Carotid versus axillary artery cannulation for descending aorta remodeling in type A acute aortic dissection

BACKGROUND Arterial cannulation sites for the surgical repair of type A aortic dissection(AAD)have evolved from right axillary artery(AA)cannulation to bilateral carotid artery(CA)based of femoral artery(FA)cannulation.Postoperative descending aorta remodeling is closely linked to the false lumen area ratio(FLAR),defined as false lumen area/aortic area,as well as to the incidence of renal replacement therapy(RRT).AIM To investigate the effect of the updated arterial cannulation strategy on descending aortic remodeling.METHODS A total of 443 AAD patients who received FA combined cannulation between March 2015 and March 2023 were included in the study.Of these,209 received right AA cannulation and 234 received bilateral CA cannulation.The primary outcome was the change in FLAR,as calculated from computed tomography angiography in three segments of the descending aorta:Thoracic(S1),upper abdominal(S2),and lower abdominal(S3).Secondary outcomes were the incidence of RRT and the serum inflammation response,as observed by the levels of high sensitivity C reaction protein(hs-CRP)and Interleukin-6(IL-6).RESULTS The postoperative/preoperative ratio of FLAR in S2 and S3 was higher in the AA group compared to the CA group(S2:0.80±0.08 vs 0.75±0.07,P<0.001;S3:0.57±0.12 vs 0.50±0.12,P<0.001,respectively).The AA group also had a significantly higher incidence of RRT(19.1%vs 8.5%,P=0.001;odds ratio:2.533,95%CI:1.427-4.493)and higher levels of inflammation cytokines 24 h after the procedure[hr-CRP:117±17 vs 104±15 mg/L;IL-6:129(103,166)vs 83(69,101)pg/mL;both P<0.001]compared to the CA group.CONCLUSION The CA cannulation strategy was associated with better abdominal aorta remodeling after AAD repair compared to AA cannulation,as observed by a greater change in FLAR and lower incidence of RRT.

Failed biliary cannulation: Clinical and technical outcomes after tertiary referral endoscopic retrograde cholangiopancreatography

AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center. METHODS: Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP. RESULTS: Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary can- nulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identif iable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 nave pa-pilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or postERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017). CONCLUSION: Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.

Clinical significance of different periampullary diverticulum classifications for endoscopic retrograde cholangiopancreatography cannulation

BACKGROUND Different types of periampullary diverticulum(PAD) may differentially affect the success of endoscopic retrograde cholangiopancreatography(ERCP) cannulation,but the clinical significance of the two current PAD classifications for cannulation is limited.AIM To verify the clinical value of our newly proposed PAD classification.METHODS A new PAD classification(Li-Tanaka classification) was proposed at our center.All PAD patients with native papillae who underwent ERCP from January 2012 to December 2017 were classified according to three classification systems, and the effects of various types of PAD on ERCP cannulation were compared.RESULTS A total of 3564 patients with native papillae were enrolled, including 967(27.13%)PAD patients and 2597(72.87%) non-PAD patients. In the Li-Tanaka classification, type Ⅰ PAD patients exhibited the highest difficult cannulation rate(23.1%, P = 0.01), and type Ⅱ and Ⅳ patients had the highest cannulation success rates(99.4% in type Ⅱ and 99.3% in type Ⅳ, P < 0.001). In a multivariableadjusted logistic model, the overall successful cannulation rate in PAD patients was higher than that in non-PAD patients [odds ratio(OR) = 1.87, 95% confidence interval(CI): 1.04-3037, P = 0.037]. In addition, compared to the non-PAD group,the difficulty of cannulation in the type Ⅰ PAD group according to the Li-Tanaka classification was greater(OR = 2.04, 95%CI: 1.13-3.68, P = 0.004), and the successful cannulation rate was lower(OR = 0.27, 95%CI: 0.11-0.66, P < 0.001),while it was higher in the type Ⅱ PAD group(OR = 4.44, 95%CI: 1.61-12.29, P <0.01).CONCLUSION Among the three PAD classifications, the Li-Tanaka classification has an obvious clinical advantage for ERCP cannulation, and it is helpful for evaluating potentially difficult and successful cannulation cases among different types of PAD patients.

