A prospective randomized trial of cannulation technique in ERCP: effects on technical success and post-ERCP pancreatitis. Guidewire cannulation reduces risk of post-ERCP pancreatitis and facilitates bile duct cannulation. Wire-guided selective cannulation of the bile duct with a sphincterotome: a prospective randomized comparative study with the standard method. Can wire-guided cannulation prevent post-ERCP pancreatitis? A prospective randomized trial. A comparative study of standard ERCP catheter and hydrophilic guide wire in the selective cannulation of the common bile duct. A multicenter, prospective, randomized study of selective bile duct cannulation performed by multiple endoscopists: the BIDMEN study. A simple way of avoiding post-ERCP pancreatitis.
Inadvertent injection of contrast agent into the pancreatic duct is believed to be an important contributor to pancreatitis occurring after endoscopic retrograde cholangiopancreatography (post-ERCP pancreatitis, PEP). Our aim was to examine whether primary deep biliary cannulation with a guide wire is associated with a lower rate of PEP than conventional contrast-assisted cannulation.
                From August 2003 to April 2006 all patients with an intact papilla who were referred for ERCP were eligible. Patients with pancreatic or ampullary cancer were excluded. Patients were randomized to undergo sphincterotomy biliary cannulation using either contrast injection or a guide wire. The ERCP fellow attempted initially for 5 minutes. If unsuccessful, the consultant attempted for 5 minutes using the same technique, followed by crossover to the other technique in the same sequence and then needle-knife sphincterotomy where appropriate. Patients were assessed clinically after the procedure, then followed up with telephone interviews after 24 hours and 30 days, and serum amylase and lipase tests after 24 hours.
                Out of 1654 patients undergoing ERCP, 413 were included in the study. PEP occurred in 29/413 (7.0 %): 16 in the guide-wire arm, 13 in the contrast arm ( P = 0.48). The overall cannulation success rate was 97.3 %. Cannulation was successful without crossover in 323/413 patients (78.2 %): 167/202 (81.4 %) in the guide-wire arm and 156/211 (73.9 %) in the contrast arm ( P = 0.03). Multivariate analysis demonstrated female sex (OR = 2.7, P = 0.04), suspected sphincter of Oddi dysfunction (OR = 5.5, P = 0.01), and complete filling of the pancreatic duct with contrast agent (OR = 3.5, P = 0.02) to be independently associated with PEP. The risk of PEP increased incrementally with each attempt at the papilla (OR 1.4 per attempt, P = 0.04) to greater than 10 % after four or more attempts.
                The guide-wire technique improves the primary success rate for biliary cannulation during ERCP but does not reduce the incidence of PEP compared to the conventional contrast technique. The incidence of PEP increases incrementally with each attempt at the papilla. To evaluate if using a soft-tipped guidewire to cannulate the common bile duct may ameliorate development of post-ERCP pancreatitis and facilitate cannulation of the CBD.
                A single-center, blinded, randomized trial of conventional cannulation technique using sphinctertome and contrast injection versus guidewire cannulation technique.
                We prospectively randomized 300 patients to conventional cannulation (group I) or guidewire cannulation (group II) technique.
                Primary outcome measure was incidence of acute pancreatitis and secondary outcome measures were ease of cannulation of common bile duct (assessed by attempts required for common bile duct cannulation & rates of precut sphincterotomy) and overall complication rates.
                Guidewire cannulation was associated with significantly lower likelihood of post-ERCP pancreatitis (adjusted OR 0.43, 95% CI 0.21-0.89, P= 0.02). Twenty-five patients (16.6%) in group I and thirteen patients (8.6%) in group II developed acute pancreatitis, P= 0.037. All instances of pancreatitis were mild. There were more women in group II; 41 in group I and 59 in group II, P= 0.028. Otherwise the two groups were comparable for age, age under 35 yr, indication for ERCP, diagnosis, and number of patients with SOD. The number of patients requiring 0-3, 4-6, and 7-10 attempts for successful cannulation of the common bile duct were 87, 48, and 15 in group I and 117, 24, and 9 in group II, respectively, P= 0.001. A total of 33 patients in group I and 13 patients in group II required precut sphincterotomy, P= 0.007. Rates of accidental pancreatic duct cannulation were 21 in group I and 27 in group II, P= 0.34. Rates of overall complication were not significantly different in the two groups.
