Introduction
ERCP can still represents a challenge for endoscopists. In a variable percentage of cases (about 15%), cannulation of the common bile duct (CBD) is defined as “difficult”. In these cases, various advanced techniques are used to ensure access to the biliary tract. These methods can be summarised as follows: when an accidental cannulation of the pancreatic duct (PD) has occurred, the double guidewire technique (DGW) or the transpancreatic sphincterotomy (TPBS) technique can be performed; when access to the PD has not been achieved, freehand precut (trans papillary or fistulotomy) can be performed.1
It has been shown that these methods are burdened by higher complication rates (in particular post- ERCP pancreatitis [PEP]) compared to standard cannulation of the CBD.2 In particular, TPBS carries a stigma of risk and complexity. The ESGE guidelines propose its use as a second line after failure of DGW technique and only by expert endoscopists.1 Recent studies have shown a certain distrust among endoscopists towards TPBS.3
Aims & Methods
We conducted a one-year prospective study with the aim of evaluating the efficacy and safety of TPBS in cases of difficult cannulation, comparing it with the DGW technique and trans papillary precut. All patients undergoing ERCP in a secondary centre were enrolled. A total of 169 ERCPs were performed by three endoscopists (two seniors and one junior with experience < 200 ERCPs). The most frequent indication was lithiasis of the CBD (74% of cases). The protocol adopted in case of difficult cannulation was the following: in the case of failed access to the PD, trans papillary precut was attempted. In the case of access to PD, the endoscopist chose at his discretion to perform the DGW technique or TPBS. In the case of PD cannulation, no pancreatic stent placement was performed. Other measures were taken to prevent PEP (rectal indomethacin and intravenous hydration during ERCP). Patients were followed up until discharge and peri- and post-procedural complications were recorded.
Results
The overall cannulation rate for naive papillae was 92.8%. Advanced techniques were used in 19% of the cases to achieve cannulation of the bile duct: 73% were successful. TPBS achieved 100% cannulation of CBP, compared to 66.7% of DWS and 55.6% of pre-cutting, showing a statistically significant better performance (p=0.02). A total of five bleedings, two cholangitis, one cholecystitis and two PEP were recorded. Of all these, only three (respectively one PEP, one bleeding and one cholecystitis) occurred after the above-mentioned advanced CBD cannulation methods were used.
| cannulation | double-guided technique
No. (%) | trans-pancreatic sphincterotomy
No. (%) | precut
No. (%) | total
No. (%) |
P value |
| no / yes | 2 (33,3) / 4 (66,7) | 0 (0) / 14 (100) | 4 (44,4) / 5 (55,6) | 6 (20,7) / 23 (79,3) | 0.02 |
| complication | 1 cholecystitis | 1 delayed bleeding | 1 acute pancreatitis |
|
The advanced methods of access to the CBD were performed by all three endoscopists involved and the observed complications were equally distributed among the operators.
Conclusion
In conclusion, this single-centre prospective observational study, despite its limited sample size, demonstrates that TPBS is a safe and effective method in case of difficult bile duct cannulation when PD cannulation is achieved. In particular TPBS seems to be more efficient than DGW and precut, showing a similar security profile. This technique can also be performed safely by non-expert endoscopists.
Finally, it is important to underline that, despite not placing the pancreatic prosthesis after cannulation of the PD (24 patients) none of them presented PEP.
References
1.Testoni PA, Mariani A, Aabakken L, Arvanitakis M, Bories E, Costamagna G, Devière J, Dinis-Ribeiro M, Dumonceau JM, Giovannini M, Gyokeres T, Hafner M, Halttunen J, Hassan C, Lopes L, Papanikolaou IS, Tham TC, Tringali A, van Hooft J, Williams EJ. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016 Jul;48(7):657-83. doi: 10.1055/s-0042-108641. Epub 2016 Jun 14. PMID: 27299638.
2.Fung BM, tea TCTabibian JH. Difficult Biliary Cannulation in Endoscopic Retrograd2 Cholangiopancreatography: Definitions, Risk Factors, and Implications. Eur Med J Hepatol. 2021 Aug;9(1):64-72. Epub 2021 Aug 5. PMID: 34621527; PMCID: PMC8494185.
3.Kouanda A, Bayudan A, Hussain A, Avila P, Kamal F, Hasan MK, Dai SC, Munroe C, Thiruvengadam N, Arain MA. Current state of biliary cannulation techniques during endoscopic retrograde cholangiopancreatography (ERCP): International survey study. Endosc Int Open. 2023 Jun 21;11(6):E588-E598. doi: 10.1055/a-2085-4565. PMID: 37564727; PMCID: PMC10410689.