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.

Endoscopic retrograde cholangiopancreatography in elderly patients: Difficult cannulation and adverse events

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is a valuable therapeutic technique for pancreatobiliary diseases,and its application in the elderly is no longer limited.However,a higher incidence of procedure difficulty and periprocedural adverse events might be expected in elderly patients due to the presence of other medical disorders and the poor general condition of this population.AIM To evaluate the incidence,causes,and management of difficult biliary cannulation during ERCP in elderly patients and the role of difficult cannulation as a risk factor for adverse events.METHODS A total of 614 patients who underwent ERCP during the study period were prospectively studied and divided into two groups based on their age.One hundred and forty-six patients were aged 80 years or older and 468 patients were aged less than 80 years.The primary outcome measurements were cannulation difficulty,cannulation success rate,ERCP procedure time,and related adverse events.RESULTS There was no difference in the incidence of difficult cannulation among the two groups(32.9%vs 34.4%,P=0.765),as well as in the cannulation success rate(96.6%vs 96.8%,P=0.54).The cannulation techniques were shown to be safe and efficient in achieving successful cannulation.Logistic regression analysis showed that patients aged 80 years or older were not associated with increased adverse events;however,difficult cannulation cases[adjusted odds ratio(AOR)=3.478;95%confidence interval(CI):1.877-6.442;P<0.001]and patients with Charlson Comorbidity Index≥2(AOR=1.824;95%CI:0.993-3.349;P=0.045)were more likely to develop adverse events.In contrast,other factors including age≤65(AOR=3.460;95%CI:1.511-7.922;P=0.003),female gender(AOR=2.362;95%CI=1.089-5.124;P=0.030),difficult cannulation(AOR=4.527;95%CI:2.078-9.860;P<0.001),and patients with cholangitis(AOR=3.261;95%CI:1.204-8.832;P=0.020)were strongly associated with a higher rate of post-ERCP pancreatitis.CONCLUSION Advanced age has not been proved to be a risk factor for difficult cannulation,and secondary cannulation techniques can be safely and efficaciously utilized in this group.Patients with a Charlson Comorbidity Index≥2 and difficult cannulation are associated with an increased overall adverse events rate,while age≥80 years is not.

Evaluation of the Effects of Venous Cannulation Sites on Postoperative Delirium in Children: Hand or Foot?

Introduction: Choosing an appropriate cannulation site is important for doctors and patients. In our clinical practice, we have observed that agitation and pain were less in the postoperative period when the cannula was inserted site. Cannulation anxiety in adults and especially in children may increase the failure of interventions by activating the sympathetic system in varying degrees we aimed to investigate whether the site of the cannula inserted following the induction of inhalation is associated with postoperative agitation and pain in preschool children who would undergo an otolaryngology operation. Methods: Pediatric patients who would undergo adenoidectomy-tonsillectomy surgery between the ages of 3 - 7 were included in our study regardless of their genders. The patients have been randomly distributed into groups (Group E—hand, Group A—foot). The evaluation was performed 0 and 30 minutes after extubation by FLAAC Pain Scala and PAED. Results: When the hand and foot groups were compared in terms of P0 (PAED 0 min. rating) values, hand group results were statistically significantly higher. Similarly, at the time of P30 (PAED 30. min rating), The Hand group was determined to be high. Conclusion: As a result of the study, we believe that choosing the feet as the cannulation site may be useful in appropriate cases in pediatric patients.

