Safety and efficacy of different techniques in difficult biliary cannulation at endoscopic retrograde cholangiopancreatography

ABSTRACT

Background

Adverse events (AEs) are commonly seen at endoscopic retrograde cholangiopancreatography (ERCP) during difficult biliary cannulation (DBC). Therefore, attaining the right technique is essential to have improved outcomes.

Methods

Patients who had DBC over a 3-year period were assessed for outcomes. The protocol included double guidewire (DGW) technique, wire-guided cannulation (WGC) after pancreatic stent, precut sphincterotomy/fistulotomy, and EUS-guided rendezvous (RV). The success of various techniques and AE was studied.

Results

As per available case analysis, a total of 3680 patient details were assessed out of which DBC was noted in 471 (12.8%) patients with a mean (SD) age of 51.5 (17.4) years; majority being 330 (70.1%) males. Most patients underwent precut sphincterotomy 230 (48.8%); however, it was not successful in the first attempt in 10 (2.1%) patients with the success rate of 220 (95.6%). The success rate of DGW cannulation was 120 (95.2%), WGC after pancreatic stent was 64 (94.1%), EUS-RV was 34 (97.1%), and wire-guided repeat ERCP after 48 h was 10 (98.3%). AEs were noted in 52 (11.1%) patients. After precut, 32 (13.9%) patients developed AE out of which post-ERCP pancreatitis was noted in 20 (8.7%). Twenty-three patients had failed biliary access after all methods and 20 (86.9%) of those received successful percutaneous transhepatic biliary drainage.

Conclusion

Repeat ERCP after 48 h and EUS-RV appear prudent for DBC. Precut remains one of the preferred choices for most endoscopists when there is no entrance to PD. Further utilizing an algorithmic approach can contribute to higher success rates without compromising safety.

KEYWORDS:

• Endoscopic retrograde cholangiopancreatography
• difficult biliary cannulation
• precut technique
• endoscopic ultrasound
• pancreatitis

Acknowledgments

The authors thank Dr. Rajen Daftary for his dedicated anesthesia care during the procedures. They are grateful to Mr. Milind Jadhav for editing the pictures to suit journal requirements. They also thank Dr Sudheer Pargewar for the radiological interventions.

Declaration of funding

No funding was received for the production of this manuscript.

Disclosure of financial/other conflicts of interest

The authors have no relevant conflicts of interest to disclose. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

AM, AD and GP performed the procedures. SV has assisted the procedures. AM, AD, CG and GP were involved in the routine management of these patients. NK drafted the manuscript. AM, AD and GP gave vital inputs to it. All authors gave final approval to the version submitted.