GEEW June 20-22, 2016

Brussels

www.live-endoscopy.com

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

• Anatomical Conditions – Gastric decompensation

– Papilla in D3

• Extrinsic Compressions – Hepatectomy (left hypertrophy)

– Left hepatic mass

– Pancreatic Pseudocyst/ tumor

• Higher stability in the duodenum

• Better manoeuvrability

Anatomy of the ampulla

Courtesy G. Costamagna

Major papilla: landmarks

1. Orifice

2. Axis

3. Infundibulum

4. Transv. fold

5. Frenulum

Bile duct:

- Angle

- Diametre

30° ≤ α ≥ 55°

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 29 Chun SY et al Hepatogastroenterology 2014

Detachable Ball tip wire

23/12/2015 30

BEAMS, ULB, Brussels

INDICATIONS :

THE CLEAREST IS THE SAFEST

Pancreatitis Any

Complications

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

GEEW June 20-22, 2016

Brussels

www.live-endoscopy.com