Precut sphincterotomy:A reliable salvage for difficult biliary cannulation

Even experienced endoscopists have 90% success in achieving deep biliary cannulation with standard methods. Biliary cannulation may become difficult in 10%-15% of patients with biliary obstruction and pre- cut (access) sphincterotomy is frequently chosen as a rescue treatment in these cases. Generally, precut sphincterotomy ensures a rate of 90%-100% success- ful deep biliary cannulation. The precut technique has been performed as either a fistulotomy with a needle knife sphincterotome or as a transpapillary septotomy with a standard sphincterotome. Both methods have similar efficacy and complication rates when adminis- tered to the proper patient. Although precut sphincter- otomy ensures over 90% success of biliary cannula- tion, it has been characterized as an independent risk factor for pancreatitis. The complications of the precut technique are not limited to pancreatitis. Two more important ones, bleeding and perforation, are also re- ported in some publications as being observed more commonly than during standard sphincterotomy. It is also reported that precut sphincterotomy increases morbidity when performed in patients without dilata- tion of their biliary tract. Nevertheless, precut sphinc- terotomy is a good alternative as a rescue method in the setting of a failed standard cannulation method. This paper discusses the technical details, timing, ef- ficacy and potential complications of precut sphincter- otomy.

Comparison of efficacy and safety of transpancreatic septotomy, needle-knife fistulotomy or both based on biliary cannulation unintentional pancreatic access and papillary morphology

Background: Precut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography(ERCP). However, scarce data are available on different precut techniques for difficult biliary cannulation. This study aimed to evaluate the efficacy and safety of transpancreatic septotomy(TPS), needle-knife fistulotomy(NKF) or both based on the presence of unintentional pancreatic access and papillary morphology. Methods: Between March 2008 and December 2016, 157 consecutive patients undergoing precutting for an inaccessible bile duct during ERCP were identified. Precut techniques were chosen depending on repetitive inadvertent pancreatic cannulation and the papillary morphology. We retrospectively assessed the rates of cannulation success and procedure-related complications among three groups, namely TPS, NKF, and TPS followed by NKF. Results: The baseline characteristics of the three groups were comparable. The overall success rate of biliary cannulation reached 98.1%, including 111 of 113(98.2%) with TPS, 35 of 36(97.2%) with NKF and 8 of 8(100%) with NKF following TPS, without significant difference among groups. The incidences of total complications and post-ERCP pancreatitis were 9.6% and 7.6%, respectively. There was a trend towards less frequent post-ERCP pancreatitis after NKF(0%) compared with 11 cases(9.7%) after TPS and one case(12.5%) after NKF following TPS, but not significantly different( P = 0.07). No severe adverse event occurred during this study period. Conclusions: The choice of precut techniques by the presence of unintended pancreatic access and the papillary morphology brought about a high success rate without increasing risk in difficult biliary cannulation.

Pancreatic guidewire placement for achieving selective biliary cannulation during endoscopic retrograde cholangio-pancreatography

AIM: To investigate the frequency and risk factors for acute pancreatitis after pancreatic guidewire placement (P-GW) in achieving cannulation of the bile duct during endoscopic retrograde cholangio-pancreatography (ERCP). METHODS: P-GW was performed in 113 patients in whom cannulation of the bile duct was difficult. The success rate of biliary cannulation, the frequency and risk factors of post-ERCP pancreatitis, and the frequency of spontaneous migration of the pancreatic duct stent were investigated. RESULTS: Selective biliary cannulation with P-GW was achieved in 73% of the patients. Post-ERCP pancreatitis occurred in 12% (14 patients: mild, 13; moderate, 1). Prophylactic pancreatic stenting was attempted in 59% of the patients. Of the 64 patients who successfully underwent stent placement, three developed mild pancreatitis (4.7%). Of the 49 patients without stent placement, 11 developed pancreatitis (22%: mild, 10; moderate, 1). Of the five patients in whom stent placement was unsuccessful, two developed mild pancreatitis. Univariate and multivariate analyses revealed no pancreatic stenting to be the only significant risk factor for pancreatitis. Spontaneous migration of the stent was observed within two weeks in 92% of the patients who had undergone pancreatic duct stenting.CONCLUSION: P-GW is useful for achieving selective biliary cannulation. Pancreatic duct stenting after P-GW can reduce the incidence of post-ERCP pancreatitis, which requires evaluation by means of prospective randomized controlled trials.

