BILIARY CANNULATION: WHICH IS THE BEST TECHNIQUE WHEN THE GUIDEWIRE IS UNEXPECTEDLY INSERTED INTO PANCREATIC DUCT?

Aims Incidental guidewire insertion into pancreatic duct (PD) is traditionally associated with a higher risk of post-ERCP pancreatitis (PEP).

To compare the efficacy and safety of different biliary cannulation techniques after an unexpected insertion of the guidewire into pancreatic duct.

Methods Analysis of a multicenter prospective endoscopy database (2012-2021). Patients with naive papilla undergone first ERCP performed by expert endoscopists, were included. There were analyzed four biliary cannulation techniques after the guidewire was unexpectedly inserted into PD: repeated attempts after guidewire was withdrawn from PD (RA), keeping guidewire in PD to aid biliary cannulation (double guidewire technique- DGT), transpancreatic pre-cut (TPc) and TPc, pancreatic stenting and biliary cannulation over stent (TPc-BCoS). In the last one, TPc was performed after the first unexpected guidewire insertion into PD.

Results 527 patients included (age: 70.10±0.71 years, 52.7% women). Biliary cannulation techniques: 189 (35.8%) RA, 65 (12.3%) DGT, 219 (41.5%) TPc and 54 (10.2%) TPc-BCoS. Global biliary cannulation rate (BCR): 91.5% and complication rate: 10.6%. TPc-BCoS reached the highest BCR: 100%, p=0.01 and the lowest complication rate: 5.6%, p=0.02. In this group, no PEP appeared. Conversely, TPc showed the highest perforation rate: 6.8%, p=0.03. There were no

differences in hemorrhage, cholangitis and death. Unlike TPc-BCoS, in a third of RA, DGT and TPc a further freehand pre-cut was required.

Conclusions Transpancreatic pre-cut, pancreatic stenting and biliary cannulation over stent was the most effective and safest biliary cannulation technique. Therefore, it should be the first choice after unexpected insertion of the guidewire into pancreatic duct.

Publication History

Article published online:
14 April 2022