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Cannulation and Sphincterotomy: Beyond the Basics

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Abstract

Cannulation and sphincterotomy are two of the most fundamental techniques required to perform ERCP successfully. Both of these techniques have evolved over the years and have been the subject of intense scrutiny. Modern cannulation and sphincterotomy techniques are designed to maximize efficiency and minimize harm to the patient. This chapter reviews basic and advanced techniques for cannulation and sphincterotomy.

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References

  1. Williams EJ, Ogollah R, Thomas P, Logan RF, Martin D, Wilkinson ML, Lombard M. What predicts failed cannulation and therapy at ERCP? Results of a large-scale multicenter analysis. Endoscopy. 2012;44(7):674–83.

    Article  CAS  PubMed  Google Scholar 

  2. Schwacha H, Allgaier HP, Deibert P, Olschewski M, Allgaier U, Blum HE. A sphincterotome-based technique for selective transpapillary common bile duct cannulation. Gastrointest Endosc. 2000;52(3):387–91.

    Article  CAS  PubMed  Google Scholar 

  3. Cortas GA, Mehta SN, Abraham NS, Barkun AN. Selective cannulation of the common bile duct: a prospective randomized trial comparing standard catheters with sphincterotomes. Gastrointest Endosc. 1999;50(6):775–9.

    Article  CAS  PubMed  Google Scholar 

  4. Karamanolis G, Katsikani A, Viazis N, Stefanidis G, Manolakopoulos S, Sgouros S, Papadopoulou E, Mantides A. A prospective cross-over study using a sphincterotome and a guidewire to increase the success rate of common bile duct cannulation. World J Gastroenterol. 2005;11(11):1649–52.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Laasch HU, Tringali A, Wilbraham L, Marriott A, England RE, Mutignani M, Perri V, Costamagna G, Martin DF. Comparison of standard and steerable catheters for bile duct cannulation in ERCP. Endoscopy. 2003;35(8):669–74.

    Article  PubMed  Google Scholar 

  6. Halttunen J, Kylänpää L. A prospective randomized study of thin versus regular-sized guide wire in wire-guided cannulation. Surg Endosc. 2013;27(5):1662–7.

    Article  PubMed  Google Scholar 

  7. Verma D, Gostout CJ, Petersen BT, Levy MJ, Baron TH, Adler DG. Establishing a true assessment of endoscopic competence in ERCP during training and beyond: a single-operator learning curve for deep biliary cannulation in patients with native papillary anatomy. Gastrointest Endosc. 2007;65(3):394–400.

    Article  PubMed  Google Scholar 

  8. Lella F, Bagnolo F, Colombo E, Bonassi U. A simple way of avoiding post-ERCP pancreatitis. Gastrointest Endosc. 2004;59(7):830–4.

    Article  PubMed  Google Scholar 

  9. Adler DG, Verma D, Hilden K, Chadha R, Thomas K. Dye-free wire-guided cannulation of the biliary tree during ERCP is associated with high success and low complication rates: outcomes in a single operator experience of 822 cases. J Clin Gastroenterol. 2010;44(3):e57–62.

    Article  PubMed  Google Scholar 

  10. Cheung J, Tsoi KK, Quan WL, Lau JY, Sung JJ. Guidewire versus conventional contrast cannulation of the common bile duct for the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis. Gastrointest Endosc. 2009;70(6):1211–9.

    Article  PubMed  Google Scholar 

  11. Bailey AA, Bourke MJ, Williams SJ, Walsh PR, Murray MA, Lee EY, Kwan V, Lynch PM. A prospective randomized trial of cannulation technique in ERCP: effects on technical success and post-ERCP pancreatitis. Endoscopy. 2008;40(4):296–301.

    Article  CAS  PubMed  Google Scholar 

  12. Katsinelos P, Paroutoglou G, Kountouras J, Chatzimavroudis G, Zavos C, Pilpilidis I, Tzelas G, Tzovaras G. A comparative study of standard ERCP catheter and hydrophilic guide wire in the selective cannulation of the common bile duct. Endoscopy. 2008;40(4):302–7.

