Incision Improves Success and Safety for Difficult Biliary Access Compared With Wire- or Stent-Guided Entry
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Incision Improves Success and Safety for Difficult Biliary Access Compared With Wire- or Stent-Guided Entry

Bret T. Petersen, MD, MASGE, reviewing Facciorusso A, et al. Gastrointest Endosc 2021 Sep 16.

A variety of techniques have been described for achieving deep biliary cannulation, a necessary prelude to most endoscopic retrograde cholangiographic (ERCP) procedures. The rate of successful cannulation is commonly touted as a useful quality measure.  

The authors of this study performed a network meta-analysis of 17 randomized studies comprised of 2015 patients to identify the relative efficacy of 5 adjunctive techniques: persistence with standard techniques (PSTs), needle-knife sphincterotomy (NKS), transpancreatic sphincterotomy (TPS), pancreatic guidewire-assisted cannulation, and pancreatic stent-assisted cannulation.

Despite the low quality of evidence among the studies, by GRADE criteria, the success of difficult biliary cannulation using TPS was superior to all other techniques, with NKS a close second. Post-ERCP pancreatitis (PEP) was lowest with NKS, and both NKS and TPS minimized PEP compared with PST or either technique with wire or stent assistance.

Bret T. Petersen, MD, FASGE

COMMENT

Not uncommonly, gaining initial deep access to the duct is the most difficult maneuver during an ERCP. Among the various ancillary techniques, none has gained recognition as clearly the most successful or safe, as attested to by the soft data and relatively modest differences identified here. Nevertheless, this study suggests transpancreatic and needle-knife sphincterotomies both exceed the success and safety of stent- and wire-facilitated techniques. The NKS alternatives, fistulotomy versus sphincterotomy beginning from the papillary os, were not distinguished here due to study heterogeneity, but fistulotomy has been reported to be even safer than incision started distally. The safety of both NKS and TPS likely correlates with timeliness in performance because PSTs generally increase the risk of papillary trauma and pancreatitis.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

CITATION(S)

Facciorusso A, Ramai D, Gkolfakis P, et al. Comparative efficacy of different methods for difficult biliary cannulation in ERCP: a systematic review and network meta-analysis. Gastrointest Endosc 2021 Sep 16. (Epub ahead of print) (https://doi.org/10.1016/j.gie.2021.09.010)

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