AIM: To perform wire-guided cannulation using a newly designed J-shaped tip guidewire, and to verify feasibility and safety for use. METHODS: The study was conducted on endoscopic retrograde cholangiopancreatography (...AIM: To perform wire-guided cannulation using a newly designed J-shaped tip guidewire, and to verify feasibility and safety for use. METHODS: The study was conducted on endoscopic retrograde cholangiopancreatography (ERCP) patients with na ve papilla undergoing diagnosis and treatment of biliary diseases between September 2011 and July 2012. We performed ERCP in a succession of 50 cases with a J-shaped tip guidewire. The first insertion attempt began with a trainee who had 5 min to complete cannulation, followed if necessary by the trainer for another 5 min. We assessed the primary success rate of selective biliary cannulation within 10 min and adverse events such as post-ERCP pancreatitis (PEP), bleeding or perforation.RESULTS: The primary success rate was 90% (45/50) within 10 min, the initial success rate within 5 min by trainee staff was 76% (38/50). The rate of PEP was 6% (3/50), but all 3 cases were mild pancreatitis. All patients were managed successfully with conservative treatment. There was no bleeding or perforation. CONCLUSION: A newly designed J-shaped tip guidewire has the possibility to facilitate selective biliary cannulation for ERCP and appears to be safe.展开更多
AIM:To compare the clinical outcomes between 0.025-inch and 0.035-inch guide wires(GWs) when used in wire-guided cannulation(WGC).METHODS:A single center,randomized study was conducted between April 2011 and March 201...AIM:To compare the clinical outcomes between 0.025-inch and 0.035-inch guide wires(GWs) when used in wire-guided cannulation(WGC).METHODS:A single center,randomized study was conducted between April 2011 and March 2013. This study was approved by the Medical Ethics Committee at our hospital. Informed,written consent was obtained from each patient prior to study enrollment. Three hundred and twenty-two patients with a na?ve papilla of Vater who underwent endoscopic retrograde cholangiopancreatography(ERCP) for the purpose of selective bile duct cannulation with WGC were enrolled in this study. Fifty-three patients were excluded based on the exclusion criteria,and 269 patients were randomly allocated to two groups by a computer and analyzed:the 0.025-inch GW group(n = 109) and the 0.035-inch GW group(n = 160). The primary endpoint was the success rate of selective bile duct cannulation with WGC. Secondary endpoints were the success rates of the pancreatic GW technique and precutting,selective bile duct cannulation time,ERCP procedure time,the rate of pancreatic duct stent placement,the final success rate of selective bile duct cannulation,andthe incidence of post-ERCP pancreatitis(PEP).RESULTS:The primary success rates of selective bile duct cannulation with WGC were 80.7%(88/109) and 86.3%(138/160) for the 0.025-inch and the 0.035-inch groups,respectively(P = 0.226). There were no statistically significant differences in the success rates of selective bile duct cannulation using the pancreatic duct GW technique(46.7% vs 52.4% for the 0.025-inch and 0.035-inch groups,respectively; P = 0.884) or in the success rates of selective bile duct cannulation using precutting(66.7% vs 63.6% for the 0.025-inch and 0.035-inch groups,respectively; P = 0.893). The final success rates for selective bile duct cannulation using these procedures were 92.7%(101/109) and 97.5%(156/160) for the 0.025-inch and 0.035-inch groups,respectively(P = 0.113). There were no significant differences in selective bile duct cannulation time(median ± interquartile range:3.7 ± 13.9 min vs 4.0 ± 11.2 min for the 0.025-inch and 0.035-inch groups,respectively; P = 0.851),ERCP procedure time(median ± interquartile range:32 ± 29 min vs 30 ± 25 min for the 0.025-inch and 0.035-inch groups,respectively; P = 0.184) or in the rate of pancreatic duct stent placement(14.7% vs 15.6% for the 0.025-inch and 0.035-inch groups,respectively; P = 0.832). The incidence of PEP was 2.8%(3/109) and 2.5%(4/160) for the 0.025-inch and 0.035-inch groups,respectively(P = 0.793).CONCLUSION:The thickness of the GW for WGC does not appear to affect either the success rate of selective bile duct cannulation or the incidence of PEP.展开更多
BACKGROUND Needle-knife precut papillotomy(NKP)is typically performed freehand.However,it remains unclear whether pancreatic stent(PS)placement can improve the outcomes of NKP.AIM To explore whether PS placement impro...BACKGROUND Needle-knife precut papillotomy(NKP)is typically performed freehand.However,it remains unclear whether pancreatic stent(PS)placement can improve the outcomes of NKP.AIM To explore whether PS placement improves the success rate of NKP in patients with difficult biliary cannulation.METHODS This single-center retrospective study included 190 patients who underwent NKP between January 2017 and December 2021 after failed conventional biliary cannulation.In cases with incidental pancreatic duct cannulation during conventional biliary cannulation,the decision for pre-NKP PS placement was made at the endoscopist's discretion.The primary outcome was the difference in the NKP success rate between patients with and without PS placement;the secondary outcome was the adverse event rate.RESULTS Among the 190 participants,82 received pre-NKP PS(PS-NKP group)whereas 108 did not[freehand or freehand NKP(FH-NKP)group].Post-NKP selective biliary cannulation was successful in 167(87.9%)patients,and the PS-NKP had a significantly higher success rate than the FH-NKP group(93.9%vs 83.3%,P=0.027).The overall adverse event rates were 7.3%and 11.1%in the PS-NKP and FH-NKP groups,respectively(P=0.493).A periampullary diverticulum(PAD)and significant intraoperative bleeding during NKP were independently associated with NKP failure;however,a pre-NKP PS was the only predictor of NKP success.Among the 44 participants with PADs,the PS-NKP group had a non-significantly higher NKP success rate than the FH-NKP group(87.5%and 65%,respectively;P=0.076).CONCLUSION PS significantly improved the success rate of NKP in patients with difficult biliary cannulation.展开更多
BACKGROUND Endoscopic retrograde cholangiopancreatography is a challenging procedure involving bile duct cannulation.Despite the development of several cannulation devices,none have effectively facilitated the procedu...BACKGROUND Endoscopic retrograde cholangiopancreatography is a challenging procedure involving bile duct cannulation.Despite the development of several cannulation devices,none have effectively facilitated the procedure.AIM To evaluate the efficacy of a recently developed catheter for bile duct cannulation.METHODS We retrospectively examined 342 patients who underwent initial cholangiopan-creatography.We compared the success rate of bile duct cannulation and the incidence of complications between the groups using existing and novel catheters.RESULTS The overall success rates of bile duct cannulation were 98.3%and 99.1%in the existing and novel catheter groups,respectively(P=0.47).The bile duct cannulation rate using the standard technique was 73.0%and 82.1%in the existing and novel catheter groups,respectively(P=0.042).Furthermore,when catheterization was performed by expert physicians,the bile duct cannulation rate was significantly higher in the novel catheter group(81.3%)than in the existing catheter group(65.2%)(P=0.017).The incidence of difficult cannulation was also significantly lower in the novel catheter group(17.4%)than in the existing catheter group(33.0%)(P=0.019).CONCLUSION The novel catheter improved the bile duct cannulation rate using the standard technique and reduced the frequency of difficult cannulation cases,valuable tool in endoscopic retrograde cholangiopancreatography procedures performed by experts.展开更多
