Double guidewire technique vs transpancreatic precut sphincterotomy in difficult biliary cannulation

Abstract

Aim: To compare the outcomes between double-guidewire technique (DGT) and transpancreatic precut sphincterotomy (TPS) in patients with difficult biliary cannulation.

Methods: This was a prospective, randomized study conducted in single tertiary referral hospital in Korea. Between January 2005 and September 2010. A total of 71 patients, who bile duct cannulation was not possible and selective pancreatic duct cannulation was achieved, were randomized into DGT (n = 34) and TPS (n = 37) groups. DGT or TPS was done for selective biliary cannulation. We measured the technical success rates of biliary cannulation, median cannulation time, and procedure related complications.

Results: The distribution of patients after randomization was balanced, and both groups were comparable in baseline characteristics, except the higher percentage of endoscopic nasobiliary drainage in the DGT group (55.9% vs 13.5%, P < 0.001). Successful cannulation rate and mean cannulation times in DGT and TPS groups were 91.2% vs 91.9% and 14.1 ± 13.2 min vs 15.4 ± 17.9 min, P = 0.732, respectively. There was no significant difference between the two groups. The overall incidence of post- endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis was 38.2% vs 10.8%, P < 0.011 in the DGT group and the TPS group; post-procedure pancreatitis was significantly higher in the DGT group. But the overall incidence of post-ERCP hyperamylasemia was no significant difference between the two groups; DGT group vs TPS group: 14.7% vs 16.2%, P < 1.0.

Conclusion: When free bile duct cannulation was difficult and selective pancreatic duct cannulation was achieved, DGT and TPS facilitated biliary cannulation and showed similar success rates. However, post-procedure pancreatitis was significantly higher in the DGT group.

Keywords: Duoble guidewire technique; Endoscopic retrograde cholangiopancreatography; Post-endoscopic retrograde cholangiopancreatography pancreatitis; Transpancrestic precut sphincterotomy.

Figure 1

Radiologic images showing the use of double-guidewire technique and transpancreatic precut sphincterotomy. A: Guidewire inserted and left in the pancreatic duct (PD) [double-guidewire technique (DGT)]; B: Common bile duct cannulation with a guidewire after previous insertion of a guidewire in the PD (DGT); C: Sphincterotomy performed with a cutting wire along the biliary direction at 11 o’clock [transpancreatic precut sphincterotomy (TPS)] with guidewire inserted and left in the PD (TPS); D: The bile duct orifice exposed to the left and below the pancreatic orifice (TPS). And then common bile duct cannulation after transpancreatic sphincterotomy.

Figure 2

Subject flow in the study. CBD: Common bile duct; DGT: Double-guidewire technique; TPS: Transpancreatic sphincterotomy.