A Comparative Study of Transpancreatic Sphincterotomy, Double Guidewire Technique, and Precut Sphincterotomy in Difficult Naive Biliary Cannulations in a Tertiary Care Center in Western India

Abstract

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.

Keywords

difficult biliary cannulation - ERCP - double guidewire - precut - transpancreatic sphincterotomy

Ethical Approval

This study was approved by the institutional review board (approval no.: IEC/92/22).

Publication History

Article published online:
12 August 2024

• References

• 1 Adler DG, Baron TH, Davila RE. et al; Standards of Practice Committee of American Society for Gastrointestinal Endoscopy. ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas. Gastrointest Endosc 2005; 62 (01) 1-8
• 2 Testoni PA, Mariani A, Aabakken L. et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2016; 48 (07) 657-683
• 3 Faulx AL, Lightdale JR, Acosta RD. et al; ASGE Standards of Practice Committee. Guidelines for privileging, credentialing, and proctoring to perform GI endoscopy. Gastrointest Endosc 2017; 85 (02) 273-281
• 4 Goff JS. Common bile duct pre-cut sphincterotomy: transpancreatic sphincter approach. Gastrointest Endosc 1995; 41 (05) 502-505
• 5 Yoo YW, Cha SW, Lee WC, Kim SH, Kim A, Cho YD. Double guidewire technique vs transpancreatic precut sphincterotomy in difficult biliary cannulation. World J Gastroenterol 2013; 19 (01) 108-114
• 6 Choudhary A, Bechtold ML, Arif M. et al. Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review. Gastrointest Endosc 2011; 73 (02) 275-282
• 7 Kubota K, Sato T, Kato S. et al. Needle-knife precut papillotomy with a small incision over a pancreatic stent improves the success rate and reduces the complication rate in difficult biliary cannulations. J Hepatobiliary Pancreat Sci 2013; 20 (03) 382-388
• 8 Wang P, Zhang W, Liu F. et al. Success and complication rates of two precut techniques, transpancreatic sphincterotomy and needle-knife sphincterotomy for bile duct cannulation. J Gastrointest Surg 2010; 14 (04) 697-704
• 9 Saritas U, Ustundag Y, Harmandar F. Precut sphincterotomy: a reliable salvage for difficult biliary cannulation. World J Gastroenterol 2013; 19 (01) 1-7
• 10 Dalal A, Gandhi C, Patil G, Kamat N, Vora S, Maydeo A. Safety and efficacy of different techniques in difficult biliary cannulation at endoscopic retrograde cholangiopancreatography. Hosp Pract 2022; 50 (01) 61-67
• 11 Angsuwatcharakon P, Thongsuwan C, Ridtitid W. et al. Morphology of the major duodenal papilla for the selection of advanced cannulation techniques in difficult biliary cannulation. Surg Endosc 2023; 37 (08) 5807-5815
• 12 Catalano MF, Linder JD, Geenen JE. Endoscopic transpancreatic papillary septotomy for inaccessible obstructed bile ducts: comparison with standard pre-cut papillotomy. Gastrointest Endosc 2004; 60 (04) 557-561
• 13 Halttunen J, Keränen I, Udd M, Kylänpää L. Pancreatic sphincterotomy versus needle knife precut in difficult biliary cannulation. Surg Endosc 2009; 23 (04) 745-749
• 14 Herreros de Tejada A, Calleja JL, Díaz G. et al; UDOGUIA-04 Group. Double-guidewire technique for difficult bile duct cannulation: a multicenter randomized, controlled trial. Gastrointest Endosc 2009; 70 (04) 700-709
• 15 Pin F, Conti Bellocchi MC, Crinò SF, Bernardoni L, Facciorusso A, Gabbrielli A. Double guide-wire technique versus transpancreatic biliary sphincterotomy for difficult biliary cannulation: real life experience from a referral center. Dig Liver Dis 2022; 54 (11) 1548-1553
• 16 Sugiyama H, Tsuyuguchi T, Sakai Y. et al. Transpancreatic precut papillotomy versus double-guidewire technique in difficult biliary cannulation: prospective randomized study. Endoscopy 2018; 50 (01) 33-39
• 17 Facciorusso A, Ramai D, Gkolfakis P. et al. Comparative efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis. Gastrointest Endosc 2022; 95 (01) 60-71.e12