Pancreatic stent improves the success rate of needle-knife papillotomy in patients with difficult biliary cannulation

BACKGROUND Needle-knife precut papillotomy(NKP)is typically performed freehand.However,it remains unclear whether pancreatic stent(PS)placement can improve the outcomes of NKP.AIM To explore whether PS placement improves the success rate of NKP in patients with difficult biliary cannulation.METHODS This single-center retrospective study included 190 patients who underwent NKP between January 2017 and December 2021 after failed conventional biliary cannulation.In cases with incidental pancreatic duct cannulation during conventional biliary cannulation,the decision for pre-NKP PS placement was made at the endoscopist's discretion.The primary outcome was the difference in the NKP success rate between patients with and without PS placement;the secondary outcome was the adverse event rate.RESULTS Among the 190 participants,82 received pre-NKP PS(PS-NKP group)whereas 108 did not[freehand or freehand NKP(FH-NKP)group].Post-NKP selective biliary cannulation was successful in 167(87.9%)patients,and the PS-NKP had a significantly higher success rate than the FH-NKP group(93.9%vs 83.3%,P=0.027).The overall adverse event rates were 7.3%and 11.1%in the PS-NKP and FH-NKP groups,respectively(P=0.493).A periampullary diverticulum(PAD)and significant intraoperative bleeding during NKP were independently associated with NKP failure;however,a pre-NKP PS was the only predictor of NKP success.Among the 44 participants with PADs,the PS-NKP group had a non-significantly higher NKP success rate than the FH-NKP group(87.5%and 65%,respectively;P=0.076).CONCLUSION PS significantly improved the success rate of NKP in patients with difficult biliary cannulation.

Endoscopic salvage therapy after failed biliary cannulation using advanced techniques:A concise review

Therapeutic endoscopic retrograde cholangiopancreatography(ERCP)begins with successful biliary cannulation.However,it is not always be successful.The failure of the initial ERCP is attributed to two main aspects:the papilla/biliary orifice is endoscopically accessible,or it is inaccessible.When the papilla/biliary orifice is accessible,bile duct cannulation failure can occur even with advanced cannulation techniques,including double guidewire techniques,transpancreatic sphincterotomy,needle-knife precut papillotomy,or fistulotomy.There is currently no consensus on the next steps of treatment in this setting.Therefore,this review aims to propose and discuss potential endoscopic options for patients who have failed ERCP due to difficult bile duct cannulation.These options include interval ERCP,percutaneous-transhepatic-endoscopic rendezvous procedures(PTE-RV),and endoscopic ultrasound-assisted rendezvous procedures(EUS-RV).The overall success rate for interval ERCP was 76.3%(68%-79% between studies),and the overall adverse event rate was 7.5%(0-15.9% between studies).The overall success rate for PTE-RV was 88.7%(80.4%-100%between studies),and the overall adverse event rate was 13.2%(4.9%-19.2% between studies).For EUS-RV,the overall success rate was 82%-86.1%,and the overall adverse event rate was 13%-15.6%.Because interval ERCP has an acceptably high success rate and lower adverse event rate and does not require additional expertise,facilities,or other specialists,it can be considered the first choice for salvage therapy.EUS-RV can also be considered if local experts are available.For patients in urgent need of biliary drainage,PTE-RV should be considered.

Impact of changing our cannulation method on the incidenceof post-endoscopic retrograde cholangiopancreatography pancreatitis after pancreatic guidewire placement

AIM： To clarify whether the incidence of post-endoscopic retrograde cholangiopancreatography （ERCP） pancreatitis （PEP） after pancreatic guidewire placement （PGW） can be reduced by using a different cannulation method. METHODS： BebNeen April 2001 and October 2009, PGW was performed in 142 patients with native papilla to overcome difficult biliary cannulation. Our cannulation method for ERCP was changed from contrast injection （CI） using a single-lumen catheter （April 2001-May 2008） to wire-guided cannulation （WGC） using a double-lumen catheter （June 2008-October 2009）. The CI protocol was also changed during the study period： in the first period it was used for routine pancreatography for detecting small pancreatic cancer （April 2001-November 2002）, whereas in the second period it was not （December 2002-May 2008）. In PGW with CI using a single- lumen catheter, the contrast medium in the catheter lumen was injected into the pancreatic duct. The success rate of biliary cannulation, the incidence of PEP according to the cannulation method, and the impact of CI using a single-lumen catheter on PEP in comparison with WGC using a double-lumen catheter were investigated.RESULTS： CI with routine pancreatography, CI without routine pancreatography, and WGC were performed in 27 patients, 77 patients and 38 patients, respectively. Routine pancreatography did not contribute to the early diagnosis of pancreatic cancer in our study period. In CI without routine pancreatography and WGC, diagnostic pancreatography was performed in 17 patients and no patients, respectively. The success rate of biliary cannulation by PGW alone was 69%, and the final success rate was increased to 80.3% by the addition of consecutive maneuvers or a second ERCP. PEP occurred in 22 patients （15.5%）, and the severity was mild in all cases. When analyzed according to cannulation method, the incidence of PEP was 37.0% （10/27） in the patients who underwent CI with routine pancreatography, 14.3% （11/77） in those who underwent CI without routine pancreatography, and 2.6% （1/38） in those who underwent WGC. In all patients who underwent CI using a singlelumen catheter, the incidence of PEP was 20% （21/104）, which was significantly higher than that in WGC using a double-lumen catheter. In univariate and multivariate analysis, CI using a single-lumen catheter showed a high, statistically significant, odds ratio for PEP after PGW. CONCLUSION： The practice of a cannulation method involving the use of a double-lumen catheter minimizes the CI dose administered to the pancreatic duct and reduces the incidence of PEP after PGW.