Veno-arterial extracorporeal membrane oxygenation(VA-ECMO)is a life support intervention for patients with refractory cardiogenic shock or severe cardiopulmonary failure.However,the choice of cannulation strategy rema...Veno-arterial extracorporeal membrane oxygenation(VA-ECMO)is a life support intervention for patients with refractory cardiogenic shock or severe cardiopulmonary failure.However,the choice of cannulation strategy remains contentious,partly due to insufficient understanding of hemodynamic characteristics associated with the site of arterial cannulation.In this study,a geometrical multiscale model was built to offer a mathematical tool for addressing the issue.The outflow cannula of ECMO was inserted into the ascending aorta in the case of central cannulation,whereas it was inserted into the right subclavian artery(RSA)or the left iliac artery(LIA)in the case of peripheral cannulation.Numerical simulations conducted on three patient-specific aortas demonstrated that the central cannulation outperformed the two types of peripheral cannulation in evenly delivering ECMO flow to branch arteries.Both the central and RSA cannulations could maintain an approximately normal hemodynamic state in the aortas,although the area of aortic walls exposed to abnormal wall shear stress(WSS)was considerably enlarged in comparison with the normal physiological condition.In contrast,the LIA cannulation not only led to insufficient delivery of ECMO flow to the right upper body(with ECMO flow fractions<0.5),but also induced marked flow disturbance in the aorta,causing about 40%of the abdominal aortic wall and over 65%of the resting aortic wall to suffer from high time-averaged WSS(>5 Pa)and low time-averaged WSS(<0.4 Pa),respectively.The LIA cannulation also resulted in significantly prolonged blood residence time(>40 s)in the ascending aorta,which,along with abnormal WSS,may considerably increase the risk of thrombosis.In summary,our numerical study elucidated the impact of arterial cannulation site in VA-ECMO intervention on aortic hemodynamics and ECMO flow distribution.The findings provide compensatory biomechanical information for traditional clinical studies and may serve as a theoretical reference for guiding the evaluation and selection of cannulation strategies in clinical practice.展开更多
Background:The endoscopic appearance of the major duodenal papilla influences biliary cannulation and complications.This study aimed to investigate the role of major duodenal papillae in the endoscopic treatment of co...Background:The endoscopic appearance of the major duodenal papilla influences biliary cannulation and complications.This study aimed to investigate the role of major duodenal papillae in the endoscopic treatment of common bile duct(CBD)stones.Methods:This retrospective study was conducted at Bishan Hospital of Chongqing Medical University between January 2018 and August 2022.Patients with native papillae who underwent endoscopic treatment for CBD stones were recruited and divided into four groups according to Haraldsson's classification of papillae(typesⅠ-Ⅳ).Univariate and multivariate logistic regression analyses were used to identify risk factors for difficult cannulation and post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP).Results:A total of 596 patients with CBD stones were enrolled.The proportion of patients with typeⅠpapilla was the highest(n=231,38.8%),followed by typeⅢpapilla(n=175,29.4%),typeⅣpapilla(n=101,16.9%)and typeⅡpapilla(n=89,14.9%).Difficult cannulation occurred in 188 of 596 patients(31.5%),with most cases occurring in those with typeⅢpapilla(71/175,40.6%,P=0.020).Multivariate logistic analysis revealed that age[odds ratio(OR)=1.034,95%confidence interval(CI):1.021–1.047,P<0.001],typeⅢpapilla(OR=2.255,95%CI:1.439–3.535,P<0.001),gallbladder in situ(OR=2.486,95%CI:1.346–4.590,P=0.004),and CBD diameter<10 mm(OR=1.600,95%CI:1.049–2.441,P=0.029)were risk factors for difficult cannulation.The total incidence of PEP was 10.9%.Compared with the other types of papillae,the rate of PEP was the highest in those with typeⅠpapilla(15.2%,P=0.030).Multivariate analysis demonstrated that PEP was associated with difficult cannulation(OR=1.811,95%CI:1.044–3.143,P=0.035)and white blood cells(WBCs)<10×10~9/L(OR=2.199,95%CI:1.051–4.600,P=0.036).Conclusions:The endoscopic appearance of the major papilla is an important factor that influences both biliary cannulation and outcomes.TypeⅢpapilla is more frequently difficult to cannulate in the endoscopic treatment of CBD stones.展开更多
Endoscopic retrograde cholangiopancreatography(ERCP)is a vital diagnostic and therapeutic technique in evaluating and treating biliary and pancreatic disorders.Since its inception in the late 20th century,ERCP has tra...Endoscopic retrograde cholangiopancreatography(ERCP)is a vital diagnostic and therapeutic technique in evaluating and treating biliary and pancreatic disorders.Since its inception in the late 20th century,ERCP has transitioned from a mostly diagnostic instrument to a chiefly interventional procedure,owing to the emergence of less invasive imaging techniques like magnetic resonance cholangiopancreatography and endoscopic ultrasonography.Successful biliary cannulation is the most important and difficult step of the procedure.However,there are many challenges associated with cannulation,such as the anatomy of the major duodenal papilla,the direction of the common bile duct and pancreatic duct in the ampulla of Vater,the presence of periampullary diverticula,and scope position.Advanced techniques for cannulation are necessary when basic techniques fail.Double guidewire,precut methods,and transpancreatic sphincterotomy are examples of these advanced techniques.This review aims to summarize the challenges of biliary cannulation and tips for performing cannulation techniques.展开更多
BACKGROUND Despite advancements,endoscopic retrograde cholangiopancreatography(ERCP)poses challenges,including the risk of post-ERCP pancreatitis and difficulty of biliary cannulation.AIM To compare dome and tapered t...BACKGROUND Despite advancements,endoscopic retrograde cholangiopancreatography(ERCP)poses challenges,including the risk of post-ERCP pancreatitis and difficulty of biliary cannulation.AIM To compare dome and tapered tip sphincterotomes,focusing on their efficacy in achieving successful biliary cannulation and reducing the incidence of post-ERCP pancreatitis.METHODS In this prospective,single-blind,randomized pilot study conducted at Inha Uni-versity Hospital,85 patients undergoing ERCP were equally divided into dome and tapered tip sphincterotome groups.The co-primary outcomes were the success rate of selective biliary cannulation and incidence of post-ERCP pancre-atitis.The secondary outcomes included biliary cannulation time,number of unintended pancreatic duct access events,and total procedure time.RESULTS The success rates of selective biliary cannulation were 74.4%and 85.7%in the dome and tapered tip groups,respectively,with no significant difference(P=0.20).Similarly,the incidence of post-ERCP pancreatitis did not differ significantly between the groups(5 cases in the tapered tip group vs 6 in the dome tip group,P=0.72).However,difficult cannulation was significantly more common in the dome tip group than in the tapered tip group(P=0.05).Selective biliary cannula-tion time emerged as a significant predictor of post-ERCP pancreatitis(multivariate odds ratio=9.33,95%confi-dence interval:1.31-66.44,P=0.03).CONCLUSION This study indicated that the sphincterotome tip type does not markedly affect biliary cannulation success or post-ERCP pancreatitis rates.However,cannulation duration is a key risk factor for post-ERCP pancreatitis.These findings provide preliminary insights that highlight the importance of refining ERCP practices,including sphinc-terotome selection,while underscoring the need for larger multicenter studies to improve procedure time and patient safety.展开更多
