Guideline 657Testoni Pier Alberto et al. Papillary cannulation and sphincterotomy techniques at ERCP… Endoscopy 2016; 48: 657-683 This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It provides practical advice on how to achieve successful cannulation and sphincterotomy at minimum risk to the patient. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations1 ESGE suggests that difficult biliary cannulation is defined by the presence of one or more of the following: more than 5 contacts with the papilla whilst attempting to cannulate; more than 5 minutes spent attempting to cannulate following visualization of the papilla; more than one unintended pancreatic duct cannulation or opacification (low quality evidence, weak recommendation). 2 ESGE recommends the guidewire-assisted technique for primary biliary cannulation, since it reduces the risk of post-ERCP pancreatitis (moderate quality evidence, strong recommendation). 3 ESGE recommends using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation is difficult and repeated unintentional access to the main pancreatic duct occurs (moderate quality evidence, strong recommendation). ESGE recommends attempting prophylactic pancreatic stenting in all patients with PGW-assisted attempts at biliary cannulation (moderate quality evidence, strong recommendation). 4 ESGE recommends needle-knife fistulotomy as the preferred technique for precutting (moderate quality evidence, strong recommendation). ESGE suggests that precutting should be used only by endoscopists who achieve selective biliary cannulation in more than 80 % of cases using standard cannulation techniques (low quality evidence, weak recommendation). When access to the pancreatic duct is easy to obtain, ESGE suggests placement of a pancreatic stent prior to precutting (moderate quality evidence, weak recommendation).5 ESGE recommends that in patients with a small papilla that is difficult to cannulate, transpancreatic biliary sphincterotomy should be considered if unintentional insertion of a guidewire into the pancreatic duct occurs (moderate quality evidence, strong recommendation). In patients who have had transpancreatic sphincterotomy, ESGE suggests prophylactic pancreatic stenting (moderate quality evidence, strong recommendation). 6 ESGE recommends that mixed current is used for sphincterotomy rather than pure cut current alone, as there is a decreased risk of mild bleeding with the former (moderate quality evidence, strong recommendation). 7 ESGE suggests endoscopic papillary balloon dilation (EPBD) as an alternative to endoscopic sphincterotomy (EST) for extracting CBD stones < 8 mm in patients without anatomical or clinical contraindications, especially in the presence of coagulopathy or altered anatomy (moderate quality evidence, strong recommendation). 8 ESGE does not recommend r...

Capsule endoscopy is an effective and well-tolerated method for evaluating small-bowel pathology in patients with PJS.

Background: The precut timing during the biliary cannulation algorithm is a subject of controversy. Some studies suggest that early institution of precut is a safe and effective strategy even though the extent to which this approach may affect the duration of the ERCP is seldom addressed.

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.