Endoscopic ultrasound-guided biliary access versus precut papillotomy in patients with failed biliary cannulation: a retrospective study

Abstract

Precut papillotomy is widely used after failed biliary cannulation. Endoscopic ultrasound (EUS)-guided biliary access techniques are newer methods to facilitate access and therapy in failed cannulation. We evaluated the impact of EUS-guided biliary access on endoscopic retrograde cholangiopancreatography (ERCP) success and compared these techniques to precut papillotomy. We retrospectively compared two ERCP cohorts. One cohort consisted of biliary ERCPs (n = 1053) attempted in patients with native papillae and surgically unaltered anatomy in whom precut papillotomy and/or EUS-guided biliary access were routinely performed immediately after failed cannulation. This cohort was compared with a similar ERCP cohort (n = 1062) in which only precut papillotomy was available for failed cannulation. The following outcomes were compared: conventional cannulation success, rates of attempted advanced access techniques (precut or EUS), precut success, EUS-guided biliary access success, and ERCP failure rates. Although conventional cannulation success, rates of attempted advanced access technique (precut or EUS), and precut success were similar, the ERCP failure rate was lower when both EUS-guided biliary access and precut were available (1.0 % [95 % confidence interval (CI) 0.4 - 1.6]), compared with when only precut was possible for failed access (3.6 % [95 %CI 2.5 - 4.7]; < 0.001). Success for EUS-guided biliary access (95.1 % [95 %CI 89.7 - 100]) was significantly higher than for precut (75.3 % [95 %CI 68.2 - 82.4]; < 0.001), and mainly due to superiority in malignant obstruction (93.5 % vs. 64 %; < 0.001). EUS-guided biliary access decreases the rate of therapeutic biliary ERCP failure. Our results support the use of EUS-guided biliary access to optimize single-session ERCP success. In experienced hands, these techniques appear as effective, if not more so, than precut papillotomy.

EUS-guided biliary drainage: A comprehensive review of the literature

“…A recent retrospective study showed that the ERCP failure rate decreases when EUS-BD is available. [ 23 ] The success for EUS-BD (95.1%, 95% CI, 89.7–100) was significantly higher than for precut (75.3%, 95% CI, 68.2–82.4), P < 0.001 which supports the role for EUS-BD as an alternative to precut after failed cannulation.…”

EUS-guided biliary drainage for difficult cannulation

“…To the best of our knowledge, only two retrospective studies have compared the efficacy of precut papillotomy and EUS-BD in patients with failed bile duct cannulation. [1140] Table 2 summarizes the results of these two studies. [1140] Lee et al .…”

“…[1140] Table 2 summarizes the results of these two studies. [1140] Lee et al . conducted a retrospective, multicenter, cohort study on patients with selective bile duct cannulation failure who underwent precut papillotomy plus EUS-BD or precut papillotomy alone.…”

“…They showed that the failure rate for ERCP was significantly lower, and technical success rate was higher in the precut papillotomy plus EUS-BD group than those in the precut papillotomy alone group. [40]…”

Flail, flay, or fail: needle-knife versus transpancreatic sphincterotomy to access the difficult-to-cannulate bile duct during ERCP

“…Neither should be used for a solely diagnostic process. Moreover, a percutaneous transhepatic biliary or endoscopic ultrasound-facilitated rendezvous procedure may, at times, be safer and more effective than either TPS or NKPP, particularly in the setting of variant anatomy [9,10]. Finally, there is no shame in recognizing that some of these patients may be best handled at a pancreaticobiliary referral center prior to a prolonged ERCP attempt and the potential for an iatrogenic catastrophe.…”