Double wire, transpancreatic sphincterotomy and needle knife experience in real world setting: Balancing Optimism and Reality

Aims Around 11% of Endoscopic retrograde cholangiopancreatography (ERCP) associate difficult cannulation [1]. We aimed to extract real world data on difficult cannulation over a 3-year period to assess if the outcomes were comparable to the reported literature on cannulation success rate and adverse events.

Methods A retrospective study was conducted from September 2020 to January 2024 at a high volume centre. All patients who underwent ERCP by a single independent ERCPist were included in the analysis. Primary outcomes were rate of first pass cannulation, advanced techniques performance, adverse events (AEs) including 30-day mortality [2] [3] [4] [5] [6].

Results A total of 438 patients underwent ERCP by the operator during the study period. Cannulaion was achieved in 389 (88.9%). Of these patients, first pass cannulation was achieved in 325/438 (74.2%) Of those who Pancreatic duct (PD) was inadvertently cannulated≥2 times, double wire was used, 36/438 (8.21%), unsuccessful in 17 (47.2%), but of this, 9 cases were salvaged -4 patients managed common bile duct (CBD) cannulation after PD stent was placed, 3 patients had needle knife (KN) precut and 2 transpancreatic sphincterotomy. Failed patients had etiology of biliopancreatic cancer and one had a big duodenal diverticulum as deterrents. Needle Knife was used in 25/438 (5.7%) of which failed in 12/25 (48%)- despite this unfavourable outcome, out of these failures, this helped in 6 patients during the following ERCP as scarring exposed the ampullary opening better. 4 patients were never reattempted so we cannot know if KN would have been useful, and 2 failed in a tertiary centre. Transpancreatic sphincterotomy (TPS) was attempted 8 times (1.82%) usually after double wire failed. This achieved cannulation in 5/8 (62.5%). Adverse events (AEs): Of all ERCP-related AEs, double wire associated higher risk of post-ERCP pancreatitis -OR 3.96(1.02- 15.3) p=0.04, but when stratified, this association was only significant in those cases when prophylactic PD stent was not placed after double wire use (all due to technical difficulty)

Conclusions When confronted with difficult cannulation, double wire succeeded 52.8% of the time. (Variability in literature ranges from 44-80%). There was strong association to post-ERCP pancreatitis only when prophylactic PD stent was not used. When other techniques added to failed double wire, the total cannulation rate increased to 77.8% Precut sphincterotomy only succeeded in 52%, much lower than described in literature (> 75%). Learning curve and patient suboptimal tolerance likely contributed to this. Despite this, needle knife helped in many cases to achieve cannulation another day. TPS was linked with higher success at 62.5%. None of these two techniques statistically associated higher pancreatitis, bleed, perforation or death compared to standard cannulation.

Publication History

Article published online:
27 March 2025

• References

• 1 Davee T, Garcia JA, Baron TH.. Precut sphincterotomy for selective biliary duct cannulation during endoscopic retrograde cholangiopancreatography. Ann Gastroenterol 2012; 25 (4): 291-302
• 2 Pécsi D, Farkas N, Hegyi P.. et al. Transpancreatic sphincterotomy has a higher cannulation success rate than needle-knife precut papillotomy – a meta-analysis. Endoscopy. 2017; 49 (9): 874-887
• 3 Testoni PA, Mariani A, Aabakken L.. et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016; 48 (7): 657-83
• 4 Testoni PA, Testoni S, Giussani A.. et al. Difficult biliary cannulation during ERCP: how to facilitate biliary access and minimize the risk of post-ERCP pancreatitis. Dig Liver Dis 2011; 43: 596-603
• 5 Liao WC, Angsuwatcharakon P, Isayama H.. et al. International consensus recommendations for difficult biliary access. Gastrointest Endosc 2017; 85 (2): 295-304
• 6 Berry R, Han JY, Tabibian JH.. Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist. World J Gastrointest Endosc 2019; 11 (1): 5-21