Transpancreatic biliary sphincterotomy: justified or overkill?

Kylänpää et al. recently published the results of a multicenter randomized controlled trial that compared a double-guidewire (DGW) technique with transpancreatic biliary sphincterotomy (TPBS) for patients with difficult biliary cannulation, and evaluated the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) after use of these techniques [1]. There was no difference in PEP rates between patients who underwent DGW vs. TPBS (13.5 % vs. 16.2 %; P = 0.69). The overall cannulation success rate of TPBS was higher than that of DGW (84.6 % vs. 69.7 %; P = 0.01). However, 10 patients (11.4 %) in the TPBS group required additional precut sphincterotomy. This makes us question whether it was the precut procedure that facilitated cannulation, rather than TPBS.

Long-term complications of endoscopic pancreatic sphincterotomy include risk of papillary stenosis with fibrosis, changes in the pancreatic duct with recurrent pancreatitis, and infections [2]. The need to perform an additional pancreatic sphincterotomy in patients with biliary pathology is overtreatment and is associated with a risk of long-term complications. As mentioned by Kylänpää et al., in patients with failed DGW technique, TPBS was used in 90 % with successful cannulation in 77.8 %; hence, in patients with failed DGW, TPBS may be considered an alternative.

The European Society of Gastrointestinal Endoscopy guidelines on management of ERCP-related adverse events recommend the use of prophylactic pancreatic stents in patients at high risk of PEP (inadvertent pancreatic cannulation and DGW technique), with administration of rectal nonsteroidal anti-inflammatory drugs for all patients prior to the procedure to mitigate the risk of PEP [3]. Kylänpää et al. showed that prophylactic pancreatic stent placement was performed in only 8.7 % and 11.1 % of the TPBS and DGW groups, respectively. In patients with high risk, as in this study, placement of a pancreatic stent would have been preferable. To conclude, TPBS may represent overtreatment with need for pancreatic sphincterotomy, and TPBS may be an alternative in the event of a failed DGW technique for biliary cannulation.

Publication History

Article published online:
26 August 2021

• References

• 1 Kylänpää L, Koskensalo V, Saarela A. et al. Transpancreatic biliary sphincterotomy versus double guidewire in difficult biliary cannulation: a randomized controlled trial. Endoscopy 2021;
• 2 Buscaglia JM, Kalloo AN. Pancreatic sphincterotomy: technique, indications, and complications. World J Gastroenterol 2007; 13: 4064-4071
• 3 Dumonceau JM, Kapral C, Aabakken L. et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 127-149