Biliary cannulation with contrast and guide-wire versus exclusive guide-wire: A prospective, randomized, double-blind trial

Pereira-Lima, Júlio Carlos; Sanmartin, Ivan David Arciniegas; Watte, Guilherme; Contin, Isabela; Pereira-Lima, Guilherme; Onófrio, Fernanda de Quadros; Altmayer, Stephan; Santos, Carlos Eduardo Oliveira dos

doi:10.1016/j.pan.2020.12.018

Cited by 5 publications

(5 citation statements)

References 25 publications

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“…1 Interestingly, it has been seen that an early application of NKS can actually reduce the overall risk of complications, especially PEP from 6.1% to 3.9%. 13 In our study NKS was not found to be responsible for PEP through univariate and logistic regression analysis. Although the risk of PEP was low for our study (3.5%) the only factor that did contribute to the occurrence of PEP was inadvertent PD cannulation.…”

Section: Discussioncontrasting

confidence: 47%

“…The rate of PEP for our study was comparable to many large-centre randomized studies 14 and the fact that precut is not associated with increased risk of PEP was also supported by multiple similar studies. 1,[12][13][14][15][16][17] However, a local study reported pre-cut and NKS as a significant contributor towards PEP with 64% of the total PEP cases being directly related to pre-cut sphincterotomy. 6 This raises the question whether pre-cut PEP is operator dependent and if yes, whom should be allowed to do biliary sphincterotomies?…”

Section: Discussionmentioning

confidence: 99%

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Does early application of needle-knife sphincterotomy (NKS) in patients with difficult biliary cannulation increase the risk of postERCP pancreatitis? A single centre study

Khan

Alam²,

Saeed

et al. 2023

Pak J Med Sci

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Objective: To determine that early needle-knife sphincterotomy does not increase post-ERCP pancreatitis in patients with difficult biliary cannulation as compared to standard cannulation. Method: This prospective single-centre cohort study was carried out at Pak Emirates Military Hospital from January 2021 to June 2021. Patients requiring ERCP were enrolled in the study (according to inclusion and exclusion criteria) and were subsequently allotted different groups according to the technique used for deep biliary cannulation. Qualitative data was analysed using frequencies and chi square statistics whereas, quantitative data was analysed using mean±SD and one way ANOVA test. Result: The cohort included 114 patients with 52.6% male patients and predominance of relatively younger age group (31-45 years). The most common indication for ERCP was choledocholithiasis (36%) with an overall technical success rate of 96%. Deep cannulation was achieved either through standard cannulation (56%), double guidewire and/or pancreatic stent assisted (10.5%), use of early Needle-Knife Sphincterotomy (19%), NKS as a last resort (3.5%) or Transpancreatic Stenting and/or combined sphincterotomy (6%). Pancreatitis as a complication occurred in 4(3.5%) patients, bleeding in 2(1.8%), on-table desaturation in 2(1.8%) and perforation in 1(0.9%) patient. The occurrence of pancreatitis was only related significantly to inadvertent PD cannulation through univariate and logistic regression analysis whereas, multiple cannulations (>5), gender, age, classification of papilla and the use of early NKS had no impact on pancreatitis or the occurrence of other complications. Conclusion: NKS is an effective and safe modality for deep biliary cannulation and achieving technical success where cannulation is deemed difficult and does not increase the risk of PEP if done by experienced endoscopists in high volume centres. doi: https://doi.org/10.12669/pjms.39.3.6777 How to cite this: Khan RSA, Alam L, Saeed F, Sher F, Khan RZA. Does early application of needle-knife sphincterotomy (NKS) in patients with difficult biliary cannulation increase the risk of postERCP pancreatitis? A single centre study. Pak J Med Sci. 2023;39(3):698-703. doi: https://doi.org/10.12669/pjms.39.3.6777 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Section: Discussioncontrasting

confidence: 47%

Section: Discussionmentioning

confidence: 99%

Does early application of needle-knife sphincterotomy (NKS) in patients with difficult biliary cannulation increase the risk of postERCP pancreatitis? A single centre study

Khan

Alam²,

Saeed

et al. 2023

Pak J Med Sci

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“…Although this survey did not distinguish between these approaches, in a recent randomized trial, a hybrid WGC technique (wire plus contrast injection as needed) resulted in a shorter cannulation time, and less need for precut techniques and procedure time compared to an 'exclusive' WGC approach. There was no difference in PEP rates between the two groups [24]. The most frequently reported secondary biliary cannulation technique was the DWT (65.8%).…”

Section: E593mentioning

confidence: 76%

Current state of biliary cannulation techniques during endoscopic retrograde cholangiopancreatography (ERCP): International survey study

