Double-guidewire-assisted biliary cannulation: experiences from a single tertiary referral center.

Abstract

Even in experienced hands, a common problem with endoscopic retrograde cholangiopancreatography (ERCP) is difficulty reaching a deep biliary cannulation. The most recent alternative method for difficult biliary cannulation is the double-guidewire technique. The current prospective study aimed to clarify the feasibility and safety of the double-guidewire-assisted biliary cannulation at the authors' institution.
All consecutive patients (n=284) admitted for biliary ERCP during 2009 who had unhindered access to a native papilla were included in the study. The application and success rates of the double-guidewire method for deep biliary cannulation and the complications of ERCP procedures using the double-guidewire technique were determined. The overall success rate for biliary cannulation in these cases also was determined, and the times from the first touch to the papilla to deep biliary cannulation and for the entire ERCP procedure were recorded.
The double-guidewire-assisted cannulation technique was applied in 18% (50/284) of ERCPs with a success rate of 66% (33/50). In these 50 cases, the overall success rate for biliary cannulation was 98% (49/50). The median cannulation time was 8 min, and the median duration of the entire ERCP procedure was 20 min. The rate of post-ERCP pancreatitis was 2% (1/50).
The double-guidewire technique is a feasible and safe method for difficult biliary cannulation with low rate of post-ERCP pancreatitis. However, it seems important to proceed to alternative cannulation techniques if the double-guidewire technique appears troublesome.

Full text

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Double-guidewire-assisted biliary cannulation: experiences
from a single tertiary referral center
Juha M. Gro ¨nroos•Hanna Vihervaara•
Risto Gullichsen•Simo Laine•Jukka Karvonen•
Paulina Salminen
Received: 10 June 2010/Accepted: 28 September 2010
? Springer Science+Business Media, LLC 2010
Abstract
Background
problem with endoscopic retrograde cholangiopancreatog-
raphy (ERCP) is difficulty reaching a deep biliary cannu-
lation. The most recent alternative method for difficult
biliary cannulation is the double-guidewire technique. The
current prospective study aimed to clarify the feasibility
and safety of the double-guidewire-assisted biliary cannu-
lation at the authors’ institution.
Methods
All consecutive patients (n = 284) admitted for
biliary ERCP during 2009 who had unhindered access to a
native papilla were included in the study. The application
and success rates of the double-guidewire method for deep
biliary cannulation and the complications of ERCP proce-
dures using the double-guidewire technique were deter-
mined. The overall success rate for biliary cannulation in
these cases also was determined, and the times from the
first touch to the papilla to deep biliary cannulation and for
the entire ERCP procedure were recorded.
Results
The double-guidewire-assisted cannulation tech-
nique was applied in 18% (50/284) of ERCPs with a suc-
cess rate of 66% (33/50). In these 50 cases, the overall
success rate for biliary cannulation was 98% (49/50). The
median cannulation time was 8 min, and the median
duration of the entire ERCP procedure was 20 min. The
rate of post-ERCP pancreatitis was 2% (1/50).
Conclusions
The double-guidewire technique is a feasi-
ble and safe method for difficult biliary cannulation with
low rate of post-ERCP pancreatitis. However, it seems
Even in experienced hands, a common
important to proceed to alternative cannulation techniques
if the double-guidewire technique appears troublesome.
Keywords
ERCP ? Pancreatic duct
Bile duct ? Cannulation ? Double guidewire ?
Despite advances in equipment and expertise, endoscopic
retrograde cholangiopancreatography (ERCP) procedures
still are occasionally challenging even for an experienced
ERCP endoscopist. The most common problem during
ERCP is difficulty reaching a selective cannulation of the
common bile duct.
For difficult biliary cannulation, a variety of alternative
endoscopic techniques have been developed to achieve
deep cannulation when standard cannulation maneuvers
with guidewire or cannula prove unsuccessful. The precut
papillotomy [1] and its modifications such as needleknife
fistulotomy are of utmost clinical importance in difficult
cases.
The most recent alternative method in difficult biliary
cannulation is the double-guidewire technique (i.e., the use
of an additional pancreatic guidewire to occupy the pan-
creatic duct physically and straighten both ducts, facilitat-
ing difficult biliary cannulation). Since its first description
[2], the adoption of this technique has improved the success
rate of biliary cannulation for cases in which the guidewire
passes repeatedly into the pancreatic duct. The literature
contains some case reports [2, 3], some case series [4–6],
and two prospective randomized trials [7, 8] on the role
of the double-guidewire technique in difficult biliary
cannulation.
Double-guidewire-assisted biliary cannulation was a
highlight of the 15th United European Gastroenterology
Week in Paris, France, in 2007. After that meeting, we
J. M. Gro ¨nroos (&) ? H. Vihervaara ? R. Gullichsen ?
S. Laine ? J. Karvonen ? P. Salminen
Departments of Surgery and Emergency, University of Turku,
PO Box 52, 20521 Turku, Finland
e-mail: juha.gronroos@tyks.fi
123
Surg Endosc
DOI 10.1007/s00464-010-1458-3

