If the increasing rate of PEP is taken as defining factor, the wire-guided cannulation of a native papilla can be considered difficult after 5 min, five attempts, and two pancreatic guide-wire passages when any of those limits is exceeded.
Background and Aims: Certain appearances of the major duodenal papilla have been claimed to make cannulation more difficult during ERCP. This study uses a validated classification of the endoscopic appearance of the major duodenal papilla to determine if certain types of papilla predisposes to difficult cannulation. Methods: Patients, with a naïve papilla, scheduled for ERCP, were included. The papilla was classified into one of 4 papilla types before cannulation started. Time to successful bile duct cannulation, attempts and number of pancreatic duct passages were recorded. Difficult cannulation was defined as, after 5 minutes, 5 attempts, or 2 pancreatic guide-wire passages. Results: One thousand four hundred one patients were included from 9 different centers in the Nordic countries. The overall frequency of difficult cannulation was 42% (95% CI, 39%-44%). Type 2, small papilla, (52%; 95% CI, 45%-59%) and Type 3 protruding or pendulous papilla (48%; 95% CI, 42%-53%) were more frequently difficult to cannulate compared with Type 1, regular papilla (36%; 95% CI, 33%-40%, both p<0.001). If an inexperienced endoscopist started cannulation, the frequency of failed cannulation increased from 1.9% to 6.3% (p<0.0001), even though they were replaced by a senior endoscopist after 5 minutes. Conclusion: The endoscopic appearance of the major duodenal papilla influences bile duct cannulation. Small, Type 2, and protruding or pendulous Type 3 papillae are more frequently
A 6-month treatment with either six 10-Fr plastic stents or with one 10-mm cSEMS produced good long-term relief of biliary stricture caused by chronic pancreatitis.Study registered at ClinicalTrials.gov (NCT01085747).
Background Pancreatic duct disruption is common and is associated with high morbidity in cases of acute necrotizing pancreatitis (ANP). In this study, we tested the feasibility and safety of prophylactic pancreatic duct stenting (PPDS) in ANP and compared PPDS with conservative treatment.
Methods We prospectively enrolled patients (aged 18 – 75 years) diagnosed with ANP between February 2011 and July 2015. These patients were prospectively randomized to receive PPDS or conservative treatment at two tertiary centers. PPDS was performed as soon as possible after randomization.
Results Concern regarding iatrogenic infections with pancreatic necrosis in the PPDS group prompted interim analysis, which confirmed a highly elevated risk. Thus, the trial was terminated prematurely for ethical reasons. Of the 11 patients in the PPDS group, all patients with successful pancreatic duct placement (5/5, 100 %) presented with infection, compared with only 3 of the 13 patients (23.1 %) in the conservative treatment group (P = 0.01). Analysis revealed success rates of 63.6 % for pancreatic duct cannulation, 45.5 % for pancreatic duct stenting, and 18.2 % for placement of a stent bridging the necrosis. Cannulation and stenting failures were due to duodenal edema and pancreatic duct stenosis.
Conclusions PPDS in ANP is associated with an unacceptably high risk of pancreatic necrosis infection. In addition, the procedure is technically challenging due to duodenal edema and ductal stenosis.
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