Transpancreatic biliary sphincterotomy for biliary access is safe also on a long-term scale

Abstract

Background Transpancreatic biliary sphincterotomy (TPBS) is an advanced cannulation method for accessing common bile duct (CBD) in endoscopic retrograde cholangiopancreatography (ERCP). If CBD cannulation is difficult, an endoscopist can open the septum between the pancreatic and biliary duct with a sphincterotome to gain access. Long-term results of this procedure are unclear. We wanted to evaluate the short-and long-term complications of TPBS on patients with native papilla and benign indication for ERCP. Patients and Methods ERCPs performed in Helsinki University Hospital between 2007 and 2013 were reviewed. The study group comprised 143 consecutive patients with TPBS and 140 controls (CG). Data were collected from patient records and a phone survey was performed as a follow-up ≥ 4 years after the index ERCP. Results Post-ERCP pancreatitis (PEP) developed in seven patients (4.9%) in TPBS and one patient (0.7%) in CG (p = 0.067). The rates of other acute complications were similar between the groups. ERCP ended with no access to CBD in four cases (2.8%) in TPBS. The median length of follow-up was 6 years in TPBS and 7 years in CG. During this period, three patients (2.1%) in TPBS and six patients (4.3%) in CG suffered from acute pancreatitis (AP) (p = 0.238). One (0.7%) patient in CG and none in TPBS developed chronic pancreatitis (CP). Abdominal pain was suffered by ten patients (6.9%) in TPBS and twelve patients (8.6%) in CG daily, whereas by six patients (4.2%) in TPBS and twelve patients (8.6%) in CG weekly. Conclusion TPBS is a useful procedure, with acceptable complication rates. No significant difference occurred between the groups when evaluating the short-term or long-term complications with a follow-up period of four to 10 years. Additionally, no significant differences occurred in upper abdominal pain, episodes of AP, or development of CP.

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

“…Concerns related to long-term complications of TPBS have been expressed [22,34]. A recent retrospective casecontrol study from Helsinki found similar long-term complication rates between the TPBS group and a control group in which only biliary sphincterotomy was performed [35]. We plan to perform a follow-up study of the present multicenter trial in order to assess the long-term adverse events associated with TPBS.…”

Biliary Cannulation in Endoscopic Retrograde Cholangiography: How to Tackle the Difficult Papilla

“…Theoretical concerns of TPS-related long-term consequences like PD stenosis [54] have not been confirmed in one prospective study [52]; however, studies comprising follow-up beyond 1 year have been stipulated [55]. In 2020, 2 retrospective single-center studies from Finland (n = 143) [56] and from the Stanford University (n = 369) [57] found TPS to be safe even on a long-term scale [56]. Compared to needle-knife precut, a 2017 meta-analysis [32] showed significantly higher biliary cannulation rates and less bleeding complications for TPS, while PEP risk was not significantly different.…”

“…Furthermore, a prospective randomized multicenter study published in 2021 compared TPS and DGW and found no difference in PEP-risk but a superior biliary cannulation rate for TPS (84.6% vs. 69.7%) [68]. Promoting TPS as an advanced technique early in the course of DBC [50,56,57] is also supported by the meta-analysis data displaying a higher cannulation success and lower bleeding rate for TPS even when compared to the long-time standard NKPP [32]. In situations with DBC as defined by the ESGE "5-5-2 criteria" [1], a recent study labeled TPS an "effective advanced cannulation method with an acceptable complication rate" [8].…”

Reply to Sundaram and Jagtap

“…In our recent case-control study, 143 TPBS patients and 140 control patients were followed for 4-10 years after index ERCP. No difference in long-term complications occurred between the groups [4]. Sundaram and Jagtap, as well as guidelines from the European Society of Gastrointestinal Endoscopy [3], suggest that in difficult cannulation situations, a prophylactic pancreatic stent should be placed and rectal nonsteroidal anti-in-flammatory drugs (NSAIDs) administered to prevent PEP.…”