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Background: When cannulation is challenging during endoscopic retrograde cholangiopancreatography (ERCP), and the standard guidewire technique with sphincterotomy is unsuccessful, alternative cannulation techniques can be used to access the biliary tree. The purpose of this study was to compare the incidence of adverse events and cannulation success rates between transpancreatic sphincterotomy (TPS) and precut sphincterotomy (PCS). Methods: Data from the Swedish Registry for Gallstone Surgery and ERCP (GallRiks), collected from 2011 to 2022, were analyzed. A total of 105,303 ERCP procedures were recorded in GallRiks during the study period. After exclusions, the study population consisted of 47,486 ERCP procedures. Of these, 4547 received PCS and 3273 received TPS. The remaining 39,666 ERCP procedures with conventional sphincterotomy served as the control group. The primary endpoints were successful cannulation and adverse events within 30 days. Results: Successful cannulation was more frequent with the TPS technique than with the PCS technique (86.5% vs. 69.7%), but both groups had a lower cannulation rate than the control group (92.4%; OR-PCS 0.20, 95% CI 0.18–0.21; OR-TPS 0.58, 95% CI 0.52–0.64). The TPS group had a higher incidence of adverse events than the PCS group (24.1% vs. 18.8%) and both groups had a higher incidence of adverse events than the control group (15.5%; OR-PCS 1.25, 95% CI 1.15–1.36; OR-TPS 1.71, 95% CI 1.57–1.87). Adverse events for TPS were driven by a higher incidence of pancreatitis (10.5% vs. 6.4% vs. 4.5%; OR 2.53, 95% CI 2.23–2.86) and perforation (1.6% vs. 0.8% vs. 0.5%; OR 2.99, 95% CI 2.20–4.06) compared to both PCS and control. Conclusion: TPS is more successful at cannulation than PCS; however, this success comes at a higher cost in terms of adverse events, particularly pancreatitis and perforation. [ABSTRACT FROM AUTHOR]

Introduction Difficult biliary cannulation leads to prolonged papillary manipulation and repeated attempts at cannulation are known to increase the risk of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. This study aims to compare the efficacy and complications of three rescue methods, transpancreatic biliary sphincterotomy (TP), double guidewire technique (DGW), and precut sphincterotomy (precut) in difficult common bile duct (CBD) cannulations.

Introduction Difficult biliary cannulation leads to prolonged papillary manipulation and repeated attempts at cannulation are known to increase the risk of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. This study aims to compare the efficacy and complications of three rescue methods, transpancreatic biliary sphincterotomy (TP), double guidewire technique (DGW), and precut sphincterotomy (precut) in difficult common bile duct (CBD) cannulations. Methods Seventy-six patients (>12 years of age) with a native papilla undergoing ERCP for biliary cannulation were recruited. Those who had inadvertent pancreatic duct cannulations (>1) were included. A pancreatic stent was inserted in all cases. They underwent either DGW (n = 25), precut (n = 25), or TP (n = 26) as rescue methods and were compared in terms of the success of cannulation and post-ERCP complications. Results Of the total 76 cases, 82% were for benign indications, the most common being choledocholithiasis (69.7%). Jaundice was noted in 52% (n = 13/25), 60% (n = 15/25), and 38.5% (n = 10/26) of the DGW, precut, and TP cases, while 40% (n = 10/25), 12% (n = 3/25), and 30.8% (n = 8/26), respectively, were in cholangitis at presentation. The most common type of papilla was type 1 overall and each subgroup. While successful cannulation was achieved in 88.5% (n = 23/26) of TP and 84% (n = 21/25) of the DGW group, only 64% (n = 16/25) of the precut cases were cannulated. Three (n = 3/25) cases had mild bleeding and two mild pancreatitis, one severe pancreatitis, and one perforation were recorded in the precut group. One patient each had severe and mild pancreatitis in the DGW group, while one had mild pancreatitis and two had moderate pancreatitis in the TP group. All the patients were managed conservatively. Conclusion There was no significant difference in the technical success rate (p = 0.075) as well as complications (p = 0.117) between the three salvage methods for difficult naive CBD cannulations. [ABSTRACT FROM AUTHOR]

