Pancreatic guidewire placement for achieving selective biliary cannulation during endoscopic retrograde cholangio-pancreatography

Abstract

CONCLUSION: P-GW is useful for achieving selective biliary cannulation. Pancreatic duct stenting after P-GW can reduce the incidence of post-ERCP pancreatitis, which requires evaluation by means of prospective randomized controlled trials. INTRODUCTIONEndoscopic retrograde cholangio-pancreatography (ERCP), which was first reported in the late 1960's [1] , is a well-accepted technique for evaluating pancreatobiliary diseases. Although selective cannulation of the bile duct is mandatory for therapeutic ERCP of biliary diseases, anatomical difficulties or papillary spasm sometimes preclude it. Numerous techniques have been developed for selective biliary cannulation [2,3] . Pancreatic guidewire placement (P-GW) has been reported to be effective in patients with difficult cannulation of the bile duct [4][5][6][7] . Since P-GW is usually attempted in patients with difficult cannulation of the bile duct, this technique entails a possible increased risk of post-ERCP pancreatitis. The aim of this study was to investigate the frequency and risk factors for acute pancreatitis after P-GW in achieving cannulation of the bile duct during ERCP. Abstract AIM: To investigate the frequency and risk factors for acute pancreatitis after pancreatic guidewire placement (P-GW) in achieving cannulation of the bile duct during endoscopic retrograde cholangio-pancreatography (ERCP). METHODS: P-GW was performed in 113 patients in whom cannulation of the bile duct was difficult. The success rate of biliary cannulation, the frequency and risk factors of post-ERCP pancreatitis, and the frequency of spontaneous migration of the pancreatic duct stent were investigated. RESULTS: Selective biliary cannulation with P-GW was achieved in 73% of the patients. Post-ERCP pancreatitis occurred in 12% (14 patients: mild, 13; moderate, 1). Prophylactic pancreatic stenting was attempted in 59% of the patients. Of the 64 patients who successfully underwent stent placement, three developed mild pancreatitis (4.7%). Of the 49 patients without stent placement, 11 developed pancreatitis (22%: mild, 10; moderate, 1). Of the five patients in whom stent placement was unsuccessful, two developed mild pancreatitis. Univariate and multivariate analyses revealed no pancreatic stenting to be the only significant risk factor for pancreatitis. Spontaneous migration of the stent was observed within two weeks in 92% of the patients who had undergone pancreatic duct stenting.

A multicenter, prospective, randomized study of selective bile duct cannulation performed by multiple endoscopists: the BIDMEN study

“…The reported time limits within which the regularly used SBDC technique is used vary between 10 and 30 min [3][4][5][6][11][12][13]. The 15-to 30-min limits are used less consistently [14][15][16][17][18][19][20]. More refined methodology appears to be necessary to clarify the definition of the allocated procedure time regarding SBDC.…”

Advances in endoscopic retrograde cholangiopancreatography cannulation

“…PostERCP pancreatitis occurred in 12% of patients. The rate of pancreatitis was lower in patients who underwent prophylactic pancreatic stenting (4.7%) compared to those who did not (22%) [36] . In a later study of 107 patients undergoing ERCP, selective biliary cannulation was difficult in 53 patients (unsuccessful after 10 min) and these patients were randomly assigned to either preinsertion of a guide wire into the pancreatic duct or persistent attempts with a conventional catheter [35] .…”

Management of difficult bile duct cannulation in ERCP

“…Of course, if endoscopic methods fail, the transhepatic route can be used directly without an endoscopist or the rendezvous technique can be applied, depending on the problem. [3,30] Standard catheter with guide wire 81 [3] Sphincterotome 78 to 84 [4,29] Sphincterotome with guide wire 97 to 99 [26,30] Success in difficult cannulation after primary failure with standard method Persistence 73 to 75 [2,49] Needle knife 67 to 91 [2,6,9,34,37] Erlangen knife 78 to 100 [32,50] Pancreatic sphincterotomy 91 to 100 [10,12,13,22,40,41] Pancreatic stent 97 to 100 [28,47] Pancreatic guide wire 73 to 93 [5,8] Pancreatitis rate after difficult cannulation Persistence 2-4 [2,49] Needle knife 1-11 [2,6,9,34,37] Erlangen knife 3-7 [32,50] Pancreatic sphincterotomy 0-12 [10,12,13,22,40,41] Pancreatic stent 5-7 [28,47] Pancreatic guide wire 0-2 [5,8] Randomized controlled tri...…”

“…The 15-to 30-min limits are used less consistently [7][8][9][10][11][12] . In addition to time, when defining difficulty the number of passages or contrast injections into the pancreatic duct must also be considered.…”