BACKGROUND Endoscopic retrograde cholangiopancreatography involves selective bile duct cannulation,which is often challenging and associated with complications.In difficult cannulation cases,early precutting is freque...BACKGROUND Endoscopic retrograde cholangiopancreatography involves selective bile duct cannulation,which is often challenging and associated with complications.In difficult cannulation cases,early precutting is frequently used.However,its efficacy and optimal indications require further evaluation.AIM To evaluate the efficacy and safety of early precut(EP)in difficult bile duct cannulation.METHODS This retrospective analysis of endoscopic retrograde cholangiopancreatography procedures was performed for bile duct cannulation in patients with naive papillae who required advanced cannulation techniques(ACTs).These patients were admitted between April 2020 and March 2024 and were analyzed for risk factors,success rates,and complications.Outcomes were compared between the EP group and the conventional other ACTs group,with a focus on cases with oral protrusion large(oral protrusion-L).RESULTS The need for ACTs was identified as an independent risk factor for complications[odds ratio(OR)=5.4;95%confidence interval:1.887-15.53].Malignant biliary strictures(OR=2.58)and oral protrusion-L(OR=2.77)were also identified as independent risk factors for requiring ACTs.The EP group had a significantly higher second-line cannulation success rate(97.9%vs 73.2%,P=0.001)and lower complication rate(8.3%vs 39.0%,P=0.001)than the other ACTs group.Additionally,similar benefits were observed in the oral protrusion-L cases.CONCLUSION This study provides compelling evidence that EP is a viable alternative and a superior strategy in cases requiring ACTs,particularly oral protrusion-L.展开更多
Even experienced endoscopists have 90% success in achieving deep biliary cannulation with standard methods. Biliary cannulation may become difficult in 10%-15% of patients with biliary obstruction and pre- cut (access...Even experienced endoscopists have 90% success in achieving deep biliary cannulation with standard methods. Biliary cannulation may become difficult in 10%-15% of patients with biliary obstruction and pre- cut (access) sphincterotomy is frequently chosen as a rescue treatment in these cases. Generally, precut sphincterotomy ensures a rate of 90%-100% success- ful deep biliary cannulation. The precut technique has been performed as either a fistulotomy with a needle knife sphincterotome or as a transpapillary septotomy with a standard sphincterotome. Both methods have similar efficacy and complication rates when adminis- tered to the proper patient. Although precut sphincter- otomy ensures over 90% success of biliary cannula- tion, it has been characterized as an independent risk factor for pancreatitis. The complications of the precut technique are not limited to pancreatitis. Two more important ones, bleeding and perforation, are also re- ported in some publications as being observed more commonly than during standard sphincterotomy. It is also reported that precut sphincterotomy increases morbidity when performed in patients without dilata- tion of their biliary tract. Nevertheless, precut sphinc- terotomy is a good alternative as a rescue method in the setting of a failed standard cannulation method. This paper discusses the technical details, timing, ef- ficacy and potential complications of precut sphincter- otomy.展开更多
BACKGROUND: Getting directly into the common bile duct (CBD) is the most important step for successful therapeutic biliary endoscopy. In 5%-10% of cases, the CBD remains inaccessible, necessitating pre-cut papillotomy...BACKGROUND: Getting directly into the common bile duct (CBD) is the most important step for successful therapeutic biliary endoscopy. In 5%-10% of cases, the CBD remains inaccessible, necessitating pre-cut papillotomy or fistulotomy with a needle-knife. The aim of this study was to assess the value of early application of the needle-knife in difficult biliary cannulation for endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Patients with failed biliary cannulation after 10 minutes or guide wire entering the pancreatic tube 3 times were randomly divided into group of needle-knife cut and group of persistent cannulation by standard techniques. The cannulation times, success rates and complication rates were compared between the two groups. RESULTS: A total of 948 therapeutic biliary ERCP procedures were performed between October 2004 and February 2006. Of 91 patients with difficult biliary cannulation, 43 patients underwent needle-knife cut: the cannulation success rate was 90.7%, the mean cannulation time was 5.6 minutes, and the complication rate was 9.3%. The other 48 patients underwent persistent cannulation by standard techniques: the cannulation success rate was 75%, the mean cannulation time was 10.2 minutes, and the complication rate was 14.6%. Significant differences were observed in cannulation success rate and cannulation time but in complication rate between the two groups.CONCLUSION: The early application of the needle-knife in difficult biliary cannulation is time-saving, safe and effective, with no increase in complication rate.展开更多
Background: Precut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography(ERCP). However, scarce...Background: Precut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography(ERCP). However, scarce data are available on different precut techniques for difficult biliary cannulation. This study aimed to evaluate the efficacy and safety of transpancreatic septotomy(TPS), needle-knife fistulotomy(NKF) or both based on the presence of unintentional pancreatic access and papillary morphology. Methods: Between March 2008 and December 2016, 157 consecutive patients undergoing precutting for an inaccessible bile duct during ERCP were identified. Precut techniques were chosen depending on repetitive inadvertent pancreatic cannulation and the papillary morphology. We retrospectively assessed the rates of cannulation success and procedure-related complications among three groups, namely TPS, NKF, and TPS followed by NKF. Results: The baseline characteristics of the three groups were comparable. The overall success rate of biliary cannulation reached 98.1%, including 111 of 113(98.2%) with TPS, 35 of 36(97.2%) with NKF and 8 of 8(100%) with NKF following TPS, without significant difference among groups. The incidences of total complications and post-ERCP pancreatitis were 9.6% and 7.6%, respectively. There was a trend towards less frequent post-ERCP pancreatitis after NKF(0%) compared with 11 cases(9.7%) after TPS and one case(12.5%) after NKF following TPS, but not significantly different( P = 0.07). No severe adverse event occurred during this study period. Conclusions: The choice of precut techniques by the presence of unintended pancreatic access and the papillary morphology brought about a high success rate without increasing risk in difficult biliary cannulation.展开更多
