Difficult biliary cannulation: use of physician-controlled wire-guided cannulation over a pancreatic duct stent to reduce the rate of precut sphincterotomy (with video)
Received 7 February 2009; accepted 23 August 2009. published online 19 November 2009.
Background
Successful cannulation of the common bile duct (CBD) remains the benchmark for ERCP. Use of a pancreatic duct (PD) stent to facilitate biliary cannulation has been described, although the majority of patients require precut sphincterotomy to achieve CBD cannulation.
Objective
To report the performance characteristics of using a PD stent in conjunction with physician-controlled wire-guided cannulation (WGC) to facilitate bile duct cannulation.
Design
Retrospective cohort.
Setting
Two tertiary care, academic medical centers.
Patients
All undergoing ERCP with native papillae.
Intervention
In cases of difficult biliary access in which the PD is cannulated, a pancreatic stent is placed. After this, physician-controlled WGC is attempted by using the PD stent to direct the sphincterotome into the biliary orifice. If cannulation is unsuccessful after several minutes, a precut sphincterotomy is performed over the PD stent or the procedure is terminated.
Main Outcome Measurements
Frequency of successful bile duct cannulation and precut sphincterotomy.
Results
A total of 2345 ERCPs were identified, 1544 with native papillae. Among these, CBD and PD cannulation failed in 16 (1.0%) patients, whereas 76 (4.9%) patients received a PD stent to facilitate biliary cannulation. Successful cannulation was achieved in 71 (93.4%) of 76 patients, 60 (78.9%) of whom did not require precut sphincterotomy. Complications included mild post-ERCP pancreatitis in 4 (5.3%) and aspiration in 1 (1.3%). Precut sphincterotomy was complicated by hemorrhage, controlled during the procedure in 2 (13.3%) of 15.
Conclusions
Physician-controlled WGC over a PD stent facilitates biliary cannulation while maintaining a low rate of precut sphincterotomy.
Current affiliations: Division of Gastroenterology (G.A.C.), Indiana University, Indianapolis, Indiana, Department of Medicine (M.A., S.A.E., S.S.J., R.R.A.), Division of Gastroenterology, Washington University, St. Louis, Missouri, Department of Medicine (R.P., D.K.P.), Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
Reprint requests: Riad Azar, MD, Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, St. Louis, MO 63110.
DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.
If you would like to chat with an author of this article, you may contact Dr. Coté at gcote@iupui.edu.
ABSTRACT
Difficult biliary cannulation: use of physician-controlled wire-guided cannulation over a pancreatic duct stent to reduce the rate of precut sphincterotomy (with video)