Endoscopic retrograde cholangiopancreatography in periampullary diverticulum: The challenge of cannulation

Periampullary diverticulum(PAD) is duodenal outpunching defined as herniation of the mucosa or submucosa that occurs via a defect in the muscle layer within an area of 2 to 3 cm around the papilla. Although PAD isusually asymptomatic and discovered incidentally during endoscopic retrograde cholangiopancreatography(ERCP), it is associated with different pathological conditions such as common bile duct obstruction, pancreatitis, perforation, bleeding, and rarely carcinoma. ERCP has a low rate of success in patients with PAD,suggesting that this condition may complicate the technical application of the ERCP procedure. Moreover, cannulation of PAD can be challenging, time consuming, and require the higher level of skill of more experienced endoscopists. A large portion of the failures of cannulation in patients with PAD can be attributed to inability of the endoscopist to detect the papilla. In cases where the papilla is identified but does not point in a suitable direction for cannulation, different techniques have been described. Endoscopists must be aware of papilla identification in the presence of PAD and of different cannulation techniques, including their technical feasibility and safety, to allow for an informed decision and ensure the best outcome. Herein, we review the literature on this practical topic and propose an algorithm to increase the success rate of biliary cannulation.

Application of needle-knife in difficult biliary cannulation for endoscopic retrograde cholangiopancreatography

BACKGROUND: Getting directly into the common bile duct (CBD) is the most important step for successful therapeutic biliary endoscopy. In 5%-10% of cases, the CBD remains inaccessible, necessitating pre-cut papillotomy or fistulotomy with a needle-knife. The aim of this study was to assess the value of early application of the needle-knife in difficult biliary cannulation for endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Patients with failed biliary cannulation after 10 minutes or guide wire entering the pancreatic tube 3 times were randomly divided into group of needle-knife cut and group of persistent cannulation by standard techniques. The cannulation times, success rates and complication rates were compared between the two groups. RESULTS: A total of 948 therapeutic biliary ERCP procedures were performed between October 2004 and February 2006. Of 91 patients with difficult biliary cannulation, 43 patients underwent needle-knife cut: the cannulation success rate was 90.7%, the mean cannulation time was 5.6 minutes, and the complication rate was 9.3%. The other 48 patients underwent persistent cannulation by standard techniques: the cannulation success rate was 75%, the mean cannulation time was 10.2 minutes, and the complication rate was 14.6%. Significant differences were observed in cannulation success rate and cannulation time but in complication rate between the two groups.CONCLUSION: The early application of the needle-knife in difficult biliary cannulation is time-saving, safe and effective, with no increase in complication rate.

Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist

Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography(ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.

Needle-knife fistulotomy vs double-guidewire technique in patients with repetitive unintentional pancreatic cannulations

AIM: To compare the success rates and adverse events of early needle-knife fistulotomy(NKF) and double-guidewire technique(DGT) in patients with repetitive unintentional pancreatic cannulations.METHODS: From a total of 1650 patients admitted for diagnostic or therapeutic endoscopic retrograde cholangiopancreatography(ERCP) at a single tertiary care hospital(Pusan National University Yangsan Hospital, Yangsan, South Korea) between January2009 and December 2012, 134(8.1%) patients with unsuccessful biliary cannulation after 5 min trial of conventional methods, together with 5 or more repetitive unintentional pancreatic cannulations, were enrolled in the study. Early NKF and DGT groups were assigned 67 patients each. In the DGT group, NKF was performed for an additional 7 min if successful cannulation was not achieved.RESULTS: The success rates with early NKF andthe DGT were 79.1%(53/67) and 44.8%(30/67)(P< 0.001), respectively. The incidence of post-ERCP pancreatitis(PEP) was lower in the early NKF group than in the DGT group [4.5%(3/67) vs 14.9%(10/67),P = 0.041]. The mean cannulation times in the early NKF and DGT groups after assignment were 257 s and312 s(P = 0.013), respectively.CONCLUSION: Our data suggest that early NKF should be considered as the first approach to selective biliary cannulation in patients with repetitive unintentional pancreatic cannulations.

Cannulation of the intradiverticular papilla using a duodenoscope:Is it a safe method?