Periampullary diverticulum(PAD) is duodenal outpunching defined as herniation of the mucosa or submucosa that occurs via a defect in the muscle layer within an area of 2 to 3 cm around the papilla. Although PAD isusua...Periampullary diverticulum(PAD) is duodenal outpunching defined as herniation of the mucosa or submucosa that occurs via a defect in the muscle layer within an area of 2 to 3 cm around the papilla. Although PAD isusually asymptomatic and discovered incidentally during endoscopic retrograde cholangiopancreatography(ERCP), it is associated with different pathological conditions such as common bile duct obstruction, pancreatitis, perforation, bleeding, and rarely carcinoma. ERCP has a low rate of success in patients with PAD,suggesting that this condition may complicate the technical application of the ERCP procedure. Moreover, cannulation of PAD can be challenging, time consuming, and require the higher level of skill of more experienced endoscopists. A large portion of the failures of cannulation in patients with PAD can be attributed to inability of the endoscopist to detect the papilla. In cases where the papilla is identified but does not point in a suitable direction for cannulation, different techniques have been described. Endoscopists must be aware of papilla identification in the presence of PAD and of different cannulation techniques, including their technical feasibility and safety, to allow for an informed decision and ensure the best outcome. Herein, we review the literature on this practical topic and propose an algorithm to increase the success rate of biliary cannulation.展开更多
AIM To estimate the efficacy of 2 h post-endoscopic retrograde cholangiopancreatography(ERCP) serum amylase levels and other factors for predicting postERCP pancreatitis.METHODS This was a retrospective,single-center ...AIM To estimate the efficacy of 2 h post-endoscopic retrograde cholangiopancreatography(ERCP) serum amylase levels and other factors for predicting postERCP pancreatitis.METHODS This was a retrospective,single-center cohort study of consecutive patients who underwent ERCP from January 2010 to December 2013.Serum amylase levels were measured 2 h post-procedure,and patient- and procedure-related pancreatitis(PEP) risk factors wereanalyzed using a logistic model.RESULTS A total of 1520 cases(average age 72 ± 12 years,60% male) were initially enrolled in this study,and 1403 cases(725 patients) were ultimately analyzed after the exclusion of 117 cases.Fifty-five of these cases developed PEP.We established a 2 h serum amylase cutoff level of two times the upper limit of normal for predicting PEP.Multivariate analysis revealed that a cannulation time of more than 13 min [odds ratio(OR) 2.28,95%CI:1.132-4.651,P=0.0210] and 2 h amylase levels greater than the cutoff level(OR=24.1,95%CI:11.56-57.13,P<0.0001) were significant predictive factors for PEP.Forty-seven of the 55 patients who developed PEP exhibited 2 h amylase levels greater than the cutoff level(85%),and six of the remaining eight patients who developed PEP(75%) required longer cannulation times.Only 2 of the 1403 patients(0.14%) who developed PEP did not exhibit concerning 2 h amylase levels or require longer cannulation times.CONCLUSION These findings indicate that the combination of 2 h post-ERCP serum amylase levels and cannulation times represents a valuable marker for identifying patients at high risk for PEP.展开更多
Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholan...Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography(ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.展开更多
AIM: To compare the success rates and adverse events of early needle-knife fistulotomy(NKF) and double-guidewire technique(DGT) in patients with repetitive unintentional pancreatic cannulations.METHODS: From a total o...AIM: To compare the success rates and adverse events of early needle-knife fistulotomy(NKF) and double-guidewire technique(DGT) in patients with repetitive unintentional pancreatic cannulations.METHODS: From a total of 1650 patients admitted for diagnostic or therapeutic endoscopic retrograde cholangiopancreatography(ERCP) at a single tertiary care hospital(Pusan National University Yangsan Hospital, Yangsan, South Korea) between January2009 and December 2012, 134(8.1%) patients with unsuccessful biliary cannulation after 5 min trial of conventional methods, together with 5 or more repetitive unintentional pancreatic cannulations, were enrolled in the study. Early NKF and DGT groups were assigned 67 patients each. In the DGT group, NKF was performed for an additional 7 min if successful cannulation was not achieved.RESULTS: The success rates with early NKF andthe DGT were 79.1%(53/67) and 44.8%(30/67)(P< 0.001), respectively. The incidence of post-ERCP pancreatitis(PEP) was lower in the early NKF group than in the DGT group [4.5%(3/67) vs 14.9%(10/67),P = 0.041]. The mean cannulation times in the early NKF and DGT groups after assignment were 257 s and312 s(P = 0.013), respectively.CONCLUSION: Our data suggest that early NKF should be considered as the first approach to selective biliary cannulation in patients with repetitive unintentional pancreatic cannulations.展开更多
BACKGROUND Different types of periampullary diverticulum(PAD) may differentially affect the success of endoscopic retrograde cholangiopancreatography(ERCP) cannulation,but the clinical significance of the two current ...BACKGROUND Different types of periampullary diverticulum(PAD) may differentially affect the success of endoscopic retrograde cholangiopancreatography(ERCP) cannulation,but the clinical significance of the two current PAD classifications for cannulation is limited.AIM To verify the clinical value of our newly proposed PAD classification.METHODS A new PAD classification(Li-Tanaka classification) was proposed at our center.All PAD patients with native papillae who underwent ERCP from January 2012 to December 2017 were classified according to three classification systems, and the effects of various types of PAD on ERCP cannulation were compared.RESULTS A total of 3564 patients with native papillae were enrolled, including 967(27.13%)PAD patients and 2597(72.87%) non-PAD patients. In the Li-Tanaka classification, type Ⅰ PAD patients exhibited the highest difficult cannulation rate(23.1%, P = 0.01), and type Ⅱ and Ⅳ patients had the highest cannulation success rates(99.4% in type Ⅱ and 99.3% in type Ⅳ, P < 0.001). In a multivariableadjusted logistic model, the overall successful cannulation rate in PAD patients was higher than that in non-PAD patients [odds ratio(OR) = 1.87, 95% confidence interval(CI): 1.04-3037, P = 0.037]. In addition, compared to the non-PAD group,the difficulty of cannulation in the type Ⅰ PAD group according to the Li-Tanaka classification was greater(OR = 2.04, 95%CI: 1.13-3.68, P = 0.004), and the successful cannulation rate was lower(OR = 0.27, 95%CI: 0.11-0.66, P < 0.001),while it was higher in the type Ⅱ PAD group(OR = 4.44, 95%CI: 1.61-12.29, P <0.01).CONCLUSION Among the three PAD classifications, the Li-Tanaka classification has an obvious clinical advantage for ERCP cannulation, and it is helpful for evaluating potentially difficult and successful cannulation cases among different types of PAD patients.展开更多
In Encoscopic Retrograde Cholangiopancreatography(ERCP),the main concern is to gain access into the bile duct while avoiding the pancreatic duct because of the risk of post-ERCP pancreatitis.Diffi cult cannulation is ...In Encoscopic Retrograde Cholangiopancreatography(ERCP),the main concern is to gain access into the bile duct while avoiding the pancreatic duct because of the risk of post-ERCP pancreatitis.Diffi cult cannulation is defined as a situation where the endoscopist,using his/her regularly used cannulation technique,fails within a certain time limit or after a certain number of unsuccessful attempts.Different methods have been developed to manage diffi cult cannulation.The most common solution is to perform a precut papillotomy either with a needle knife or with a sphincterotome with or without a guide wire.This review describes different methods to overcome cases of difficult cannulation.We will discuss the success rate and complication rates associated with different methods of reaching the biliary tract.展开更多
AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center. METHODS: Prospective intention-to-treat analysis of pa...AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center. METHODS: Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP. RESULTS: Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary can- nulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identif iable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 nave pa-pilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or postERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017). CONCLUSION: Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.展开更多
AIM: To determine the efficacy and safety of meticulous cannulation by needle-knife.METHODS: Three needle-knife procedures were used to facilitate cannulation in cases when standard cannulation techniques failed. A to...AIM: To determine the efficacy and safety of meticulous cannulation by needle-knife.METHODS: Three needle-knife procedures were used to facilitate cannulation in cases when standard cannulation techniques failed. A total of 104 cannulationsvia the minor papilla attempted in 74 patients at our center between January 2008 and June 2014 were retrospectively reviewed.RESULTS: Standard methods were successful in79 cannulations. Of the 25 cannulations that could not be performed by standard methods, 19 were performed by needle-knife, while 17(89.5%) were successful. Needle-knife use improved the success rate of cannulation [76.0%, 79/104 vs 92.3%,(79 +17)/104; P = 0.001]. When the 6 cases not appropriate for needle-knife cannulation were excluded, the success rate was improved further(80.6%, 79/98 vs98.0%, 96/98; P = 0.000). There were no significant differences in the rates of post-endoscopic retrograde cholangiopancreatography adverse events between the group using standard methods alone and the group using needle-knife after failure of standard methods(4.7% vs 10.5%, P = 0.301).CONCLUSION: The needle-knife procedure may be an alternative method for improving the success rate of cannulation via the minor papilla, particularly when standard cannulation has failed.展开更多
基金Supported by Toho University Ohashi Medical Center
文摘AIM: To perform wire-guided cannulation using a newly designed J-shaped tip guidewire, and to verify feasibility and safety for use. METHODS: The study was conducted on endoscopic retrograde cholangiopancreatography (ERCP) patients with na ve papilla undergoing diagnosis and treatment of biliary diseases between September 2011 and July 2012. We performed ERCP in a succession of 50 cases with a J-shaped tip guidewire. The first insertion attempt began with a trainee who had 5 min to complete cannulation, followed if necessary by the trainer for another 5 min. We assessed the primary success rate of selective biliary cannulation within 10 min and adverse events such as post-ERCP pancreatitis (PEP), bleeding or perforation.RESULTS: The primary success rate was 90% (45/50) within 10 min, the initial success rate within 5 min by trainee staff was 76% (38/50). The rate of PEP was 6% (3/50), but all 3 cases were mild pancreatitis. All patients were managed successfully with conservative treatment. There was no bleeding or perforation. CONCLUSION: A newly designed J-shaped tip guidewire has the possibility to facilitate selective biliary cannulation for ERCP and appears to be safe.
文摘AIM:To compare the clinical outcomes between 0.025-inch and 0.035-inch guide wires(GWs) when used in wire-guided cannulation(WGC).METHODS:A single center,randomized study was conducted between April 2011 and March 2013. This study was approved by the Medical Ethics Committee at our hospital. Informed,written consent was obtained from each patient prior to study enrollment. Three hundred and twenty-two patients with a na?ve papilla of Vater who underwent endoscopic retrograde cholangiopancreatography(ERCP) for the purpose of selective bile duct cannulation with WGC were enrolled in this study. Fifty-three patients were excluded based on the exclusion criteria,and 269 patients were randomly allocated to two groups by a computer and analyzed:the 0.025-inch GW group(n = 109) and the 0.035-inch GW group(n = 160). The primary endpoint was the success rate of selective bile duct cannulation with WGC. Secondary endpoints were the success rates of the pancreatic GW technique and precutting,selective bile duct cannulation time,ERCP procedure time,the rate of pancreatic duct stent placement,the final success rate of selective bile duct cannulation,andthe incidence of post-ERCP pancreatitis(PEP).RESULTS:The primary success rates of selective bile duct cannulation with WGC were 80.7%(88/109) and 86.3%(138/160) for the 0.025-inch and the 0.035-inch groups,respectively(P = 0.226). There were no statistically significant differences in the success rates of selective bile duct cannulation using the pancreatic duct GW technique(46.7% vs 52.4% for the 0.025-inch and 0.035-inch groups,respectively; P = 0.884) or in the success rates of selective bile duct cannulation using precutting(66.7% vs 63.6% for the 0.025-inch and 0.035-inch groups,respectively; P = 0.893). The final success rates for selective bile duct cannulation using these procedures were 92.7%(101/109) and 97.5%(156/160) for the 0.025-inch and 0.035-inch groups,respectively(P = 0.113). There were no significant differences in selective bile duct cannulation time(median ± interquartile range:3.7 ± 13.9 min vs 4.0 ± 11.2 min for the 0.025-inch and 0.035-inch groups,respectively; P = 0.851),ERCP procedure time(median ± interquartile range:32 ± 29 min vs 30 ± 25 min for the 0.025-inch and 0.035-inch groups,respectively; P = 0.184) or in the rate of pancreatic duct stent placement(14.7% vs 15.6% for the 0.025-inch and 0.035-inch groups,respectively; P = 0.832). The incidence of PEP was 2.8%(3/109) and 2.5%(4/160) for the 0.025-inch and 0.035-inch groups,respectively(P = 0.793).CONCLUSION:The thickness of the GW for WGC does not appear to affect either the success rate of selective bile duct cannulation or the incidence of PEP.
文摘BACKGROUND Needle-knife precut papillotomy(NKP)is typically performed freehand.However,it remains unclear whether pancreatic stent(PS)placement can improve the outcomes of NKP.AIM To explore whether PS placement improves the success rate of NKP in patients with difficult biliary cannulation.METHODS This single-center retrospective study included 190 patients who underwent NKP between January 2017 and December 2021 after failed conventional biliary cannulation.In cases with incidental pancreatic duct cannulation during conventional biliary cannulation,the decision for pre-NKP PS placement was made at the endoscopist's discretion.The primary outcome was the difference in the NKP success rate between patients with and without PS placement;the secondary outcome was the adverse event rate.RESULTS Among the 190 participants,82 received pre-NKP PS(PS-NKP group)whereas 108 did not[freehand or freehand NKP(FH-NKP)group].Post-NKP selective biliary cannulation was successful in 167(87.9%)patients,and the PS-NKP had a significantly higher success rate than the FH-NKP group(93.9%vs 83.3%,P=0.027).The overall adverse event rates were 7.3%and 11.1%in the PS-NKP and FH-NKP groups,respectively(P=0.493).A periampullary diverticulum(PAD)and significant intraoperative bleeding during NKP were independently associated with NKP failure;however,a pre-NKP PS was the only predictor of NKP success.Among the 44 participants with PADs,the PS-NKP group had a non-significantly higher NKP success rate than the FH-NKP group(87.5%and 65%,respectively;P=0.076).CONCLUSION PS significantly improved the success rate of NKP in patients with difficult biliary cannulation.
