenoscope, which was introduced alongside the EUS-placed guidewire. The transpapillary guidewire was retrieved through its biopsy channel, and accessories were passed over the wire to perform the requisite endotherapy. MAIN OUTCOME MEASURES Comparison of the rates of technical success and complications between patients treated by the EUS-guided rendezvous and those treated by precut papillotomy techniques. Treatment success was defined as completion of the requisite endotherapy in one treatment session. RESULTS Treatment success was significantly higher for the EUS-guided rendezvous (57/58 patients) than for those undergoing precut papillotomy technique (130/144 patients) (98.3% vs 90.3%; P = .03). There was no significant difference in the rate of procedural complications between the EUS and precut papillotomy techniques (3.4% vs 6.9%, P = .27). LIMITATIONS Retrospective nonrandomized study design; highly selective patient cohort. CONCLUSIONS In this study, the EUS-guided rendezvous technique was found to be superior to precut papillotomy for single-session biliary access. Prospective randomized trials are needed to confirm these preliminary but promising findings.
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Affiliation(s)
- Vinay Dhir
- Institute of Advanced Endoscopy, Mumbai, India
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Precut fistulotomy for difficult biliary cannulation: is it a risky preference in relation to the experience of an endoscopist? Dig Dis Sci 2011; 56:1896-903. [PMID: 21082346 DOI: 10.1007/s10620-010-1483-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Accepted: 10/26/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several studies have reported on the correlation between the experience level of an endoscopist and the outcomes of precut procedures. However, there are limited data on the early use of the precut fistulotomy in relation to the experience of an endoscopist. AIM To evaluate the efficacy and safety of precut fistulotomy in difficult biliary cannulation after ERCP training. METHODS Two endoscopists, one at each tertiary referral center, performed the precut fistulotomy for difficult biliary cannulation between September 2008 and February 2010. The technical success, complications, and clinical outcomes in three groups were recorded prospectively over time. RESULTS A total of 159 (23.1%) patients underwent precut fistulotomy. The mean procedure time was decreased as the number of procedures increased (p < 0.01). The success rates of selective biliary cannulation in the three groups were 86.8, 86.8, and 88.7% respectively, for the first attempt (p = 0.77) and 93.7% for the second attempt. Post-ERCP pancreatitis developed in nine (5.7%) patients, which was not statistically significant between the three groups. As the frequency of papillary contacts increased, post-ERCP pancreatitis tended to increase (p = 0.017). In the multivariate analysis, more than 15 attempts at cannulating the major papilla prior to fistulotomy was a risk factor for pancreatitis (odds ratio 4.8, 95% CI 1.178-19.580, p = 0.029). CONCLUSIONS After therapeutic ERCP training involving at least 100 ERCPs, including at least half that were therapeutic cases and more than ten that were precut papillotomies, a precut fistulotomy can be performed safely and effectively in low-risk patients.
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Artifon ELA, da Silveira EB, Aparicio D, Takada J, Baracat R, Sakai CM, Garcia RT, Teich V, Couto DS. Management of common bile duct stones in cirrhotic patients with coagulopathy: a comparison of supra-papillary puncture and standard cannulation technique. Dig Dis Sci 2011; 56:1904-11. [PMID: 21318589 DOI: 10.1007/s10620-011-1593-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Accepted: 01/21/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND STUDY AIMS Bleeding is not uncommon following endoscopic sphincterotomy. Supra-papillary puncture (SPP) might be safer than standard cannulation (SC) techniques in patients with coagulopathy. The aim of the study was to compare the safety and effectiveness of SPP and SC. PATIENT AND METHODS This was a prospective case control intervention study. Decompensated cirrhotic patients with coagulopathy and choledocolithiasis underwent SC and SPP methods for biliary access. RESULTS One hundred five patients (56 [53.3%] men, mean [SD] age 56 [15.8]) underwent ERCP. SC and SPP were performed in 63 and 42 patients, respectively. Biliary access was achieved in 56/63 (89%) and 40/42 (95%) of patients undergoing SC and SPP, respectively (P = 0.13; 95% CI [-0.16; 0.03]). Complications occurred in 10/63 (15.8%) patients undergoing SC and 5/42 (11.9%) SPP (P = 0.28; 95% CI [-0.17, 0.16]). Five (7.9%) and two (3.2%) episodes of post-sphincterotomy bleeding was seen in the SC and SPP groups, respectively (P = 0.36; 95% CI [-0.16, 0.05]). In contrast, three (4.8%) episodes of pancreatitis were seen in the SC and none in the SPP group (P = 0.05; 95% CI [0.001; 0.004]). A cost-effectiveness analysis demonstrated that SPP is an acceptable alternative at an ICER of US$ 5,974.92 per additional successful procedure. CONCLUSION SPP is a safe and effective technique for the management of common bile duct stones in decompensated cirrhotic patients. Conditional to the willingness-to-pay and to the local ERCP-related costs, SPP is also a cost-effective alternative to the SC methods. SPP is associated with a lower rate of complications but larger studies to validate these findings are necessary.