Endoscopic cannulation of the biliary tract is a challenging technique in cases of periampullary diverticula.Many new devices and new manipulations for successful biliary cannulation have been reported.Endoscopy used to locate and cannulate a papilla hidden within a duodenal diverticulum is an effective method.However,the question of which endoscope should be chosen for this procedure,duodenoscope or gastroscope,waits to be answered.

Comparison of early pre-cutting vs standard technique for biliary cannulation in endoscopic retrograde cholangiopancreatography: A personal experience

AIM： To compare the results and complications of early pre-cutting technique with standard technique. METHODS： From January 2003 to December 2004, a total of 426 consecutive therapeutic biliary ERCP procedures were performed by one endoscopist （T.A.）. Data were retrospectively collected according to procedure indication and results. Of these, 293 procedures （70.4%） were done with standard technique （group A） and 223 procedures （29.6%） with early pre-cutting technique in case of difficult cannulation （group B）. The results and complications of ERCP were compared. RESULTS： Success rate of first attempt cannulation was 98.0% in group A and 87.8% in group 13. The overall incidence of post-ERCP pancreatitis, hemorrhage, perforation and cholangitis was 0%, 0.2%, 0.5% and 0.5%, respectively. Morbidity rate was not significantly different. No procedure-related mortality was occurred. CONCLUSION： For an experienced hand, the early pre-cutting technique for biliary cannulation is safe and effective as standard technique.

Combination of two-hour post-endoscopic retrograde cholangiopancreatography amylase levels and cannulation times is useful for predicting post-endoscopic retrograde cholangiopancreatography pancreatitis

AIM To estimate the efficacy of 2 h post-endoscopic retrograde cholangiopancreatography(ERCP) serum amylase levels and other factors for predicting postERCP pancreatitis.METHODS This was a retrospective,single-center cohort study of consecutive patients who underwent ERCP from January 2010 to December 2013.Serum amylase levels were measured 2 h post-procedure,and patient- and procedure-related pancreatitis(PEP) risk factors wereanalyzed using a logistic model.RESULTS A total of 1520 cases(average age 72 ± 12 years,60% male) were initially enrolled in this study,and 1403 cases(725 patients) were ultimately analyzed after the exclusion of 117 cases.Fifty-five of these cases developed PEP.We established a 2 h serum amylase cutoff level of two times the upper limit of normal for predicting PEP.Multivariate analysis revealed that a cannulation time of more than 13 min [odds ratio(OR) 2.28,95%CI:1.132-4.651,P=0.0210] and 2 h amylase levels greater than the cutoff level(OR=24.1,95%CI:11.56-57.13,P<0.0001) were significant predictive factors for PEP.Forty-seven of the 55 patients who developed PEP exhibited 2 h amylase levels greater than the cutoff level(85%),and six of the remaining eight patients who developed PEP(75%) required longer cannulation times.Only 2 of the 1403 patients(0.14%) who developed PEP did not exhibit concerning 2 h amylase levels or require longer cannulation times.CONCLUSION These findings indicate that the combination of 2 h post-ERCP serum amylase levels and cannulation times represents a valuable marker for identifying patients at high risk for PEP.

Management of difficult bile duct cannulation in ERCP

In Encoscopic Retrograde Cholangiopancreatography(ERCP),the main concern is to gain access into the bile duct while avoiding the pancreatic duct because of the risk of post-ERCP pancreatitis.Diffi cult cannulation is defined as a situation where the endoscopist,using his/her regularly used cannulation technique,fails within a certain time limit or after a certain number of unsuccessful attempts.Different methods have been developed to manage diffi cult cannulation.The most common solution is to perform a precut papillotomy either with a needle knife or with a sphincterotome with or without a guide wire.This review describes different methods to overcome cases of difficult cannulation.We will discuss the success rate and complication rates associated with different methods of reaching the biliary tract.

