Comparison between double guidewire technique and transpancreatic sphincterotomy technique for difficult biliary cannulation / 中华消化内镜杂志

Objective To compare the efficacy and safety of double guidewire technique ( DGT ) with transpancreatic sphincterotomy ( TPS) in cannulation of difficult biliary. Methods The data of patients undergoing endoscopic retrograde cholangiopancreatography from January 2014 to January 2016 in our hospital were retrospectively studied. DGT or TPS was performed on patients with difficult biliary cannulation and frequent unintended pancreatic cannulation. The cannulation success rate, cannulation time and complications of DGT and TPS were compared. Results Data of 237 patients with difficult biliary cannulation were collected, including 135 using DGT and 102 using TPS. The cannulation success rate was 79. 3％ (107/135) in DGT and 90. 2％ (92/102) in TPS (P=0. 023). The cannulation time was 8. 8±2. 7 min in DGT and 4. 7±1. 3 min in TPS (P=0. 017). The overall incidence of complications was 8. 9％(12/135) in DGT and 8. 8％ (9/102) in TPS (P=0. 986). Conclusion For patients with difficult biliary cannulation, TPS has higher success rate, shorter cannulation time, and similar complication rate compared with DGT. Endoscopists with skilled TPS procedure could select TPS as a preferred method in difficult biliary cannulation.

Las técnicas de rescate en la canulación biliar difícil / Rescue techniques in difficult biliary cannulation

La colangiopancreatografía retrógrada endoscópica (CPRE) es la técnica de elección para el tratamiento de diferentes enfermedades biliopancreáticas. La canulación selectiva del conducto deseado (biliar o pancreático) es el punto clave inicial del objetivo terapéutico. Actualmente, la forma más utilizada para conseguir el acceso a la vía biliar, y que podemos denominar "técnica estándar", es la que emplea un esfinterótomo asociado con una guía hidrófila. Cuando dicha canulación estándar falla, existen diferentes alternativas que nos permitirán conseguir la canulación en un alto porcentaje de pacientes. En situaciones de canulación difícil, las técnicas de rescate a utilizar pueden estar condicionadas, entre otras, por el perfil de riesgo de complicaciones del paciente, por la experiencia o las preferencias del endoscopista y por haber conseguido o no previamente la canulación del conducto pancreático. Si se consiguió la canulación del conducto pancreático puede intentarse la técnica de doble guía, la esfinterotomía transpancreática y el precorte de aguja sobre prótesis pancreática. Si no se consiguió la canulación del conducto pancreático, probablemente la mejor opción sea una fistulotomía. Es conveniente conocer, en el contexto de una canulación difícil, cuándo hay que decidir la finalización de la prueba, principalmente si no existe una urgencia de drenaje de la vía biliar para el paciente. En estos casos debemos considerar repetir el procedimiento unos días más tarde. Si la urgencia del paciente es evidente, puede intentarse el acceso de la vía biliar asistido por técnicas alternativas.

Endoscopic retrograde cholangiopancreatography (ERCP) is the technique of choice in treating different biliopancreatic diseases. Selective cannulation of the desired duct (biliary or pancreatic) is the initial key point of the therapeutic goal. Currently, the most used method to obtain access to the bile duct is what we can call "standard technique", which uses the sphincterotome associated with a hydrophilic guide. When such standard cannulation fails, there are different alternatives that will allow us to achieve cannulation in a high percentage of patients. In situations of difficult cannulation the rescue techniques may be conditioned by the risk profile of the patient's complications, by the experience and/or preferences of the endoscopist, or by whether or not he has previously been able to cannulate the pancreatic duct. If cannulation of the pancreatic duct is achieved, the double guide technique, and needle precut on pancreatic prosthesis can be attempted. If cannulation of the pancreatic duct is not achieved, fistulotomy is probably the best option. In the case of a difficult cannulation, it is important to know when to decide the end of the test, especially if there is no urgency to drain the bile duct. In these cases we should consider repeating the procedure a few days later. If the patient's urgency is evident, access to the bile duct assisted by alternative techniques can be attempted.