文摘BACKGROUND Endoscopic retrograde cholangiopancreatography is a challenging procedure involving bile duct cannulation.Despite the development of several cannulation devices,none have effectively facilitated the procedure.AIM To evaluate the efficacy of a recently developed catheter for bile duct cannulation.METHODS We retrospectively examined 342 patients who underwent initial cholangiopan-creatography.We compared the success rate of bile duct cannulation and the incidence of complications between the groups using existing and novel catheters.RESULTS The overall success rates of bile duct cannulation were 98.3%and 99.1%in the existing and novel catheter groups,respectively(P=0.47).The bile duct cannulation rate using the standard technique was 73.0%and 82.1%in the existing and novel catheter groups,respectively(P=0.042).Furthermore,when catheterization was performed by expert physicians,the bile duct cannulation rate was significantly higher in the novel catheter group(81.3%)than in the existing catheter group(65.2%)(P=0.017).The incidence of difficult cannulation was also significantly lower in the novel catheter group(17.4%)than in the existing catheter group(33.0%)(P=0.019).CONCLUSION The novel catheter improved the bile duct cannulation rate using the standard technique and reduced the frequency of difficult cannulation cases,valuable tool in endoscopic retrograde cholangiopancreatography procedures performed by experts.
基金supported by the National Natural Science Foundation of China(Grant Nos.12372309,12061131015).
文摘Veno-arterial extracorporeal membrane oxygenation(VA-ECMO)is a life support intervention for patients with refractory cardiogenic shock or severe cardiopulmonary failure.However,the choice of cannulation strategy remains contentious,partly due to insufficient understanding of hemodynamic characteristics associated with the site of arterial cannulation.In this study,a geometrical multiscale model was built to offer a mathematical tool for addressing the issue.The outflow cannula of ECMO was inserted into the ascending aorta in the case of central cannulation,whereas it was inserted into the right subclavian artery(RSA)or the left iliac artery(LIA)in the case of peripheral cannulation.Numerical simulations conducted on three patient-specific aortas demonstrated that the central cannulation outperformed the two types of peripheral cannulation in evenly delivering ECMO flow to branch arteries.Both the central and RSA cannulations could maintain an approximately normal hemodynamic state in the aortas,although the area of aortic walls exposed to abnormal wall shear stress(WSS)was considerably enlarged in comparison with the normal physiological condition.In contrast,the LIA cannulation not only led to insufficient delivery of ECMO flow to the right upper body(with ECMO flow fractions<0.5),but also induced marked flow disturbance in the aorta,causing about 40%of the abdominal aortic wall and over 65%of the resting aortic wall to suffer from high time-averaged WSS(>5 Pa)and low time-averaged WSS(<0.4 Pa),respectively.The LIA cannulation also resulted in significantly prolonged blood residence time(>40 s)in the ascending aorta,which,along with abnormal WSS,may considerably increase the risk of thrombosis.In summary,our numerical study elucidated the impact of arterial cannulation site in VA-ECMO intervention on aortic hemodynamics and ECMO flow distribution.The findings provide compensatory biomechanical information for traditional clinical studies and may serve as a theoretical reference for guiding the evaluation and selection of cannulation strategies in clinical practice.
文摘Background:The endoscopic appearance of the major duodenal papilla influences biliary cannulation and complications.This study aimed to investigate the role of major duodenal papillae in the endoscopic treatment of common bile duct(CBD)stones.Methods:This retrospective study was conducted at Bishan Hospital of Chongqing Medical University between January 2018 and August 2022.Patients with native papillae who underwent endoscopic treatment for CBD stones were recruited and divided into four groups according to Haraldsson's classification of papillae(typesⅠ-Ⅳ).Univariate and multivariate logistic regression analyses were used to identify risk factors for difficult cannulation and post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP).Results:A total of 596 patients with CBD stones were enrolled.The proportion of patients with typeⅠpapilla was the highest(n=231,38.8%),followed by typeⅢpapilla(n=175,29.4%),typeⅣpapilla(n=101,16.9%)and typeⅡpapilla(n=89,14.9%).Difficult cannulation occurred in 188 of 596 patients(31.5%),with most cases occurring in those with typeⅢpapilla(71/175,40.6%,P=0.020).Multivariate logistic analysis revealed that age[odds ratio(OR)=1.034,95%confidence interval(CI):1.021–1.047,P<0.001],typeⅢpapilla(OR=2.255,95%CI:1.439–3.535,P<0.001),gallbladder in situ(OR=2.486,95%CI:1.346–4.590,P=0.004),and CBD diameter<10 mm(OR=1.600,95%CI:1.049–2.441,P=0.029)were risk factors for difficult cannulation.The total incidence of PEP was 10.9%.Compared with the other types of papillae,the rate of PEP was the highest in those with typeⅠpapilla(15.2%,P=0.030).Multivariate analysis demonstrated that PEP was associated with difficult cannulation(OR=1.811,95%CI:1.044–3.143,P=0.035)and white blood cells(WBCs)<10×10~9/L(OR=2.199,95%CI:1.051–4.600,P=0.036).Conclusions:The endoscopic appearance of the major papilla is an important factor that influences both biliary cannulation and outcomes.TypeⅢpapilla is more frequently difficult to cannulate in the endoscopic treatment of CBD stones.
文摘Endoscopic retrograde cholangiopancreatography(ERCP)is a vital diagnostic and therapeutic technique in evaluating and treating biliary and pancreatic disorders.Since its inception in the late 20th century,ERCP has transitioned from a mostly diagnostic instrument to a chiefly interventional procedure,owing to the emergence of less invasive imaging techniques like magnetic resonance cholangiopancreatography and endoscopic ultrasonography.Successful biliary cannulation is the most important and difficult step of the procedure.However,there are many challenges associated with cannulation,such as the anatomy of the major duodenal papilla,the direction of the common bile duct and pancreatic duct in the ampulla of Vater,the presence of periampullary diverticula,and scope position.Advanced techniques for cannulation are necessary when basic techniques fail.Double guidewire,precut methods,and transpancreatic sphincterotomy are examples of these advanced techniques.This review aims to summarize the challenges of biliary cannulation and tips for performing cannulation techniques.
基金Supported by the Shihwa Medical Center Research Fund.
文摘BACKGROUND Despite advancements,endoscopic retrograde cholangiopancreatography(ERCP)poses challenges,including the risk of post-ERCP pancreatitis and difficulty of biliary cannulation.AIM To compare dome and tapered tip sphincterotomes,focusing on their efficacy in achieving successful biliary cannulation and reducing the incidence of post-ERCP pancreatitis.METHODS In this prospective,single-blind,randomized pilot study conducted at Inha Uni-versity Hospital,85 patients undergoing ERCP were equally divided into dome and tapered tip sphincterotome groups.The co-primary outcomes were the success rate of selective biliary cannulation and incidence of post-ERCP pancre-atitis.The secondary outcomes included biliary cannulation time,number of unintended pancreatic duct access events,and total procedure time.RESULTS The success rates of selective biliary cannulation were 74.4%and 85.7%in the dome and tapered tip groups,respectively,with no significant difference(P=0.20).Similarly,the incidence of post-ERCP pancreatitis did not differ significantly between the groups(5 cases in the tapered tip group vs 6 in the dome tip group,P=0.72).However,difficult cannulation was significantly more common in the dome tip group than in the tapered tip group(P=0.05).Selective biliary cannula-tion time emerged as a significant predictor of post-ERCP pancreatitis(multivariate odds ratio=9.33,95%confi-dence interval:1.31-66.44,P=0.03).CONCLUSION This study indicated that the sphincterotome tip type does not markedly affect biliary cannulation success or post-ERCP pancreatitis rates.However,cannulation duration is a key risk factor for post-ERCP pancreatitis.These findings provide preliminary insights that highlight the importance of refining ERCP practices,including sphinc-terotome selection,while underscoring the need for larger multicenter studies to improve procedure time and patient safety.
