The Efficacy of Pancreatic Duct Stent in Reducing the Risk of Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis in Double-Guidewire Cannulation: A propensity-score matched case-control study

Aims When faced with challenging cannulation, double wire technique (DWT) is a helpful method that aids biliary access. However, pancreatic ductal manipulation increases risk of post ERCP pancreatitis (PEP) and the number of pancreatic wire cannulations that warrant pancreatic duct stent (PDS) placement remain unclear. This study aimed to compare the risk of PEP between conventional single-wire cannulation and DWT. The secondary aim was to assess efficacy of PDS when DWT was used, particularly in centers where rectal indomethacin is not available.

Methods This is a retrospective propensity-score matched case-control study in adult patients who underwent ERCP in our tertiary center. The primary outcome measurement was the rate of PEP in Conventional cannulation technique, DWT cannulation, and DWT cannulation with PD stent prophylaxis in a matched cohort by cannulation difficulty (defined by cannulation time>6 minutes and procedural duration>30 minutes), gender, age, indication of ERCP, and history of PEP in 2:2:1 ratio. Secondary outcome measurement included severity of PEP, mortality rate, length of hospitalization and ICU stay, and rate of spontaneous PD stent dislodgement after 2 weeks.

Results A total of 155 patients were included (62 patients underwent conventional cannulation, 62 patients with DWT cannulation without PDS, and 31 patients underwent DWT cannulation with PDS. None of the patients received rectal Indomethacin as it was not available in Thailand. The demographic data is described in table 1. DWT cannulation was associated with higher risk of PEP compared with the conventional canulation technique (17.74% vs 4.84%; p=0.023) with one patient in DWT group developing severe PEP. When compared the DWT groups between with and without PDS placement, there was no statistically significant difference of PEP when PDS was placed for all DWT (6.45% vs 17.74%; p=0.14) however, when PD was cannulated more than 3 times, PDS was associated with a significantly lower rate of PEP (0/6 in PDS group vs 3/3 in no-PDS group; p=0.012) The spontaneous dislodgement of the 5Fr 5cm PDS at 2 weeks occurred in 64.52% of patients, leaving only a third who required additional endoscopy for PDS removal. [1] [2] [3]

Conclusions DWT cannulation tends to increase the risk of PEP compared to the conventional cannulation technique and PD stent may reduce the risk of PEP if PD is cannulated three times or less. When PD is cannulated more than 3 times, PDS placement is strongly recommended.

Conflicts of interest

Authors do not have any conflict of interest to disclose.

• References

• 1 Sasahira N. et al. "Early use of double-guidewire technique to facilitate selective bile duct cannulation: the multicenter randomized controlled EDUCATION trial.". Endoscopy 2015; 47 (05) 421-429
• 2 Angsuwatcharakon P. et al. "Success rate and cannulation time between precut sphincterotomy and double-guidewire technique in truly difficult biliary cannulation.". Journal of Gastroenterology and Hepatology 2012; 27 (02) 356-361
• 3 Tse F. et al. "Double-guidewire technique in difficult biliary cannulation for the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis.". Endoscopy 2017; 49 (01) 15-26

Publication History

Article published online:
15 April 2024