    Article  CAS  PubMed  Google Scholar 

  13. Kawakami H, Maguchi H, Mukai T, Hayashi T, Sasaki T, Isayama H, Nakai Y, Yasuda I, Irisawa A, Niido T, Okabe Y, Ryozawa S, Itoi T, Hanada K, Kikuyama M, Arisaka Y, Kikuchi S, Japan Bile Duct Cannulation Study Group. A multicenter, prospective, randomized study of selective bile duct cannulation performed by multiple endoscopists: the BIDMEN study. Gastrointest Endosc. 2012;75(2):362–72.

    Article  PubMed  Google Scholar 

  14. Maeda S, Hayashi H, Hosokawa O, Dohden K, Hattori M, Morita M, Kidani E, Ibe N, Tatsumi S. Prospective randomized pilot trial of selective biliary cannulation using pancreatic guide-wire placement. Endoscopy. 2003;35(9):721–4.

    Article  CAS  PubMed  Google Scholar 

  15. Draganov P, Devonshire DA, Cunningham JT. A new technique to assist in difficult bile duct cannulation at the time of endoscopic retrograde cholangiopancreatography. JSLS. 2005;9(2):218–21.

    PubMed  PubMed Central  Google Scholar 

  16. Belverde B, Frattaroli S, Carbone A, Viceconte G. Double guidewire technique for ERCP in difficult bile cannulation: experience with 121 cases. Ann Ital Chir. 2012;83(5):391–3.

    PubMed  Google Scholar 

  17. Kramer RE, Azuaje RE, Martinez JM, Dunkin BJ. The double-wire technique as an aid to selective cannulation of the common bile duct during pediatric endoscopic retrograde cholangiopancreatography. J Pediatr Gastroenterol Nutr. 2007;45(4):438–42.

    Article  PubMed  Google Scholar 

  18. Herreros de Tejada A, Calleja JL, Díaz G, Pertejo V, Espinel J, Cacho G, Jiménez J, Millán I, García F, Abreu L, UDOGUIA-04 Group. Double-guidewire technique for difficult bile duct cannulation: a multicenter randomized, controlled trial. Gastrointest Endosc. 2009;70(4):700–9.

    Article  PubMed  Google Scholar 

  19. Ito K, Fujita N, Noda Y, Kobayashi G, Obana T, Horaguchi J, Takasawa O, Koshita S, Kanno Y, Ogawa T. Can pancreatic duct stenting prevent post-ERCP pancreatitis in patients who undergo pancreatic duct guidewire placement for achieving selective biliary cannulation? A prospective randomized controlled trial. J Gastroenterol. 2010;45(11):1183–91.

    Article  PubMed  Google Scholar 

  20. Slivka A. A new technique to assist in bile duct cannulation. Gastrointest Endosc. 1996;44(5):636.

    Article  CAS  PubMed  Google Scholar 

  21. Goldberg E, Titus M, Haluszka O, Darwin P. Pancreatic-duct stent placement facilitates difficult common bile duct cannulation. Gastrointest Endosc. 2005;62(4):592–6.

    Article  PubMed  Google Scholar 

  22. Coté GA, Ansstas M, Pawa R, Edmundowicz SA, Jonnalagadda SS, Pleskow DK, Azar RR. Difficult biliary cannulation: use of physician-controlled wire-guided cannulation over a pancreatic duct stent to reduce the rate of precut sphincterotomy (with video). Gastrointest Endosc. 2010;71(2):275–9.

    Article  PubMed  Google Scholar 

  23. Coté GA, Mullady DK, Jonnalagadda SS, Keswani RN, Wani SB, Hovis CE, Ammar T, Al-Lehibi A, Edmundowicz SA, Komanduri S, Azar RR. Use of a pancreatic duct stent or guidewire facilitates bile duct access with low rates of precut sphincterotomy: a randomized clinical trial. Dig Dis Sci. 2012;57(12):3271–8.

    Article  PubMed  Google Scholar 

  24. Banerjee N, Hilden K, Baron TH, Adler DG. Endoscopic biliary sphincterotomy is not required for transpapillary SEMS placement for biliary obstruction. Dig Dis Sci. 2011;56(2):591–5.