ObjectiveThis study aimed to systematically evaluate the efficacy and safety of the double-guidewire technique along with other methods (persistent standard cannulation techniques, transpancreatic sphincterotomy, and pancreatic stent-assisted technique) for difficult biliary cannulation.MethodsTwo researchers searched for literature on the efficacy and safety of the double-guidewire technique and other techniques in difficult biliary cannulation in databases, including PubMed, Embase, Cochrane, China National Knowledge Infrastructure, and Wanfang Data, based on the inclusion and exclusion criteria. The success rate of cannulation, duration of cannulation, post-ERCP pancreatitis, and overall postoperative complications were also analyzed using RevMan 5.4 software.ResultsIn total, 20 randomized controlled trial (RCT) studies involving 2008 participants were identified. The success rate of cannulation in the double-guidewire technique was much higher than that in persistent standard cannulation techniques [RR = 1.37, 95%CI (1.05, 1.79), p = 0.02]. However, it was lower than the success rate observed with transpancreatic sphincterotomy [RR = 0.89, 95%CI (0.81, 0.97), p = 0.01]. There was no significance in post-ERCP pancreatitis [RR = 1.09, 95% CI (0.85, 1.40), p = 0.49], overall postoperative complications [RR = 0.90, 95% CI (0.56, 1.45), p = 0.66], and duration of cannulation [SMD = -0.14, 95%C I (−1.43, 1.15), p = 0.83] between the double-guidewire technique and other techniques.ConclusionThis study demonstrated that the success rate of cannulation ranged from transpancreatic sphincterotomy to the double-guidewire technique and then to persistent standard cannulation techniques.

Background Difficult cannulation represents a common obstacle during endoscopic retrograde cholangiopancreatography (ERCP). We assessed the efficacy and adverse events of transpancreatic sphincterotomy (TPS), and investigated potential associated confounders. Methods All patients referred to our department for ERCP during 2015-2020 were eligible if they had intact papilla and visceral anatomy. In addition to standard measures, TPS was combined with pancreatic stent placement. Apart from demographics, we retrieved data related to the indication, periampullary anatomy, necessity for TPS or fistulotomy, their outcomes and complications. Chi-square test was employed to investigate associations between TPS and independent variables. When significance was observed, the respective variables were inserted into a regression model. Results A total of 1082 individual patients were eligible, with an equal female: male ratio and a mean age of 72.7±15.82 years. Seventy-three patients (6.7%) underwent TPS, with a 95.9% successful cannulation rate. Papilla morphology or regional diverticulum did not affect the decision to perform TPS, though it was significantly associated with malignant common bile duct (CBD) obstruction as the ERCP indication (P=0.001). Considering adverse events, TPS did not increase the incidence of post-ERCP pancreatitis (PEP), though it affected bleeding (P=0.005). Regression analysis revealed a protective role of TPS against PEP (risk ratio [RR] 0.015, 95% confidence interval [CI] 0.23-5.05; P<0.001), while the aforementioned risk of hemorrhage was attributed to previous precut attempts (RR 3.02, 95%CI 1.42-6.43; P=0.004). Conclusion TPS combined with pancreatic stenting is an effective and safe modality in difficult cannulation cases and could be the first-choice alternative in malignant CBD obstruction. [ABSTRACT FROM AUTHOR]

