Endoscopic retrograde cholangiopancreatography

Abstract

DDW Highlights 855Cannulation techniques ! Assessment and comparison of cannulation techniques are notoriously difficult due to patient selection, personal preference or expertise, and other confounders. In a study from Japan [1] the utility and safety of the double guide wire technique (DGT) and/or precut sphincterotomy was assessed retrospectively in 134 patients with difficult biliary cannulation (unsuccessful within 15 minutes). DGT or precut sphincterotomy was performed as necessary if the standard single-wire technique (SGT) was unsuccessful. Pancreatic duct stenting attempted to prevent PEP in all cases. Biliary cannulation with SGT was achieved in 97 patients (72 %). A total of 10 patients with unsuccessful SGT underwent alternative diagnostic procedures. Of the remaining 27 patients, DGT was performed in 18 patients, with successful biliary cannulation in 14 (78 %). Of the 11 patients who underwent precut sphincterotomy, including 4 with unsuccessful DGT, biliary cannulation was achieved in 5 patients (45 %). PEP occurred in 8 %, 6 %, and 0 % in the SGT, DGT, and precut groups, respectively. Prophylactic pancreatic duct stenting was successfully performed in 115 patients (86 %). The incidence of PEP in patients in whom stent placement failed was significantly higher than those with successful stent placement (32 % vs. 5 %). This was a single-center experience with relatively low numbers. Nevertheless, it emphasizes several important points including the fact that the endoscopist should have several options available if the initial technique fails and also that the DGT can resolve the situation without cutting the papilla in a substantial proportion of patients. Finally, the placement of a prophylactic pancreatic stent is effective, but failed placement attempts may present the most risky situation of all. Another abstract also advocated cannulation techniques utilizing pancreatic access [2], whereas oral intake of corn oil prior to the procedure did not seem to help [3]. The US quality network of Cotton et al. was an online resource for monitoring ERCP quality parameters. More than 22 000 ERCPs were recorded by 100 endoscopists from eight countries, offering an important source of performance data from participating centers. In one of the reports from the database [4], factors affecting cannulation success were reviewed. Biliary cannulation was attempted with a native major papilla in 14460 cases, with a biliary cannulation rate of 95.6 %. Precut sphincterotomy was used in 143 (22.6 %) of the 634 cases that failed and in 5.8 % of those that succeeded. Multivariate logistic regression found the following factors to be independently predictive of cannulation success: experience (odds ratio [OR]: 1.6; 95 % confidence interval [CI] 1.3 -2.0; P < 0.001), volume (OR: 2.2; 95 %CI 1.7 -2.8; P < 0.001), USA setting (OR: 1.7; 95 %CI 1.2 -2.4 vs. non-US, non-UK countries; P = 0.002), suspected sphincter of Oddi dysfunction (SOD; intermittent/chronic pain as indication) (OR: 1.6; 95 %CI 1.0 -2.4; P = 0.03), and abse...