文摘BACKGROUND Endoscopic retrograde cholangiopancreatography involves selective bile duct cannulation,which is often challenging and associated with complications.In difficult cannulation cases,early precutting is frequently used.However,its efficacy and optimal indications require further evaluation.AIM To evaluate the efficacy and safety of early precut(EP)in difficult bile duct cannulation.METHODS This retrospective analysis of endoscopic retrograde cholangiopancreatography procedures was performed for bile duct cannulation in patients with naive papillae who required advanced cannulation techniques(ACTs).These patients were admitted between April 2020 and March 2024 and were analyzed for risk factors,success rates,and complications.Outcomes were compared between the EP group and the conventional other ACTs group,with a focus on cases with oral protrusion large(oral protrusion-L).RESULTS The need for ACTs was identified as an independent risk factor for complications[odds ratio(OR)=5.4;95%confidence interval:1.887-15.53].Malignant biliary strictures(OR=2.58)and oral protrusion-L(OR=2.77)were also identified as independent risk factors for requiring ACTs.The EP group had a significantly higher second-line cannulation success rate(97.9%vs 73.2%,P=0.001)and lower complication rate(8.3%vs 39.0%,P=0.001)than the other ACTs group.Additionally,similar benefits were observed in the oral protrusion-L cases.CONCLUSION This study provides compelling evidence that EP is a viable alternative and a superior strategy in cases requiring ACTs,particularly oral protrusion-L.
文摘Even experienced endoscopists have 90% success in achieving deep biliary cannulation with standard methods. Biliary cannulation may become difficult in 10%-15% of patients with biliary obstruction and pre- cut (access) sphincterotomy is frequently chosen as a rescue treatment in these cases. Generally, precut sphincterotomy ensures a rate of 90%-100% success- ful deep biliary cannulation. The precut technique has been performed as either a fistulotomy with a needle knife sphincterotome or as a transpapillary septotomy with a standard sphincterotome. Both methods have similar efficacy and complication rates when adminis- tered to the proper patient. Although precut sphincter- otomy ensures over 90% success of biliary cannula- tion, it has been characterized as an independent risk factor for pancreatitis. The complications of the precut technique are not limited to pancreatitis. Two more important ones, bleeding and perforation, are also re- ported in some publications as being observed more commonly than during standard sphincterotomy. It is also reported that precut sphincterotomy increases morbidity when performed in patients without dilata- tion of their biliary tract. Nevertheless, precut sphinc- terotomy is a good alternative as a rescue method in the setting of a failed standard cannulation method. This paper discusses the technical details, timing, ef- ficacy and potential complications of precut sphincter- otomy.
文摘BACKGROUND: Getting directly into the common bile duct (CBD) is the most important step for successful therapeutic biliary endoscopy. In 5%-10% of cases, the CBD remains inaccessible, necessitating pre-cut papillotomy or fistulotomy with a needle-knife. The aim of this study was to assess the value of early application of the needle-knife in difficult biliary cannulation for endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Patients with failed biliary cannulation after 10 minutes or guide wire entering the pancreatic tube 3 times were randomly divided into group of needle-knife cut and group of persistent cannulation by standard techniques. The cannulation times, success rates and complication rates were compared between the two groups. RESULTS: A total of 948 therapeutic biliary ERCP procedures were performed between October 2004 and February 2006. Of 91 patients with difficult biliary cannulation, 43 patients underwent needle-knife cut: the cannulation success rate was 90.7%, the mean cannulation time was 5.6 minutes, and the complication rate was 9.3%. The other 48 patients underwent persistent cannulation by standard techniques: the cannulation success rate was 75%, the mean cannulation time was 10.2 minutes, and the complication rate was 14.6%. Significant differences were observed in cannulation success rate and cannulation time but in complication rate between the two groups.CONCLUSION: The early application of the needle-knife in difficult biliary cannulation is time-saving, safe and effective, with no increase in complication rate.
文摘Background: Precut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography(ERCP). However, scarce data are available on different precut techniques for difficult biliary cannulation. This study aimed to evaluate the efficacy and safety of transpancreatic septotomy(TPS), needle-knife fistulotomy(NKF) or both based on the presence of unintentional pancreatic access and papillary morphology. Methods: Between March 2008 and December 2016, 157 consecutive patients undergoing precutting for an inaccessible bile duct during ERCP were identified. Precut techniques were chosen depending on repetitive inadvertent pancreatic cannulation and the papillary morphology. We retrospectively assessed the rates of cannulation success and procedure-related complications among three groups, namely TPS, NKF, and TPS followed by NKF. Results: The baseline characteristics of the three groups were comparable. The overall success rate of biliary cannulation reached 98.1%, including 111 of 113(98.2%) with TPS, 35 of 36(97.2%) with NKF and 8 of 8(100%) with NKF following TPS, without significant difference among groups. The incidences of total complications and post-ERCP pancreatitis were 9.6% and 7.6%, respectively. There was a trend towards less frequent post-ERCP pancreatitis after NKF(0%) compared with 11 cases(9.7%) after TPS and one case(12.5%) after NKF following TPS, but not significantly different( P = 0.07). No severe adverse event occurred during this study period. Conclusions: The choice of precut techniques by the presence of unintended pancreatic access and the papillary morphology brought about a high success rate without increasing risk in difficult biliary cannulation.
文摘Periampullary diverticulum(PAD) is duodenal outpunching defined as herniation of the mucosa or submucosa that occurs via a defect in the muscle layer within an area of 2 to 3 cm around the papilla. Although PAD isusually asymptomatic and discovered incidentally during endoscopic retrograde cholangiopancreatography(ERCP), it is associated with different pathological conditions such as common bile duct obstruction, pancreatitis, perforation, bleeding, and rarely carcinoma. ERCP has a low rate of success in patients with PAD,suggesting that this condition may complicate the technical application of the ERCP procedure. Moreover, cannulation of PAD can be challenging, time consuming, and require the higher level of skill of more experienced endoscopists. A large portion of the failures of cannulation in patients with PAD can be attributed to inability of the endoscopist to detect the papilla. In cases where the papilla is identified but does not point in a suitable direction for cannulation, different techniques have been described. Endoscopists must be aware of papilla identification in the presence of PAD and of different cannulation techniques, including their technical feasibility and safety, to allow for an informed decision and ensure the best outcome. Herein, we review the literature on this practical topic and propose an algorithm to increase the success rate of biliary cannulation.