Objective To investigate the effect of transpancreatic sphincterotomy(TPS) on post-ERCP pancreatitis (PEP) during endoscopic retrograde cholangiopancreatography (ERCP) for difficult biliary intubation. Methods A total of 103 cases undergoing ERCP in our hospital from June 2018 to November 2019 were analyzed retrospectively. Complications including PEP were compared between the cases in the group(42 cases) of early TPS in which the patients had sphincterotomy immediately after guidewire running into pancreatic duct for the second time and the cases in the control group (61 cases) in which the guidewire had entered pancreatic duct for more than 2 times before successful bile duct access by selective intubation or TPS. Results All the patients in both groups had biliary intubation successfully. However, the operative time in group of early TPS was much shorter than that in the control group [(9.59±1.54) min vs. (13.33±2.09) min, P=0.022]. There were 3 cases of PEP in the group of early TPS and 15 cases in the control group with statistical difference (P=0.033). All the cases of PEP were mild and recovered after conservative treatment. There were no biliary infections or postoperative bleedings in both groups. Logistic multivariate analysis showed that the time of intubation (≥10 min) and the times (>2 times) for the guidewire entering the pancreatic duct are the risk factors for PEP. Conclusions Early TPS when guidewire enters pancreatic duct ≤2 times would be safe. It could be helpful to shorten the time of intubation, increase the success rate of intubation and reduce the incidence of PEP.

Abstract Background Selective deep biliary cannulation is the first and the most important step before further biliary therapy. Transpancreatic sphincterotomy (TPS), and needle knife fistulotomy (NKF) were commonly used in patients with difficult cannulation, but few studies compare the outcome between TPS and NKF. Methods A total of 78 patients who met the criteria of difficult cannulation in the National Taiwan University hospital from October 2015 to October 2017 were retrospectively reviewed. Their baseline demographics, success rate of biliary cannulation, and the rate of adverse events were assessed. Results 31 patients and 47 patients underwent TPS and NKF for difficult biliary access, respectively. The characteristics of the 2 groups were similar, but patients in TPS group had more frequent pancreatic duct cannulation. Bile duct cannulation was successful in 23 patients (74.2%) in the TPS group and 39 (83.0%) in the NKF group (P = 0.34). There was no difference between the TPS and NKF in the rate of adverse events, including post-ERCP pancreatitis (PEP) (16.1% vs. 6.4%, p = 0.17), and hemorrhage (3.2% vs. 8.5%, p = 0.35). No perforation occurred. Conclusions Both TPS and NKF have good biliary access rate in patient with difficult cannulation. TPS has acceptable successful rate and similar complication rate, compared with NKF.

Background: In the setting of a naïve papilla, biliary cannulation is a key step in successfully performing endoscopic retrograde cholangiography. Difficult biliary cannulation (DBC) is associated with an increased risk of post-ERCP pancreatitis and failure of the whole procedure. Summary: Recommendations for biliary cannulation can be divided into (a) measures to reduce the likelihood of a difficult papilla situation a priori and (b) rescue techniques in case the endoscopist is actually facing DBC. (a) Careful inspection of the papillary anatomy and optimizing its accessibility by scope positioning is fundamental. A sphincterotome in combination with a soft-tip hydrophilic guidewire rather than a standard catheter with a standard guidewire should be used in most situations. (b) The most important rescue techniques are needle-knife precut, double-guidewire technique, and transpancreatic sphincterotomy. In few cases, anterograde cannulation techniques are needed. To this regard, the EUS-guided biliary drainage followed by rendezvous is increasingly used as an alternative to percutaneous transhepatic biliary drainage. Key Messages: Biliary cannulation can be accomplished with alternative retrograde or less frequently by salvage anterograde techniques, once conventional direct cannulation attempts have failed. Considering recent favorable data for the early use of transpancreatic sphincterotomy, an adopted version of the 2016 European Society for Gastrointestinal Endoscopy (ESGE) algorithm on biliary cannulation is proposed. [ABSTRACT FROM AUTHOR]

