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.

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.

Primary needle-knife fistulotomy for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis:Importance of the endoscopist’s expertise level

BACKGROUND Needle-knife fistulotomy(NKF)is used as a rescue technique for difficult cannulation.However,the data are limited regarding the use of NKF for primary biliary cannulation,especially when performed by beginners.AIM To assess the effectiveness and safety of primary NKF for biliary cannulation,and the role of the endoscopist’s expertise level(beginner vs expert).METHODS We retrospectively evaluated the records of 542 patients with naïve prominent bulging papilla and no history of pancreatitis,who underwent bile duct cannulation at a tertiary referral center.The patients were categorized according to the endoscopist’s expertise level and the technique used for bile duct cannulation.We assessed the rates of successful cannulation and adverse events.RESULTS The baseline characteristics did not differ between the experienced and lessexperienced endoscopists.The incidence rate of post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP)was significantly affected by the endoscopist’s expertise level in patients who received conventional cannulation with sphincterotomy(8.9%vs 3.4%for beginner vs expert,P=0.039),but not in those who received NKF.In the multivariable analysis,a lower expertise level of the biliary endoscopist(P=0.037)and longer total procedure time(P=0.026)were significant risk factor of PEP in patients who received conventional cannulation with sphincterotomy but only total procedure time(P=0.004)was significant risk factor of PEP in those who received NKF.CONCLUSION Primary NKF was effective and safe in patients with prominent and bulging ampulla,even when performed by less-experienced endoscopist.We need to confirm which level of endoscopist’s experience is needed for primary NKF through prospective randomized study.