    Article  PubMed  Google Scholar 

  25. Hayashi T, Kawakami H, Osanai M, Ishiwatari H, Naruse H, Hisai H, Yanagawa N, Kaneto H, Koizumi K, Sakurai T, Sonoda T. No benefit of endoscopic sphincterotomy before biliary placement of self-expandable metal stents for unresectable pancreatic cancer. Clin Gastroenterol Hepatol. 2015;13(6):1151–8.e2.

    Article  PubMed  Google Scholar 

  26. Onal IK, Parlak E, Akdogan M, Yesil Y, Kuran SO, Kurt M, Disibeyaz S, Ozturk E, Odemis B. Do aspirin and non-steroidal anti-inflammatory drugs increase the risk of post-sphincterotomy hemorrhage--a case-control study. Clin Res Hepatol Gastroenterol. 2013;37(2):171–6.

    Article  CAS  PubMed  Google Scholar 

  27. Elta GH, Barnett JL, Wille RT, et al. Pure cut electrocautery current for sphincterotomy causes less post-procedure pancreatitis than blended current. Gastrointest Endosc. 1998;47:149–53.

    Article  CAS  PubMed  Google Scholar 

  28. Stefanidis G, Karamanolis G, Viazis N, et al. A comparative study of postendoscopic sphincterotomy complications with various types of electrosurgical current in patients with choledocholithiasis. Gastrointest Endosc. 2003;57:192–7.

    Article  PubMed  Google Scholar 

  29. Verma D, Kapadia A, Adler DG. Pure versus mixed electrosurgical current for endoscopic biliary sphincterotomy: a meta-analysis of adverse outcomes. Gastrointest Endosc. 2007;66(2):283–90.

    Article  PubMed  Google Scholar 

  30. Siegel JH. Precut papillotomy: a method to improve success of ERCP and papillotomy. Endoscopy. 1980;12(3):130–3.

    Article  CAS  PubMed  Google Scholar 

  31. Davee T, Garcia JA, Baron TH. Precut sphincterotomy for selective biliary duct cannulation during endoscopic retrograde cholangiopancreatography. Ann Gastroenterol. 2012;25(4):291–302.

    PubMed  PubMed Central  Google Scholar 

  32. Harewood GC, Baron TH. An assessment of the learning curve for precut biliary sphincterotomy. Am J Gastroenterol. 2002;97(7):1708–12.

    Article  CAS  PubMed  Google Scholar 

  33. Bailey AA, Bourke MJ, Kaffes AJ, Byth K, Lee EY, Williams SJ. Needle-knife sphincterotomy: factors predicting its use and the relationship with post-ERCP pancreatitis (with video). Gastrointest Endosc. 2010;71(2):266–71.

    Article  PubMed  Google Scholar 

  34. Manes G, Di Giorgio P, Repici A, Macarri G, Ardizzone S, Porro GB. An analysis of the factors associated with the development of complications in patients undergoing precut sphincterotomy: a prospective, controlled, randomized, multicenter study. Am J Gastroenterol. 2009;104(10):2412–7.

    Article  PubMed  Google Scholar 

  35. Ayoubi M, Sansoè G, Leone N, Castellino F. Comparison between needle-knife fistulotomy and standard cannulation in ERCP. World J Gastrointest Endosc. 2012;4(9):398–404.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Mavrogiannis C, Liatsos C, Romanos A, Petoumenos C, Nakos A, Karvountzis G. Needle-knife fistulotomy versus needle-knife precut papillotomy for the treatment of common bile duct stones. Gastrointest Endosc. 1999;50(3):334–9.

    Article  CAS  PubMed  Google Scholar 

  37. Abu-Hamda EM, Baron TH, Simmons DT, Petersen BT. A retrospective comparison of outcomes using three different precut needle knife techniques for biliary cannulation. J Clin Gastroenterol. 2005;39(8):717–21.

    Article  PubMed  Google Scholar 

  38. Goff JS. Long-term experience with the transpancreatic sphincter pre-cut approach to biliary sphincterotomy. Gastrointest Endosc. 1999;50(5):642–5.

