Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

Abstract

Guideline 657Testoni Pier Alberto et al. Papillary cannulation and sphincterotomy techniques at ERCP… Endoscopy 2016; 48: 657-683 This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It provides practical advice on how to achieve successful cannulation and sphincterotomy at minimum risk to the patient. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations1 ESGE suggests that difficult biliary cannulation is defined by the presence of one or more of the following: more than 5 contacts with the papilla whilst attempting to cannulate; more than 5 minutes spent attempting to cannulate following visualization of the papilla; more than one unintended pancreatic duct cannulation or opacification (low quality evidence, weak recommendation). 2 ESGE recommends the guidewire-assisted technique for primary biliary cannulation, since it reduces the risk of post-ERCP pancreatitis (moderate quality evidence, strong recommendation). 3 ESGE recommends using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation is difficult and repeated unintentional access to the main pancreatic duct occurs (moderate quality evidence, strong recommendation). ESGE recommends attempting prophylactic pancreatic stenting in all patients with PGW-assisted attempts at biliary cannulation (moderate quality evidence, strong recommendation). 4 ESGE recommends needle-knife fistulotomy as the preferred technique for precutting (moderate quality evidence, strong recommendation). ESGE suggests that precutting should be used only by endoscopists who achieve selective biliary cannulation in more than 80 % of cases using standard cannulation techniques (low quality evidence, weak recommendation). When access to the pancreatic duct is easy to obtain, ESGE suggests placement of a pancreatic stent prior to precutting (moderate quality evidence, weak recommendation).5 ESGE recommends that in patients with a small papilla that is difficult to cannulate, transpancreatic biliary sphincterotomy should be considered if unintentional insertion of a guidewire into the pancreatic duct occurs (moderate quality evidence, strong recommendation). In patients who have had transpancreatic sphincterotomy, ESGE suggests prophylactic pancreatic stenting (moderate quality evidence, strong recommendation). 6 ESGE recommends that mixed current is used for sphincterotomy rather than pure cut current alone, as there is a decreased risk of mild bleeding with the former (moderate quality evidence, strong recommendation). 7 ESGE suggests endoscopic papillary balloon dilation (EPBD) as an alternative to endoscopic sphincterotomy (EST) for extracting CBD stones < 8 mm in patients without anatomical or clinical contraindications, especially in the presence of coagulopathy or altered anatomy (moderate quality evidence, strong recommendation). 8 ESGE does not recommend r...

Endoscopic retrograde cholangiopancreatography complications: Techniques to reduce risk and management strategies

“…9 It has been recommended that advanced techniques (e.g., precut sphincterotomy) should only be performed by skilled endoscopists as defined by those who achieve biliary cannulation in > 80% of cases using standard methods. 29 Restraint and recognizing the need for caution are advisable with the goal toward avoiding unnecessary and/or high-risk ERCP. Restraint may be appropriate during evaluation of the potential procedure indications and patient risk factors (see below).…”

“…13,37,38 Reasonable definitions for difficult cannulation range from cannulation attempts for > 5-10 minutes, > 5-15 cannulation attempts, and/or > 1-5 inadvertent pancreatic duct manipulations. 11,29,31 In situations where biliary cannulation is difficult and repeated pancreatic cannulation occurs, some experts advocate a double guidewire technique (DGWT) to increase success. [39][40][41][42] There are, however, reports of increased PEP with DGWT 43,44 and the risk is considerably higher (20%-30%) when pancreatic stents are not placed for prophylaxis (see below).…”

“…Pancreatic stenting is recommended after attempted TPP when performed over a guidewire. 29 Papillary trauma from even standard techniques that might impair pancreatic ductal drainage is also associated with an increased risk of PEP. Repeated balloon sweeps and/or removal of large stones/fragments from the bile duct without adequate sphincterotomy has potential to cause papillary trauma.…”

Endoscopic retrograde cholangiopancreatography cannulation in the difficult duct: Which technique should you pull out of your bag?

“…4 At times, anatomy such as the shape, size or consistency of the ampulla, the position of the ampulla with a nearby diverticulum, gastrointestinal stricture or altered anatomy from prior surgery may contribute to the complexity.…”

Biopsy forceps fixation: Novel trick of the trade for duodenal guidewire unlooping

“…[1][2][3][4][5] The currently described technique allowed successful cannulation and safe sphincterotomy in our Billroth II patient with the use of a conventional side-viewing duodenoscope and standard sphincterotome. To our knowledge, this approach has not been previously reported.…”