                Guidewire technique for bile duct cannulation lowers likelihood of post-ERCP pancreatitis by facilitating cannulation and reducing need for precut sphincterotomy. Wire-guided cannulation (WGC) is expected to reduce the incidence of post-ERCP pancreatitis (PEP). Our aim was to compare the incidence of PEP and the success rate of deep biliary cannulation using WGC or the standard cannulation method with contrast injection (STD).
                A total of 172 cases with an intact papilla were randomized into the STD group (n = 86) and the WGC group (n = 86). First a trainee endoscopist attempted the cannulation and if it was not successful, an expert endoscopist tried. When the cannulation was not successful within 10 min, the other method was conducted as a second attempt. The primary endpoint was the incidence of PEP and the secondary endpoint was the success rate of selective cannulation.
                In successful cases, PEP occurred in 6.5% in the STD group and 3.0% in the WGC group in the first attempt. Overall rate of PEP was 6.0% (3, mild; 1, moderate and 1, severe) in the STD group and 2.3% (2, mild) in the WGC group, which were not significantly different. Selective cannulation rate in the first attempt was 73.8% in the STD group and 77.9% in the WGC group. After a crossover, the cannulation was successful in the second attempt in 36.4% and 42.1% and finally in 95.2% and 100% by the STD and WGC method, respectively.
                The incidence of PEP tended to be lower in the WGC method compared to the STD method. In addition, all cases of pancreatitis in the WGC group were mild. The success rate of cannulation was comparable between two groups. Among the procedure-related factors associated with post-ERCP pancreatitis, selective cannulation of the common bile duct by insertion of a guidewire may be associated with fewer complications than conventional methods of cannulation with contrast injection to access the bile duct. However, the results of studies regarding the usefulness of wire-guided cannulation (WGC) are conflicting.
                This prospective randomized trial was designed to determine whether WGC reduces the rate of post-ERCP pancreatitis.
                A prospective randomized controlled trial.
                Tertiary-care academic medical center.
                A total of 300 consecutive patients with native papilla and pancreaticobiliary disease who were candidates for therapeutic ERCP were randomized from June 2006 to May 2007.
                WGC without contrast injection or conventional cannulation with contrast injection.
                Post-ERCP pancreatitis, risk factors, and procedure-related complications were evaluated prospectively.
                A total of 3 patients (2%) in the WGC group and 17 patients (11.3%) in the conventional group had post-ERCP pancreatitis (P = .001). Among the cases of acute pancreatitis in the WGC group, 2 patients with suspected sphincter of Oddi dysfunction (SOD) and unintentional main pancreatic duct (PD) guidewire cannulation showed post-ERCP pancreatitis despite the use of WGC. In multivariate analysis, WGC was a protective factor (odds ratio 0.1; 95% CI, 0.024-0.490, P = .004), whereas female sex and SOD were risk factors for post-ERCP pancreatitis.
                Our study population was a low-risk cohort.
                WGC is associated with a lower rate of post-ERCP pancreatitis. However, WGC may not prevent post-ERCP pancreatitis in patients with suspected SOD and unintentional PD guidewire cannulation. Deep cannulation of the common bile duct (CBD) is paramount for the success of endoscopic biliary intervention. The aim of the present study was to compare standard ERCP catheter and hydrophilic guide wire (HGW) in the selective cannulation of the CBD.
                A total of 332 patients were randomly assigned to cannulation with a standard catheter (n = 165) or a HGW (n = 167). If cannulation had not succeeded after 10 minutes with the technique assigned at randomization, a further attempt was made for an additional 10 minutes using the alternative technique. The following were assessed: primary and overall selective cannulation, time to cholangiography, number of pancreatic opacifications and guide-wire pancreatic duct insertions, and complication rates.
