Comparison of Standard and Steerable Catheters for Bile Duct Cannulation in ERCP

Background and Study Aims: The aim of the study was to compare two steerable endoscopic retrograde cholangiopancreatography (ERCP) catheters with regard to speed and safety in cannulating the common bile duct.
Patients and Methods: A standard cannula, a short-nosed sphincterotome, and a bendable catheter were used. At two tertiary centres, a total of 312 patients were randomly assigned to receive treatment with one of three catheters and either by a trainee or an expert endoscopist. When cannulation failed, a further attempt was made with a different catheter. If this failed, a change in operator or other manoeuvres followed. The following were assessed: time to cholangiography and deep cannulation, number of attempts and success rates of cannulation, number of pancreatic duct injections, success of catheter cross-over, and complication rates.
Results: Both steerable catheters were significantly better for the initial cholangiogram than the standard catheter (standard catheter 75 %, bendable catheter 84 %, sphincterotome 88 %; P = 0.038), with no significant differences between the bendable catheter and the sphincterotome. Both were also better for deep cannulation of the bile duct (standard cannula 66 %, bendable catheter 69 %, sphincterotome 78 %; P = 0.15). When the standard catheter failed, a steerable catheter succeeded in 26 % of cases. Trainees experienced greater benefit from using steerable catheters. For experts, the bendable catheter was the quickest to achieve cholangiography and deep cannulation. Further manoeuvres had an 85-90 % success rate in allowing biliary access. Twenty of 23 needle-knife papillotomies (87 %) were successful when other methods had failed. The overall ERCP success rate was 97 %. Pancreatitis occurred in 5.3 % of cases.
Conclusions: Steerable catheters allow faster access and can succeed when a standard catheter fails. If cannulation is difficult, changing the catheter should be considered at an early stage. Needle-knife papillotomy is a successful technique in expert hands.