    Article  CAS  PubMed  Google Scholar 

  39. Goff JS. Common bile duct pre-cut sphincterotomy: transpancreatic sphincter approach. Gastrointest Endosc. 1995;41(5):502–5.

    Article  CAS  PubMed  Google Scholar 

  40. Akashi R, Kiyozumi T, Jinnouchi K, Yoshida M, Adachi Y, Sagara K. Pancreatic sphincter precutting to gain selective access to the common bile duct: a series of 172 patients. Endoscopy. 2004;36(5):405–10.

    Article  CAS  PubMed  Google Scholar 

  41. Kahaleh M, Tokar J, Mullick T, Bickston SJ, Yeaton P. Prospective evaluation of pancreatic sphincterotomy as a precut technique for biliary cannulation. Clin Gastroenterol Hepatol. 2004;2(11):971–7.

    Article  PubMed  Google Scholar 

  42. Katsinelos P, Gkagkalis S, Chatzimavroudis G, Beltsis A, Terzoudis S, Zavos C, Gatopoulou A, Lazaraki G, Vasiliadis T, Kountouras J. Comparison of three types of precut technique to achieve common bile duct cannulation: a retrospective analysis of 274 cases. Dig Dis Sci. 2012;57(12):3286–92.

    Article  PubMed  Google Scholar 

  43. Cennamo V, Fuccio L, Zagari RM, Eusebi LH, Ceroni L, Laterza L, Fabbri C, Bazzoli F. Can early precut implementation reduce endoscopic retrograde cholangiopancreatography-related complication risk? Meta-analysis of randomized controlled trials. Endoscopy. 2010;42(5):381–8.

    Article  CAS  PubMed  Google Scholar 

  44. Kim MH, Lee SK, Lee MH, Myung SJ, Yoo BM, Seo DW, Min YI. Endoscopic retrograde cholangiopancreatography and needle-knife sphincterotomy in patients with Billroth II gastrectomy: a comparative study of the forward-viewing endoscope and the side-viewing duodenoscope. Endoscopy. 1997;29(2):82–5.

    Article  CAS  PubMed  Google Scholar 

  45. Bergman JJ, van Berkel AM, Bruno MJ, Fockens P, Rauws EA, Tijssen JG, Tytgat GN, Huibregtse K. A randomized trial of endoscopic balloon dilation and endoscopic sphincterotomy for removal of bile duct stones in patients with a prior Billroth II gastrectomy. Gastrointest Endosc. 2001;53(1):19–26.

    Article  CAS  PubMed  Google Scholar 

  46. Disario JA, Freeman ML, Bjorkman DJ, Macmathuna P, Petersen BT, Jaffe PE, Morales TG, Hixson LJ, Sherman S, Lehman GA, Jamal MM, Al-Kawas FH, Khandelwal M, Moore JP, Derfus GA, Jamidar PA, Ramirez FC, Ryan ME, Woods KL, Carr-Locke DL, Alder SC. Endoscopic balloon dilation compared with sphincterotomy for extraction of bile duct stones. Gastroenterology. 2004;127(5):1291–9.

    Article  PubMed  Google Scholar 

  47. Alsolaiman M, Cotton P, Hawes R, et al. Techniques of pancreatic sphincterotomy: lack of expert consensus. Gastrointest Endosc. 2004;59:AB210.

    Article  Google Scholar 

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Correspondence to Douglas G. Adler M.D., F.A.C.G., A.G.A.F. .

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Video Legend

The accompanying video to this chapter demonstrates a variety of cannulation and sphincterotomy techniques in the setting of both normal and challenging anatomic variants. (85,322 kb)

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Byrne, K.R., Adler, D.G. (2016). Cannulation and Sphincterotomy: Beyond the Basics. In: Adler, D. (eds) Advanced Pancreaticobiliary Endoscopy. Springer, Cham. https://doi.org/10.1007/978-3-319-26854-5_1

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  • DOI: https://doi.org/10.1007/978-3-319-26854-5_1

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