Background: Selective deep biliary cannulation is the first and the most important step before further biliary therapy. Transpancreatic sphincterotomy (TPS), and needle knife fistulotomy (NKF) were commonly used in patients with difficult cannulation, but few studies compare the outcome between TPS and NKF.Methods: A total of 78 patients who met the criteria of difficult cannulation in the National Taiwan University hospital from October 2015 to October 2017 were retrospectively reviewed. Their baseline demographics, success rate of biliary cannulation, and the rate of adverse events were assessed.Results: 31 patients and 47 patients underwent TPS and NKF for difficult biliary access, respectively. The characteristics of the 2 groups were similar, but patients in TPS group had more frequent pancreatic duct cannulation. Bile duct cannulation was successful in 23 patients (74.2%) in the TPS group and 39 (83.0%) in the NKF group (P = 0.34). There was no difference between the TPS and NKF in the rate of adverse events, including post-ERCP pancreatitis (PEP) (16.1% vs. 6.4%, p = 0.17), and hemorrhage (3.2% vs. 8.5%, p = 0.35). No perforation occurred.Conclusions: Both TPS and NKF have good biliary access rate in patient with difficult cannulation. TPS has acceptable successful rate and similar complication rate, compared with NKF. [ABSTRACT FROM AUTHOR]

Aim: precut sphincterotomy refers to a variety of endoscopic techniques that are used in order to access the bile duct when conventional methods of cannulation have failed. There are not significant data (such as efficacy, safety) about the use of different techniques of precutting at the same session. We have described our experience with combined precut sphincterotomy (CPS) and we have compared our results to the use of an isolated precut. Patients and methods: we have performed 247 precuts of a total of 2.390 ERCPs. Patients were distributed according to the type of precut practiced: Needle-knife, transpancreatic and combined precut sphincterotomies. "Combined precut" consisted in performing first a transpancreatic sphincterotomy and, if the access was not achieved, then performing a needle-knife sphincterotomy in the same session. The data about safety and efficacy were prospectively collected. The complications were defined according to the consensus criteria. Results: we performed precutting techniques in 247 patients. Needle-knife, transpancreatic, and combined precuts were performed in 125 (6.9%), 74 (4.1%) and 48 (2.6%) patients, respectively. Bile duct cannulation was successful in 48 patients (100%) in the group of combined precut, 121 patients (96.8%) in the transpancreatic group, and 67 patients (90.5%) in the needle-knife group (p = 0.03). There were not differences in complications rates between the three groups. There was no pancreatitis in the combined precut group. The complications were successfully managed with conservative treatment. Conclusions: combined precut sphincterotomy seems to be a safe and successful technique in those cases of difficult bile duct cannulation.

In 1970, a Japanese group reported the first use of endoscopic retrograde cholangiopancreatography (ERCP), which is now carried out worldwide. Selective bile duct cannulation is a mandatory technique for diagnostic and therapeutic ERCP. Development of the endoscope and other devices has contributed to the extended use of ERCP, which has become a basic procedure to diagnose and treat pancreaticobiliary diseases. Various techniques related to selective bile duct cannulation have been widely applied. Although the classical contrast medium injection cannulation technique remains valuable, use of wire-guided cannulation has expanded since the early 2000s, and the technique is now widely carried out in the USA and Europe. Endoscopists must pay particular attention to a patient's condition and make an attendant choice about the most effective technique for selective bile duct cannulation. Some techniques have the potential to shorten procedure time and reduce the incidence of adverse events, particularly post-ERCP pancreatitis. However, a great deal of experience is required and endoscopists must be skilled in a variety of techniques. Although the development of the transpapillary biliary cannulation approach is remarkable, it is important to note that, to date, there have been no reports of transpapillary cannulation preventing post-ERCP pancreatitis. In the present article, selective bile duct cannulation techniques in the context of recent Japanese randomized controlled trials and cases of precut sphincterotomy are reviewed and discussed. [ABSTRACT FROM AUTHOR]

