GEEW June 20-22, 2016 Brussels.

Transcription

1 GEEW June 20-22, 2016 Brussels

2 Selective biliary cannulation Jacques Devière, MD, PhD Erasme Hospital Université Libre de Bruxelles Brussels, Belgium

3 Cannulation of the Papilla Opacification and deep cannulation of the desired duct Ductal anatomy within the ampulla Anatomical variations Opacification, guide-wire or both Other tricks

4 Short versus long position Higher stability in the duodenum Better manoeuvrability Anatomical Conditions Gastric decompensation Papilla in D3 Extrinsic Compressions Hepatectomy (left hypertrophy) Left hepatic mass Pancreatic Pseudocyst/ tumor

5 Courtesy G. Costamagna Anatomy of the ampulla

6 Major papilla: landmarks 1. Orifice 2. Axis 3. Infundibulum 4. Transv. fold 5. Frenulum Bile duct: 30 α 55 - Angle - Diametre Courtesy G. Costamagna

7 Normal anatomy

8 Cannulation with a catheter The Shoe horn manoeuvre

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12 Cannulation with a sphincterotome

13 Facing the papilla : Unbended Sphx Pancreatic duct filling

14 Facing the papilla : Bended sphincterotome Common bile duct filling

15 Ball-Tip vs Steerable catheter Standard cannula Sphincterotome Bendable catheter p N Success rate (opacif) 75% 88% 84% 0.04 Success rate (deep can) 66% 78% 69% 0.15 Laasch et al, Endoscopy 2003:669

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18 REAL «Intra»-diverticular papilla:

19 Over the wire or stent in the pancreas Maeda et al, Endoscopy 2003;35:721

20 Billroth II anatomy

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22 Cannulation with a guide-wire

23 Guide-wire Cannulation Soft wires (Hydrophilic) Straight tip

24 Injection vs wire Injection Direct anatomical roadmap Teaching, demonstration Safer: No risk of dissection, perforation Less traumatic? Wire Eliminates risk of repeated PD injection May improve cannulation success Less traumatic?

25 Can wire guided cannulation increase success and reduce pancreatitis? Metaanalysis of 5 RCTs Primary cannulation rate higher in the GW group (85.3% vs 74.9%; p<0.001) Final cannulation rate 93 %in both groups Use of precut higher in contrast group (14.7% vs 10.3%; p<0.01) OR for post ERCP pancreatitis was 0.23 in the GW group Cennamo V et al, Am. J. Gastr. 2009; 104;2143

26 BMJ 2003

27 Data Largely dependent upon personal and institutional preference Published studies significantly influenced by local bias and talent All published by wire supporters Conclusion regarding superior technique probably difficult

28 Reasonable Tips Avoid submucosal injection Role of GI assistant Define anatomy with early injection (if possible) In combination with wire technique Triple lumen sphincterotomes

29 Loop-Tip wire Avoids angle impaction Useful also in Billroth 2 Distal diameter 23/12/2015 Chun SY et al Hepatogastroenterology

30 Detachable Ball tip wire 23/12/ BEAMS, ULB, Brussels

31 INDICATIONS : THE CLEAREST IS THE SAFEST Complications Pancreatitis Any SOD 19,1% 21,7% CBD stones before or after cholecystectomy 2,8% 4,9% Freeman et al, 1996

32 ENDOSCOPIST'S CASE VOLUME <1 EBS/wk >1 EBS/wk Difficult cannulation 14.6% 7.1% p<0.001 N of MPD injections 2.1% 1.4% p<0.001 Failures or drainage 5.4% 1.2% p<0.001 Hemorrhage 2.9% 1.1% p<0.002 Severe complications 2.3% 0.9% p=0.01 All complications 11.1% 8.4% p=0.03 Freeman et al, NEJM 1996

33 Conclusions «Difficult» cannulation depends on case volume / experience. Many tricks or devices allow to reach >95% success rate without precut. Knowledge of papillary anatomy is a key-point of success. Hydrophilic GW are part of the cannulation process Ex-vivo training is an absolute need for the future

34 And more.. 23/12/

35 GEEW June 20-22, 2016 Brussels