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.

Strength failure and crack coalescence behavior of sandstone containing single pre-cut fissure under coupled stress, fluid flow and changing chemical environment

In order to study the strength failure and crack coalescence characteristics of cracked rocks, uniaxial compression experiments were conducted on cylindrical sandstone specimens, sampled from Longyou Grottoes of Zhejiang Province, China, with a single pre-cut crack soaking in different chemical solutions. Based on the results of uniaxial compressive test under different chemical solutions and velocities of flow, the effect of strength and deformation characteristics and main modes of crack coalescence for cracked rocks under chemical corrosion were analyzed. The results show that the pH value and velocity of the chemical solutions both have great influence on the sandstone sample's uniaxial compressive strength and deformation characteristics. Cracked sandstone samples are tension-destructed under uniaxial compression, and the crack propagation directions are consistent with the loading direction. The phenomena of crack initiation, propagation and coalescence of sandstone are well observed. Four different crack types are identified based on the crack propagation mechanism by analyzing the ultimate failure modes of sandstone containing a single pre-cut fissure. The failure process of specimen in air is similar with the specimen under chemical solutions, however, the initial time of crack occuring in specimen under chemical solutions is generally earlier than that in the natural specimen, and the crack propagation and coalescence process of specimen under chemical solutions are longer than those of the natural specimen due to softening of structure of rock caused by hydro-chemical action. Immersion velocity of flow and chemical solutions does not have influence on the ultimate modes of crack coalescence.

Pancreatic duct guidewire placement for biliary cannulation in a single-session therapeutic ERCP

AIM: To investigate the technical success and clinical complication rate of a cannulated pancreatic duct with guidewire for biliary access. METHODS: During a five-year study period, a total of 2843 patients were included in this retrospective analysis. Initial biliary cannulation method consisted of single-guidewire technique (SGT) for up to 5 attempts, followed by double-guidewire technique (DGT) when repeated unintentional pancreatic duct cannulation had taken place. Pre-cut papillotomy technique was reserved for when DGT had failed or no pancreatic duct cannulation had been previously achieved. Main outcome measurements were defined as biliary cannu-lation success and post-endoscopic retrograde cholangiopancreatography (ERCP) complication rate. RESULTS: SGT (92.3% success rate) was characterized by statistically significant enhanced patient outcome compared to either the DGT (43.8%, P < 0.001), pre-cut failed DGT (73%, P < 0.001) or pre-cut as first step method (80.6%, P = 0.002). Pre-cut as first step method offered a statistically significantly more favorable outcome compared to the DGT (P < 0.001). The incidence of post-ERCP pancreatitis did not differ in a statistically significant manner between either method (SGT: 5.3%, DGT: 6.1%, Pre-cut failed DGT: 7.9%, Pre-cut as first step: 7.5%) or with patients' gender. CONCLUSION: Although DGT success rate proved not to be superior to SGT or pre-cut papillotomy, it is considered highly satisfactory in terms of safety in order to avoid the risk of a pre-cut when biliary therapy is necessary in difficult-to-cannulate cases.

Early precut sphincterotomy and the risk of endoscopic retrograde cholangiopancreatography related complications: An updated meta-analysis

AIM: To study the cannulation and complication rates of early pre-cut sphincterotomy vs persistent attempts at cannulation by standard approach.METHODS: Systematic search of PubMed, EMBASE, Web of Science, and the Cochrane Library for relevant studies published up to February 2013. The main outcome measurements were cannulation rates and postendoscopic retrograde cholangiopancreatography(ERCP) complications. A comprehensive systematic search of the Cochrane library, PubMed, Google scholar, Scopus, National Institutes of Health, meta-register of controlled trials and published proceedings from major Gastroenterology journals and meetings until February 2013 was conducted using keywords. All Prospective randomized controlled trials(RCT) studies whichmet our inclusion criteria were included in the analysis. Prospective non-randomized studies and retrospective studies were excluded from our meta-analysis. The main outcomes of interest were post-ERCP pancreatitis, overall complication rates including cholangitis, ERCPrelated bleeding, perforation and cannulation success rates. RESULTS: Seven RCTs with a total of 1039 patients were included in the meta-analysis based on selection criteria. The overall cannulation rate was 90% in the pre-cut sphincterotomy vs 86.3% in the persistent attempts group(OR = 1.98; 95%CI: 0.70-5.65). The risk of post-ERCP pancreatitis(PEP) was not different between the two groups(3.9% in the pre-cut sphincterotomy vs 6.1% in the persistent attempts group, OR = 0.58, 95%CI: 0.32-1.05). Similarly, there was no statistically significant difference between the groups for overall complication rate including PEP, cholangitis, bleeding, and perforation(6.2% vs 6.9%, OR = 0.85, 95%CI: 0.51-1.41). CONCLUSION: This meta-analysis suggests that precut sphincterotomy and persistent attempts at cannulation are comparable in terms of overall complication rates. Early pre-cut implementation does not increase PEP complications.