                The primary success rate of selective CBD cannulation was higher in the HGW (81.4 %) than in the standard catheter group (53.9 %; P < 0.001). The overall cannulation rate after crossover was comparable between the two groups (standard catheter 84 % vs. HGW 83.8 %; P = 0.19). Time required for primary selective CBD cannulation was 3.53 +/- 0.32 minutes in the standard catheter vs. 4.48 +/- 0.32 minutes in the HGW group ( P = 0.04), and the number of insertions of the guide wire into the pancreatic duct was 3.29 +/- 0.47 in the standard catheter vs. 2.7 +/- 0.21 in the HGW group ( P = 0.22). Pancreatic opacifications occurred 3.19 +/- 0.20 times in the standard catheter vs. 1.50 +/- 0.22 times in the HGW group ( P < 0.001). Precut techniques were used in 56 patients (16.9 %) (n = 31 in the standard catheter vs. n = 25 in the HGW group; P = 0.07). The frequency of postinterventional pancreatitis and hemorrhage did not differ between the two groups. A young woman developed post-ERCP hemolytic crisis due to glucose-6-phosphate dehydrogenase deficiency. There was no procedure-related mortality.
                The use of HGW, as primary technique or as a secondary technique after failure of cannulation with a standard catheter, achieves a high rate of selective CBD cannulation. Wire-guided cannulation (WGC) with a sphincterotome (S) for selective bile duct cannulation (SBDC) has been reported to have a higher success rate and lower incidence of post-ERCP pancreatitis (PEP) than conventional methods in some randomized, controlled trials (RCTs) that were both single center and limited to only a few endoscopists.
                To estimate the difference in SBDC according to the method and catheter used in a multicenter and multiendoscopist study.
                A prospective, multicenter RCT with a 2 × 2 factorial design.
                Fifteen referral endoscopy units.
                In total, 400 consecutive patients with naive papillae who were candidates for ERCP were enrolled and randomized.
                Patients were assigned to 4 groups according to combined catheter (S or catheter [C]) and method (with/without guidewire [GW]).
                Success rate of SBDC performed in 10 minutes, SBDC time, fluoroscopy time, and incidence of complications.
                There was no significant difference in the SBDC success rate between the groups with and without GW, between C and S, or among the 4 groups (C+GW, C, S+GW, S). WGC had a tendency to significantly shorten cannulation and fluoroscopy times only in approximately 70% of patients in this study in whom SBDC was achieved in 10 minutes or less (P = .036 and .00004, respectively). All 4 groups resulted in similar outcomes in PEP (4%, 5.9%, 2%, and 2.1%, respectively).
                Non-double-blind study.
                WGC appears to significantly shorten cannulation and fluoroscopy times. However, neither the method nor type of catheter used resulted in significant differences in either SBDC success rate or incidence of PEP in this RCT. (Clinical trial registration number: UMIN000002572.).
                Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved. Pancreatitis occurs in up to 30% of patients who undergo ERCP. This study tested the hypothesis that post-ERCP pancreatitis can be avoided by initially accessing the bile duct with a soft-tipped Teflon tracer 0.035-inch guidewire.
                A single endoscopist performed ERCP in 400 consecutive patients with pancreatobiliary disease who were randomized to two groups. In Group A (200 patients), the bile duct was first accessed by insertion of a soft-tipped Teflon tracer (diameter 0.035 inch) guidewire through a 6F, double channel sphincterotome, followed by cannulation, injection of contrast, and sphincterotomy. In Group B (200 patients), the bile duct was opacified by using traditional methods of cannulation.
                No case of acute pancreatitis was detected in Group A, whereas, 8 cases were observed in Group B (6 mild, one moderate, one severe) (p < 0.01). In 9 patients in Group A vs. 39 in Group B (p < 0.001), the serum amylase rose to more than 5 times the upper normal limit during the 24 hours after the procedure. There was no procedure-related mortality.
                Accessing the bile duct with a soft-tipped tracer guidewire prevents post-ERCP pancreatitis.
Compared with the contrast-assisted cannulation technique, the guidewire-assisted cannulation technique increases the primary cannulation rate and reduces the risk of PEP, and it appears to be the most appropriate first-line cannulation technique.