Escalating complexity of endoscopic retrograde cholangiopancreatography over the last decade with increasing reliance on advanced cannulation techniques

BACKGROUND At our academic tertiary care medical center, we have noted patients referred for endoscopic retrograde cholangiopancreatography(ERCP) who increasingly require advanced cannulation techniques. This trend is noted despite increased endoscopist experience and annual ERCP volume over the same period.AIM To evaluate this phenomenon of perceived escalation in complexity of cannulation at ERCP and assessed potential underlying factors.METHODS Demographic/clinical variables and records of ERCP patients at the beginning(2008), middle(2013) and end(2018) of the last decade were reviewed retrospectively. Cannulation approaches were classified as "standard" or "advanced" and duodenoscope position was labeled as "standard"(short position) or "non-standard"(e.g., long, semi-long).RESULTS Patients undergoing ERCP were older in 2018 compared to 2008(69.7 ± 15.2 years vs 55.1 ± 14.7, P < 0.05). Increased ampullary distortion and peri-ampullary diverticula were noted in 2018(P < 0.001). ERCPs were increasingly performed with a non-standard duodenoscope position, from 2.2%(2008) to 5.6%(2013) and 16.1%(2018)(P < 0.001). Utilization of more than one advanced cannulation technique for a given ERCP increased from 0.7%(2008) to 0.9%(2013) to 6.6%(2018)(P < 0.001). Primary mass size > 4 cm, pancreatic uncinate mass, and bilirubin > 10 mg/d L predicted use of advanced cannulation techniques(P < 0.03 for each).CONCLUSION Complexity of cannulation at ERCP has sharply increased over the past 5 years, with an increased proportion of elderly patients and those with malignancy requiring advanced cannulation approaches. These data suggest that complexity of cannulation at ERCP may be predicted based on patient/ampulla characteristics. This may inform selection of experienced, high-volume endoscopists to perform these complex procedures.

A prospective cross-over study using a sphincterotome and a guidewire to increase the success rate of common bile duct cannulation

AIM: During endoscopic retrograde cholangiopancreatography (ERCP), selective cannulation of the common bile duct (CBD) is required in most of the cases.METHODS: From June 2001 till December 2002, all patients referred to our unit for ERCP were considered for entry into the study. Selective CBD cannulation was first attempted with a standard catheter with or without the use of a guidewire. In cases, where CBD cannulation was considered unsuccessful, patients were crossed over to a double-lumen sphincterotome and a guidewire. All patients were hospitalized for 24 h after the procedure in order to assess the incidence of post-ERCP complications.RESULTS: The study sample consisted of 158 patients.Selective CBD cannulation using a standard ERCP catheter with or without the assistance of a guidewire, was accomplished in 129 patients (success rate: 81.65%).From the 29 patients who were crossed over to a sphincterotome and a guidewire, selective CBD cannulation was achieved in 24; the overall success rate rising to 96.8%. Meanwhile, the use of this technique did not increase the incidence of post-ERCP complications.CONCLUSION: The use of a sphincterotome and a guidewire increases the success rate of selective bile duct cannulation in cases that this has not been accomplished with a standard catheter.

Endoscopic treatment for pancreatic diseases:Needle-knife-guided cannulation via the minor papilla

AIM: To determine the efficacy and safety of meticulous cannulation by needle-knife.METHODS: Three needle-knife procedures were used to facilitate cannulation in cases when standard cannulation techniques failed. A total of 104 cannulationsvia the minor papilla attempted in 74 patients at our center between January 2008 and June 2014 were retrospectively reviewed.RESULTS: Standard methods were successful in79 cannulations. Of the 25 cannulations that could not be performed by standard methods, 19 were performed by needle-knife, while 17(89.5%) were successful. Needle-knife use improved the success rate of cannulation [76.0%, 79/104 vs 92.3%,(79 +17)/104; P = 0.001]. When the 6 cases not appropriate for needle-knife cannulation were excluded, the success rate was improved further(80.6%, 79/98 vs98.0%, 96/98; P = 0.000). There were no significant differences in the rates of post-endoscopic retrograde cholangiopancreatography adverse events between the group using standard methods alone and the group using needle-knife after failure of standard methods(4.7% vs 10.5%, P = 0.301).CONCLUSION: The needle-knife procedure may be an alternative method for improving the success rate of cannulation via the minor papilla, particularly when standard cannulation has failed.