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Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery
Published on: February 10, 2023
Sequential algorithm analysis to facilitate selective biliary access for difficult biliary cannulation in ERCP: a
Tae Hoon Lee1, Soon Oh Hwang, Hyun Jong Choi
1Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University School of Medicine, Cheonan Hospital, 23-20 Bongmyung-dong, Cheonan, South Korea. thlee9@schmc.ac.kr.
A sequential protocol using early precut fistulotomy (EPF), double-guidewire cannulation (DGC), and precut after pancreatic stent placement (PPS) significantly improved biliary access success rates in difficult biliary cannulation (DBC) during ERCP. This approach demonstrated safety and feasibility for complex cases.
Area of Science:
- Gastroenterology
- Endoscopic Retrograde Cholangiopancreatography (ERCP)
- Biliary Interventions
Background:
- Difficult biliary cannulation (DBC) during ERCP presents a significant challenge, with limited standardized protocols to enhance success rates.
- Existing clinical trials offer various techniques, but a sequential approach for managing DBC is not well-established.
- This study aimed to evaluate a novel sequential protocol to facilitate selective biliary access in patients experiencing DBC during ERCP.
Purpose of the Study:
- To investigate the efficacy and safety of a sequential cannulation protocol for managing difficult biliary access during ERCP.
- To compare the success rates, procedure times, and complication rates of different sequential steps in DBC management.
- To establish a structured algorithm for addressing challenging cannulation scenarios in ERCP.
Main Methods:
- A prospective study enrolled 711 patients with naïve papillae undergoing ERCP.
- A sequential algorithm was applied for DBC: early precut fistulotomy (EPF), followed by double-guidewire cannulation (DGC), and then precut after pancreatic stent placement (PPS) if DGC failed or was difficult.
- Technical success, procedure outcomes, and complications were the primary outcome measures.
Main Results:
- The overall successful biliary cannulation rate was 97.1% (136/140) in patients with DBC.
- Success rates varied by technique: EPF (94.4%), DGC (47.8%), and PPS (100%). PPS was used for 36 patients who initially underwent DGC.
- Post-ERCP pancreatitis occurred in 10% of patients, with no significant difference among the sequential groups or compared to a conventional approach.
Conclusions:
- The sequential protocol involving EPF, DGC, and PPS is safe and feasible for achieving successful biliary access in DBC during ERCP.
- EPF is effective for specific DBC criteria, DGC is useful for unintentional pancreatic duct cannulations, and PPS aids in difficult or failed DGC cases.
- This structured approach may enhance cannulation success rates and procedural efficiency in challenging ERCP scenarios.
