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

Abstract

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

How to access the common bile duct

“…The method was spearheaded by the Helsinki group, who showed that the method compared favorably to free-hand precut in a large retrospective multicenter trial [15] . More recently, a systematic review also concluded that the method offered a higher cannulation success rate compared to the relevant alternatives, with a similar complication rate [16] . A recent randomized comparison found a comparable PEP risk, but a higher cannulation success rate (85% vs. 70%) in transpancreatic sphincterotomy vs. double-wire technique [17] .…”

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

“…6. Evidence-based ESGE algorithm for biliary cannulation in ERCP [1], modified according to local standards and update of evidence [46,68]. The exact technique/sequence of techniques for overcoming a DBC situation should always be selected after careful consideration with regard to patient anatomy, underlying pathology, and endoscopist's preference and level of expertise.…”

Reply to Sundaram and Jagtap

“…We thank Drs. Sundaram and Jagtap for their comments concerning our article "Transpancreatic biliary sphincterotomy versus double guidewire in difficult biliary cannulation: a randomized controlled trial," which was recently published in Endoscopy [1]. In our multicenter study, transpancreatic biliary sphincterotomy (TPBS) was performed when the guidewire was inside the pancreatic duct (PD) and access to the common bile duct (CBD) was gained by cutting the septum between the PD and CBD with the sphincterotome toward the 11 o'clock position.…”