Kouanda

Bayudan

Hussain³

et al. 2023

Endosc Int Open

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Background and study aims: Endoscopist techniques affect biliary cannulation success and the risk of adverse events during ERCP. This survey study aims to understand the current practice of biliary cannulation techniques among endoscopists. Methods: Practicing endoscopists were sent an anonymous 28- question electronic survey on biliary cannulation techniques and intraprocedural pancreatitis prophylactic strategies. Results: The survey was completed by 692 endoscopists (6.2% females). A wire-guided cannulation technique (WGT) was the preferred initial biliary cannulation approach (95%). The preferred secondary approaches were a double-wire (DWT) (65.8%), precut needle-knife technique (NKT) (25.7%), transpancreatic sphincterotomy (5.9%) or other (2.6%). Overall, 18.1% of respondents were not comfortable with NKTs. In the setting of pancreatic duct (PD) access, 81.9% and 97% reported a threshold of three or more wire passes or contrast injections into the PD respectively before changing strategy, 34% reported placement of a prophylactic PD stent <50% of the time and 12.1% reported removal of the PD stent at the end of the procedure. Advanced endoscopy fellowship (AEF) training and high volume (>200 ERCPs per year) were associated with comfort with precut needle knife techniques and likelihood of prophylactic PD stent (p<0.001 for both). Conclusions: A WGT technique followed by the DWT and NKT were the preferred biliary cannulation techniques however almost one-fifth of respondents were not comfortable with the NKT. There was considerable variability in secondary cannulation approaches, time spent attempting biliary cannulation and prophylactic pancreatic duct stent placement, factors known to be associated with cannulation success and adverse outcomes.

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“…Data were retrieved and analyzed from 1289 ERCPs conducted in two prospective trials during 2014-2019 that assessed post-ERCP pancreatitis (PEP) prevention[ 7 , 8 ]. Eligible subjects were all adults scheduled to undergo ERCP at our institution, and whose cannulation target was the biliary tree.…”

Section: Methodsmentioning

confidence: 99%

“…In the two randomized trials assessing post-ERCP pancreatitis prevention, 258 cases had difficult bile duct stones (≥ 8 stones, > 1 cm or impacted)[ 7 , 8 ]. Of these, 67 patients had the duct cleared by endoscopic sphincterotomy with or without mechanical lithotripsy and without the need for an endoscopic biliary large balloon dilation (EBLBD) since their distal ducts were wide enough to allow stone passage without balloon dilation.…”

Section: Methodsmentioning

confidence: 99%

Feasibility of endoscopic papillary large balloon dilation to remove difficult stones in patients with nondilated distal bile ducts

Lima¹,

Moresco²,

Sanmartin³

et al. 2022

WJGE

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BACKGROUND Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts. AIM To assess the feasibility of balloon dilation to remove difficult stones in patients with nondilated distal bile ducts. METHODS Data from 1289 endoscopic retrograde cholangiopancreatography (ERCP) procedures were obtained from two prospective studies. While 258 cases had difficult stones (> 1 cm, multiple > 8, impacted, or having a thin distal duct), 191 underwent biliary dilation up to 15 mm after endoscopic sphincterotomy. Cholangiographies of these cases were retrospectively reviewed in order to classify the distal bile duct and both the stone size and number. Primary outcomes were clearance rate at first ERCP and complications. RESULTS Of the 191 patients (122 women and 69 men; mean age: 60 years) who underwent biliary dilation for difficult stones, 113 (59%) had a nondilated or tapered distal duct. Patients with a dilated distal duct were older than those with nondilated distal ducts (mean 68 and 52 years of age, respectively; P < 0.05), had more stones (median 4 and 2 stones per patient, respectively; P < 0.05), and had less need for additional mechanical lithotripsy (6.4% vs 25%, respectively; P < 0.05). Clearance rate at first ERCP was comparable between patients with a dilated (73/78; 94%) and nondilated distal ducts (103/113; 91%). Procedures were faster in patients with a dilated distal duct (mean 17 vs 24 min, respectively; P < 0.005). Complications were similar in both groups (6.4% vs 7.1%, respectively). CONCLUSION Large balloon dilation for difficult stones is feasible in patients with a nondilated or even tapered distal duct.

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Biliary cannulation with contrast and guide-wire versus exclusive guide-wire: A prospective, randomized, double-blind trial

Cited by 5 publications

References 25 publications

Does early application of needle-knife sphincterotomy (NKS) in patients with difficult biliary cannulation increase the risk of postERCP pancreatitis? A single centre study

Does early application of needle-knife sphincterotomy (NKS) in patients with difficult biliary cannulation increase the risk of postERCP pancreatitis? A single centre study

Current state of biliary cannulation techniques during endoscopic retrograde cholangiopancreatography (ERCP): International survey study

Feasibility of endoscopic papillary large balloon dilation to remove difficult stones in patients with nondilated distal bile ducts

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