Objective Pancreatic duct guidewire placement (PDGP) includes double guidewire technique (DGT) and transpancreatic sphincterotomy (TPS). DGT can be switched to TPS with ease due to the existing guidewire in the pancreatic duct. In this study, we aimed to combine DGT and TPS as a single technique, named sequential PDGP, and to compare its performance with needle knife precut sphincterotomy (NKPS) in treating difficult biliary cannulation (BC). Methods A total of 83 patients with difficult BC were enrolled in this study. Of these, 63 underwent sequential PDGP and 20 underwent NKPS. Cannulation success rate, cannulation time and endoscopic retrograde cholangiopancreatography (ERCP)-related complications were prospectively recorded and compared between the two groups. Results Successful BC was achieved in 88.9% (56/63) of the patients in the sequential PDGP group compared with 70.0% (14/20) in the NKPS group ( P = 0.095). Cannulation time was 7.49 ± 5.03 min in the sequential PDGP group and 10.60 ± 7.24 min in the NKPS group ( P = 0.086). Post-ERCP pancreatitis occurred in 12.7% of patients in the sequential PDGP group and 10.0% in the NKPS group ( P = 1.000). There was no significant difference in the rates of other complications (bleeding, perforation and cholangitis) between the two groups. Conclusions Sequential PDGP is a safe and effective alternative method to NKPS in cases of difficult BC. In those with failed standard cannulation, sequential PDGP can be considered when the guidewire is inadvertently inserted into the pancreatic duct or can be placed in the pancreatic duct without difficulty. [ABSTRACT FROM AUTHOR]

Background: The aim of this retrospective study was to evaluate the success rate and complications of three precut techniques of sphincterotomy after failure of conventional techniques of cannulation of common bile duct (CBD). Patients and Methods: Between January 2003 and October 2011, 2,903 consecutive ERCPs were performed in patients with naïve major papilla. In 283 patients in whom biliary cannulation was not achieved, precut technique was performed and these patients were included in the study. Results: A total of 274 patients were included in the final analysis. Needle-knife papillotomy (NKP) was performed in 129 cases (47.1 %), suprapapillary fistulotomy (SPF) in 78 patients (28.5 %), and transpancreatic sphincterotomy (TPS) in 67 cases (24.5 %). No significant difference was observed in the initial and eventual success rate of biliary cannulation between the three groups. Overall, complications occurred in 54 patients (19.7 %), of which 33 (25.6 %) were with NKP, 6 (7.7 %) with SPF and 15 (22.4 %) with TPS, respectively, a difference statistically significant favoring the SPF group ( p = 0.006). Post-procedure acute pancreatitis was developed in 27 cases (20.9 %) with NKP, compared to two cases (2.6 %) with SPF and 15 cases (22.4 %) with TPS, a difference statistically significant favoring the SPF group. No difference was observed between the groups with regard to the occurrence of post-procedure hemorrhage and perforation. Conclusions: The three types of precut sphincterotomy have no different overall CBD cannulation rates; SPF reduces post-ERCP pancreatitis risk. [ABSTRACT FROM AUTHOR]

Background: The majority of literature on the precut technique is concerned with needle-knife sphincterotomy, whereas the comparison of transpancreatic sphincterotomy and needle-knife sphincterotomy has been rarely reported. Aim The aim of the study was to compare the success and the complication rates of transpancreatic sphincterotomy with needle-knife sphincterotomy.Methods: During May 2006 and April 2007, 3,178 consecutive endoscopic retrograde cholangiopancreatography (ERCP) procedures were performed in a prospective multicenter study on ERCP-related complications. From the files of these patients, data of cases undergoing precut sphincterotomy, including transpancreatic sphincterotomy and needle-knife sphincterotomy, were retrospectively extracted and analyzed.Results: Overall, 216 patients with precut sphincterotomy were identified; 140 cases received transpancreatic sphincterotomy, and 76 received needle-knife sphincterotomy. There was no significant difference in the initial and eventual success rates between transpancreatic and needle-knife sphincterotomy (82.9% vs. 90.8% and 90.0% vs. 90.8%, respectively). The overall incidences of complications and acute pancreatitis were not significantly different between the two groups (14.3% vs. 18.4% and 11.4% vs. 11.8%, respectively). [ABSTRACT FROM AUTHOR]