References

• 1 Deans G T, Sedman P, Martin D F. et al . Are complications of endoscopic sphincterotomy age-related?.  Gut. 1997;  41 545-548
• 2 Freeman M L, Nelson D B, Sherman S. et al . Complications of endoscopic biliary sphincterotomy.  N Engl J Med. 1996;  335 909-918
• 3 Christoforidis E, Goulimaris I, Kanellos I. et al . Post-ERCP pancreatitis and hyperamylasemia: patient-related and operative risk factors.  Endoscopy. 2002;  34 286-292
• 4 Baillie J. Predicting and preventing post-ERCP pancreatitis.  Curr Gastroenterol Rep. 2002;  4 112-119
• 5 Freeman M L, DiSario J A, Nelson D B. et al . Risk factors for post-ERCP pancreatitis: a prospective, multicenter study.  Gastrointest Endosc. 2001;  54 425-434
• 6 Rossos P G, Kortan P, Haber G. Selective common bile duct cannulation can be simplified by the use of a standard papillotome.  Gastrointest Endosc. 1993;  39 67-69
• 7 Cortas G A, Mehta S N, Abraham N S. et al . Selective cannulation of the common bile duct: a prospective randomized trial comparing standard catheters with sphincterotomes.  Gastrointest Endosc. 1999;  50 775-779
• 8 Schwacha H, Allgaier H P, Deibert P. et al . A sphincterotome-based technique for selective transpapillary common bile duct cannulation.  Gastrointest Endosc. 2000;  52 387-391
• 9 Baillie J. Needle knife sphincterotomy.  Gastrointest Endosc. 1991;  37 650
• 10 Cotton P B. Precut papillotomy: a risky technique for experts only.  Gastrointest Endosc. 1989;  35 578-579
• 11 Conio M, Saccomanno S, Aste H. et al . Precut papillotomy: primum non nocere.  Gastrointest Endosc. 1990;  36 544
• 12 Watkins J L, Etzkorn K P, Wiley T E. et al . Assessment of technical competence during ERCP training.  Gastrointest Endosc. 1996;  44 411-415
• 13 Shah S K, Mutignani M, Costamagna G. Therapeutic biliary endoscopy.  Endoscopy. 2002;  34 43-53
• 14 Seifert H, Binmoeller K F, Schmitt T. et al . A new papillotome for cannulation, pre-cut or conventional papillotomy (in German).  Z Gastroenterol. 1999;  37 1151-1155
• 15 Waye J D, Goh K L, Huibregtse K. et al . Endoscopic sphincterotomy, 2002.  Gastrointest Endosc. 2002;  55 139-140
• 16 Weston A P. Sincalide: a cholecystokinin agonist as an aid in endoscopic retrograde cholangiopancreatography - a prospective assessment.  J Clin Gastroenterol. 1997;  24 227-230
• 17 Binmoeller K F, Seifert H, Gerke H. et al . Papillary roof incision using the Erlangen-type pre-cut papillotome to achieve selective bile duct cannulation.  Gastrointest Endosc. 1996;  44 689-695
• 18 Silverman W B. Tapered-tip, triple-lumen papillotome/cannula facilitates cannulation yet accepts standard guide wires.  Gastrointest Endosc. 1997;  46 471-472
• 19 Siegel J H, Pullano W. Two new methods for selective bile duct cannulation and sphincterotomy.  Gastrointest Endosc. 1987;  33 438-440
• 20 Taylor A C, Little A F, Hennessy O F. et al . Prospective assessment of magnetic resonance cholangiopancreatography for noninvasive imaging of the biliary tree.  Gastrointest Endosc. 2002;  55 17-22
• 21 Ramirez F C, Dennert B, Sanowski R A. Success of repeat ERCP by the same endoscopist.  Gastrointest Endosc. 1999;  49 58-61
• 22 Fogel E L, Sherman S, Lehman G A. Increased selective biliary cannulation rates in the setting of periampullary diverticula: main pancreatic duct stent placement followed by pre-cut biliary sphincterotomy.  Gastrointest Endosc. 1998;  47 396-400
• 23 O'Connor H J, Bhutta A S, Redmond P L. et al . Suprapapillary fistulosphincterotomy at ERCP: a prospective study.  Endoscopy. 1997;  29 266-270
• 24 Dhir V, Swaroop V S, Mohandas K M. et al . Precut papillotomy using a needle knife: experience in 100 patients with malignant obstructive jaundice.  Indian J Gastroenterol. 1997;  16 52-53
• 25 Bruins S lot, Schoeman M N, Disario J A. et al . Needle-knife sphincterotomy as a precut procedure: a retrospective evaluation of efficacy and complications.  Endoscopy. 1996;  28 334-339
• 26 Foutch P G. A prospective assessment of results for needle-knife papillotomy and standard endoscopic sphincterotomy.  Gastrointest Endosc. 1995;  41 25-32
• 27 Rabenstein T, Ruppert T, Schneider H T. et al . Benefits and risks of needle-knife papillotomy.  Gastrointest Endosc. 1997;  46 207-211
• 28 Vandervoort J, Carr-Locke D L. Needle-knife access papillotomy: an unfairly maligned technique?.  Endoscopy. 1996;  28 365-366
• 29 Kasmin F E, Cohen D, Batra S. et al . Needle-knife sphincterotomy in a tertiary referral center: efficacy and complications.  Gastrointest Endosc. 1996;  44 48-53
• 30 Mavrogiannis C, Liatsos C, Romanos A. et al . Needle-knife fistulotomy versus needle-knife precut papillotomy for the treatment of common bile duct stones.  Gastrointest Endosc. 1999;  50 334-339
• 31 Rollhauser C, Johnson M, Al-Kawas F H. Needle-knife papillotomy: a helpful and safe adjunct to endoscopic retrograde cholangiopancreatography in a selected population.  Endoscopy. 1998;  30 691-696
• 32 Baillie J. Needle-knife papillotomy revisited.  Gastrointest Endosc. 1997;  46 282-284
• 33 Dowsett J F, Polydorou A A, Vaira D. et al . Needle knife papillotomy: how safe and how effective?.  Gut. 1990;  31 905-908
• 34 Gholson C F, Favrot D. Needle knife papillotomy in a university referral practice: safety and efficacy of a modified technique.  J Clin Gastroenterol. 1996;  23 177-180
• 35 Ching C K, Lai K C, Hu W. et al . Cannulatome-aided selective intrahepatic bile duct cannulation.  Gastrointest Endosc. 1996;  43 632-633
• 36 Slivka A. Directed guide wire placement during ERCP using a papillotome.  Gastrointest Endosc. 1996;  44 187-189