文摘AIM To estimate the efficacy of 2 h post-endoscopic retrograde cholangiopancreatography(ERCP) serum amylase levels and other factors for predicting postERCP pancreatitis.METHODS This was a retrospective,single-center cohort study of consecutive patients who underwent ERCP from January 2010 to December 2013.Serum amylase levels were measured 2 h post-procedure,and patient- and procedure-related pancreatitis(PEP) risk factors wereanalyzed using a logistic model.RESULTS A total of 1520 cases(average age 72 ± 12 years,60% male) were initially enrolled in this study,and 1403 cases(725 patients) were ultimately analyzed after the exclusion of 117 cases.Fifty-five of these cases developed PEP.We established a 2 h serum amylase cutoff level of two times the upper limit of normal for predicting PEP.Multivariate analysis revealed that a cannulation time of more than 13 min [odds ratio(OR) 2.28,95%CI:1.132-4.651,P=0.0210] and 2 h amylase levels greater than the cutoff level(OR=24.1,95%CI:11.56-57.13,P<0.0001) were significant predictive factors for PEP.Forty-seven of the 55 patients who developed PEP exhibited 2 h amylase levels greater than the cutoff level(85%),and six of the remaining eight patients who developed PEP(75%) required longer cannulation times.Only 2 of the 1403 patients(0.14%) who developed PEP did not exhibit concerning 2 h amylase levels or require longer cannulation times.CONCLUSION These findings indicate that the combination of 2 h post-ERCP serum amylase levels and cannulation times represents a valuable marker for identifying patients at high risk for PEP.
文摘Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography(ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.
基金Supported by a 2-year Research Grant of Pusan National University
文摘AIM: To compare the success rates and adverse events of early needle-knife fistulotomy(NKF) and double-guidewire technique(DGT) in patients with repetitive unintentional pancreatic cannulations.METHODS: From a total of 1650 patients admitted for diagnostic or therapeutic endoscopic retrograde cholangiopancreatography(ERCP) at a single tertiary care hospital(Pusan National University Yangsan Hospital, Yangsan, South Korea) between January2009 and December 2012, 134(8.1%) patients with unsuccessful biliary cannulation after 5 min trial of conventional methods, together with 5 or more repetitive unintentional pancreatic cannulations, were enrolled in the study. Early NKF and DGT groups were assigned 67 patients each. In the DGT group, NKF was performed for an additional 7 min if successful cannulation was not achieved.RESULTS: The success rates with early NKF andthe DGT were 79.1%(53/67) and 44.8%(30/67)(P< 0.001), respectively. The incidence of post-ERCP pancreatitis(PEP) was lower in the early NKF group than in the DGT group [4.5%(3/67) vs 14.9%(10/67),P = 0.041]. The mean cannulation times in the early NKF and DGT groups after assignment were 257 s and312 s(P = 0.013), respectively.CONCLUSION: Our data suggest that early NKF should be considered as the first approach to selective biliary cannulation in patients with repetitive unintentional pancreatic cannulations.
基金Supported by the National Natural Science Foundation of China,NO.31570509.
文摘BACKGROUND Different types of periampullary diverticulum(PAD) may differentially affect the success of endoscopic retrograde cholangiopancreatography(ERCP) cannulation,but the clinical significance of the two current PAD classifications for cannulation is limited.AIM To verify the clinical value of our newly proposed PAD classification.METHODS A new PAD classification(Li-Tanaka classification) was proposed at our center.All PAD patients with native papillae who underwent ERCP from January 2012 to December 2017 were classified according to three classification systems, and the effects of various types of PAD on ERCP cannulation were compared.RESULTS A total of 3564 patients with native papillae were enrolled, including 967(27.13%)PAD patients and 2597(72.87%) non-PAD patients. In the Li-Tanaka classification, type Ⅰ PAD patients exhibited the highest difficult cannulation rate(23.1%, P = 0.01), and type Ⅱ and Ⅳ patients had the highest cannulation success rates(99.4% in type Ⅱ and 99.3% in type Ⅳ, P < 0.001). In a multivariableadjusted logistic model, the overall successful cannulation rate in PAD patients was higher than that in non-PAD patients [odds ratio(OR) = 1.87, 95% confidence interval(CI): 1.04-3037, P = 0.037]. In addition, compared to the non-PAD group,the difficulty of cannulation in the type Ⅰ PAD group according to the Li-Tanaka classification was greater(OR = 2.04, 95%CI: 1.13-3.68, P = 0.004), and the successful cannulation rate was lower(OR = 0.27, 95%CI: 0.11-0.66, P < 0.001),while it was higher in the type Ⅱ PAD group(OR = 4.44, 95%CI: 1.61-12.29, P <0.01).CONCLUSION Among the three PAD classifications, the Li-Tanaka classification has an obvious clinical advantage for ERCP cannulation, and it is helpful for evaluating potentially difficult and successful cannulation cases among different types of PAD patients.
文摘In Encoscopic Retrograde Cholangiopancreatography(ERCP),the main concern is to gain access into the bile duct while avoiding the pancreatic duct because of the risk of post-ERCP pancreatitis.Diffi cult cannulation is defined as a situation where the endoscopist,using his/her regularly used cannulation technique,fails within a certain time limit or after a certain number of unsuccessful attempts.Different methods have been developed to manage diffi cult cannulation.The most common solution is to perform a precut papillotomy either with a needle knife or with a sphincterotome with or without a guide wire.This review describes different methods to overcome cases of difficult cannulation.We will discuss the success rate and complication rates associated with different methods of reaching the biliary tract.
文摘AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center. METHODS: Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP. RESULTS: Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary can- nulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identif iable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 nave pa-pilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or postERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017). CONCLUSION: Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.
文摘AIM: To determine the efficacy and safety of meticulous cannulation by needle-knife.METHODS: Three needle-knife procedures were used to facilitate cannulation in cases when standard cannulation techniques failed. A total of 104 cannulationsvia the minor papilla attempted in 74 patients at our center between January 2008 and June 2014 were retrospectively reviewed.RESULTS: Standard methods were successful in79 cannulations. Of the 25 cannulations that could not be performed by standard methods, 19 were performed by needle-knife, while 17(89.5%) were successful. Needle-knife use improved the success rate of cannulation [76.0%, 79/104 vs 92.3%,(79 +17)/104; P = 0.001]. When the 6 cases not appropriate for needle-knife cannulation were excluded, the success rate was improved further(80.6%, 79/98 vs98.0%, 96/98; P = 0.000). There were no significant differences in the rates of post-endoscopic retrograde cholangiopancreatography adverse events between the group using standard methods alone and the group using needle-knife after failure of standard methods(4.7% vs 10.5%, P = 0.301).CONCLUSION: The needle-knife procedure may be an alternative method for improving the success rate of cannulation via the minor papilla, particularly when standard cannulation has failed.
