PROSPECTIVE STUDY EVALUATING SAFETY AND EFFICACY OF DIFFERENT TECHNIQUES FOR BILIARY ACCESS IN PATIENTS WITH DIFFICULT BILIARY CANNULATION AT ENDOSCOPIC RETROGRADE CHOLANGIO-PANCREATOGRAPHY

Aims Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is technically challenging and complex among all therapeutic endoscopy procedures. difficult biliary cannulation (DBC) increases post procedure complications. hence, getting the cannulation technique right is sine qua non in successful cannulation.

Methods Patients with DBC (as per ESGE guidelines) were prospectively enrolled over a three-year period. DBC protocol for failed cannulation included, pancreatic guidewire (GW) / double GW technique, precut after placement of a pancreatic stent, precut sphincterotomy/papillotomy/fistulotomy and EUS-guided rendezvous (RV). The technical, clinical success, safety rate, and adverse events was studied and a sequential algorithm was proposed.

Results Out of 3680 patients, 471(12.8%) had DBC. Their mean (SD) age was 51.5 (17.4) years; 330(70.1%) male. Majority of the patients 230(48.8%) underwent precut, but it was unsuccessful in 10(2.1%) patients in first attempt. The success rate of Precut Sphincterotomy was 220(86.9%), Double guidewire cannulation was 120(95.2%), Wire guided after Pancreatic stent placement was 64(94.1%), EUS-RV was 34(97.1%) and Wire guided- repeat ERCP after 48 hrs was 10(98.3%). Precut Sphincterotomy had higher complication rate of 59(25.6%) out of which post ERCP pancreatitis was seen in 41(17.8%). 3(0.6%) underwent successful Percutaneous transhepatic biliary drainage without complications.

Conclusions Our results indicate that EUS-RV and repeat ERCP after 48 hrs appears relatively safe and effective for DBC. Further algorithmic modifications to the current techniques without compromising safety is needed to increase technical success of future procedures.