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Selective biliary cannulation Jacques Devière, MD, PhD Erasme Hospital Université Libre de Bruxelles Brussels, Belgium
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
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
Courtesy G. Costamagna Anatomy of the ampulla
Major papilla: landmarks 1. Orifice 2. Axis 3. Infundibulum 4. Transv. fold 5. Frenulum Bile duct: 30 α 55 - Angle - Diametre Courtesy G. Costamagna
Normal anatomy
Cannulation with a catheter The Shoe horn manoeuvre
Cannulation with a sphincterotome
Facing the papilla : Unbended Sphx Pancreatic duct filling
Facing the papilla : Bended sphincterotome Common bile duct filling
Ball-Tip vs Steerable catheter Standard cannula Sphincterotome Bendable catheter p N 107 101 104 Success rate (opacif) 75% 88% 84% 0.04 Success rate (deep can) 66% 78% 69% 0.15 Laasch et al, Endoscopy 2003:669
REAL «Intra»-diverticular papilla:
Over the wire or stent in the pancreas Maeda et al, Endoscopy 2003;35:721
Billroth II anatomy
Cannulation with a guide-wire
Guide-wire Cannulation Soft wires (Hydrophilic) Straight tip
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?
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
BMJ 2003
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
Reasonable Tips Avoid submucosal injection Role of GI assistant Define anatomy with early injection (if possible) In combination with wire technique Triple lumen sphincterotomes
Loop-Tip wire Avoids angle impaction Useful also in Billroth 2 Distal diameter 23/12/2015 Chun SY et al Hepatogastroenterology 2014 29
Detachable Ball tip wire 23/12/2015 30 BEAMS, ULB, Brussels
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
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
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
And more.. 23/12/2015 34
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