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Park SH, Park DH, Lee TH, Lee HS, Lee YS, Lee SH, Lee CK, Lee SH, Chung IK, Kim HS, Lee HJ, Kim SJ. Feasibility of the mucosa-tracking technique in precut papillotomy with the iso-tome as an alternative to the needle-knife technique. Gut Liver 2010; 4:76-83. [PMID: 20479916 DOI: 10.5009/gnl.2010.4.1.76] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 12/01/2009] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND/AIMS 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). METHODS 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). RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Sang-Heum Park
- Division of Gastroenterology/Hepatology, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Udd M, Kylänpää L, Halttunen J. Management of difficult bile duct cannulation in ERCP. World J Gastrointest Endosc 2010; 2:97-103. [PMID: 21160709 PMCID: PMC2999064 DOI: 10.4253/wjge.v2.i3.97] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 01/29/2010] [Accepted: 02/05/2010] [Indexed: 02/05/2023] Open
Abstract
In Encoscopic Retrograde Cholangiopancreatography (ERCP), the main concern is to gain access into the bile duct while avoiding the pancreatic duct because of the risk of post-ERCP pancreatitis. Difficult cannulation is defined as a situation where the endoscopist, using his/her regularly used cannulation technique, fails within a certain time limit or after a certain number of unsuccessful attempts. Different methods have been developed to manage difficult cannulation. The most common solution is to perform a precut papillotomy either with a needle knife or with a sphincterotome with or without a guide wire. This review describes different methods to overcome cases of difficult cannulation. We will discuss the success rate and complication rates associated with different methods of reaching the biliary tract.
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Affiliation(s)
- Marianne Udd
- Marianne Udd, Leena Kylänpää, Jorma Halttunen, Department of Gastrointestinal and General Surgery, Helsinki University Central Hospital, POB 340, HUS 00029, Helsinki, Finland
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Kethu SR, Adler DG, Conway JD, Diehl DL, Farraye FA, Kantsevoy SV, Kaul V, Kwon RS, Mamula P, Pedrosa MC, Rodriguez SA, Tierney WM. ERCP cannulation and sphincterotomy devices. Gastrointest Endosc 2010; 71:435-45. [PMID: 20189502 DOI: 10.1016/j.gie.2009.07.038] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Accepted: 07/28/2009] [Indexed: 12/12/2022]
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Yoon KW, Park CH, Park SY, Cho SB, Lee WS, Joo YE, Kim HS, Choi SK, Rew JS. Guidewire cannulation increases the success rate of needle-knife fistulotomy for difficult bile duct access. J Gastroenterol Hepatol 2010; 25:14-8. [PMID: 19780878 DOI: 10.1111/j.1440-1746.2009.05947.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIM Selective bile duct cannulation is a prerequisite for performing therapeutic endoscopic biliary intervention. This study aimed to evaluate if using a soft-tipped guidewire to cannulate the bile duct would increase the success rate of needle-knife fistulotomy for difficult bile duct access. METHODS We reviewed sixty 60 patients with difficult bile duct access who underwent conventional cannulation with radiocontrast dye (29) or guidewire cannulation (31) after needle-knife fistulotomy. RESULTS There were no significant differences in the demographic data between the two groups. The initial success rate of selective bile duct cannulation was significantly higher in the guidewire cannulation group compared with the conventional cannulation group: 100% versus 79.3%, P = 0.009. The success rate of selective biliary cannulation in the patients with non-dilated common bile duct (< 8 mm) was significantly higher in the guidewire cannulation group compared with the conventional cannulation group: 100% versus 68.4%, P = 0.003. The incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis was not significantly different between the two groups. No serious complications occurred in either group. CONCLUSIONS In this retrospective and small case series, guidewire cannulation after needle-knife fistulotomy increased the success rate of selective bile duct cannulation in patients with difficult bile duct access.
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Affiliation(s)
- Kyoung W Yoon
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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Cennamo V, Fuccio L, Zagari RM, Eusebi LH, Ceroni L, Laterza L, Fabbri C, Bazzoli F. Can a wire-guided cannulation technique increase bile duct cannulation rate and prevent post-ERCP pancreatitis?: A meta-analysis of randomized controlled trials. Am J Gastroenterol 2009; 104:2343-50. [PMID: 19532133 DOI: 10.1038/ajg.2009.269] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The most common technique used to achieve primary deep biliary cannulation is the standard contrast-assisted method. To increase the success rate and reduce the risk of complications, a wire-guided cannulation strategy has been proposed. Prospective studies provided conflicting results as to whether the wire-guided cannulation technique increases the cannulation rate and reduces post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis risk compared with the standard method. The objective of this study was to carry out a meta-analysis of randomized controlled trials (RCTs) that compares primary biliary cannulation and post-ERCP pancreatitis rates with the wire-guided method and the standard cannulation technique. METHODS Literature searches of electronic databases and online clinical trial registers up to March 2009 were conducted to identify RCTs comparing primary cannulation and post-ERCP pancreatitis rates with the wire-guided method and the standard cannulation technique. A meta-analysis of these clinical trials was performed. RESULTS Five RCTs were included. Overall, the primary cannulation rates reported with the wire-guided cannulation technique and the standard method were 85.3 and 74.9%, respectively. The pooled analysis of all the selected studies comparing the wire-guided cannulation technique with the standard method yielded an odds ratio (OR) of 2.05 (95% confidence interval (CI): 1.27-3.31). The pooled analysis comparing the post-ERCP pancreatitis rates for the wire-guided-cannulation groups with those for the standard-method groups yielded an OR of 0.23 (95% CI: 0.13-0.41). CONCLUSIONS This meta-analysis shows that the wire-guided technique increases the primary cannulation rate and reduces the risk of post-ERCP pancreatitis compared with the standard contrast-injection method. Further large, well-performed, randomized controlled studies are needed to confirm these findings.
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Affiliation(s)
- Vincenzo Cennamo
- Department of Internal Medicine and Gastroenterology, University of Bologna, Bologna 40138, Italy
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Goasguen N, Bourrier A, Ponsot P, Bastien L, Lesurtel M, Prat F, Dousset B, Sauvanet A. Endoscopic management of pancreatic fistula after distal pancreatectomy and enucleation. Am J Surg 2009; 197:715-20. [DOI: 10.1016/j.amjsurg.2008.03.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2007] [Revised: 03/14/2008] [Accepted: 03/14/2008] [Indexed: 10/21/2022]
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