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adopted this technique into clinical use at our institution. In
this report, we describe our experience with double-
guidewire-assisted biliary cannulation.
Patients and methods
A total of 452 patients were admitted to Turku University
Hospital for ERCP during 2009. Our hospital, an 850-bed
tertiary referral teaching hospital serving one-tenth of all
Finns, is the only hospital in this area with ERCP facilities.
All the ERCP procedures were performed (or supervised;
one younger surgeon was receiving ERCP training) by four
surgeons with substantial ERCP experience. After an
overnight fast, the patients were positioned on their left
side for the procedure. Premedication, given 1 h before
ERCP, included pethidine (50 mg administered subcuta-
neously [SC]), atropine (0.6 mg SC), and cefuroxime
(1.5 g administered intravenously [IV]).
The ERCP procedures were performed with the patient
under conscious sedation using midatzolam (IV) and fen-
tanyl (IV). During the procedure, additional oxygen was
given to patients. Heart rate, blood pressure, and oxygen
saturation were documented.
After exclusion of the patients whose papilla could not
be reached due to duodenal stricture or previous surgery,
those with intended pancreatic duct cannulation, and those
with previous procedures on the papilla, the study group
consisted of 284 consecutive patients (151 females and 133
males) with unhindered access to a native papilla admit-
ted for biliary ERCP. The mean age of the patients was
65 years (range, 13–95 years).
The primary methods for biliary cannulation at our
institution are the conventional methods, usually with the
guidewire loaded into the cannula and infrequently with the
cannula alone. If these conventional cannulation methods
fail and the guidewire or the cannula passes into the pan-
creatic duct more than once, we use the double-guidewire
method. If even the double-guidewire-assisted cannulation
fails in terms of biliary cannulation, we may try again with
the conventional guidewire method or, as usual, proceed to
the needleknife-assisted cannulation, which in our hands
means a fistula through the neck of the papilla [9].
The main outcome measurements were the application
and success rates of the double-guidewire method for deep
biliary cannulation and the complications of ERCP proce-
dures in which the double-guidewire technique was used.
The overall success rate for biliary cannulation in these
difficult cases also was determined, and the time from the
first touch to the papilla to successful deep biliary cannu-
lation together with the findings, procedures performed,
and the duration of the entire ERCP procedure were
recorded prospectively in a database (Microsoft Excel file)
created for ERCP procedures in our endoscopy unit. The
current study was approved by our hospital’s committee on
clinical research.
Complications associated to ERCP procedures were
defined using standard criteria [10–12]. Briefly, post-ERCP
pancreatitis (PEP) was defined as the presence of new or
worsened abdominal pain associated with a threefold or
greater increase in plasma amylase activity above the upper
limit of the reference interval.
The severity of PEP was graded according to the length
of the hospital stay as mild (2–3 days of hospitaliza-
tion), moderate (4–10 days of hospitalization), or severe
([10 days of hospitalization). Bleeding was classified as
immediate or delayed, and the need for endoscopic injection
therapy and blood transfusions was recorded. Cholangitis
was defined by a typical clinical picture including fever,
upper abdominal pain, and increased levels of serum bili-
rubin and C-reactive protein. Early mortality (defined as
death within 30 days of ERCP) was recorded, and in case of
death, the relationship of the death to the procedure was
determined.
Results
The application and success rates of the double-guidewire
technique for deep biliary cannulation and the overall
success rate for deep biliary cannulation in the aforemen-
tioned cases are presented in Table 1. The double-guide-
wire-assisted method for biliary cannulation was applied
for 18% (n = 50; 31 females and 19 males) of all biliary
ERCP attempts with unhindered access to a native papilla
(n = 284; 151 females and 133 males).
The double-guidewire technique proved to be successful
for 33 (66%) of the 50 patients. As for the 17 patients
(34%) with failed double-guidewire cannulation, the con-
ventional guidewire method was attempted once more in
four cases, with a successful result for all of them. For the
remaining 13 cases, we proceeded to needleknife fistulot-
omy. For 12 of these 13 patients, the needleknife fistulot-
omy proved successful. Thus, after alternative techniques,
deep biliary cannulation could be achieved for 49 of the 50
Table 1 Application and success rates of the double-guidewire
technique for deep biliary cannulation and the overall success rate for
deep biliary cannulation in these cases
% (n)
Application rate for the double-guidewire technique18 (50/284)
Success rate for the double-guidewire technique66 (33/50)
Overall success rate for these patients98 (49/50)
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patients, giving the overall success rate of 98% for deep
biliary cannulation in these difficult cases.
In the case that met failure, needleknife-induced hem-
orrhage was encountered. Although the bleeding ceased
shortly without any endoscopic interventions, a decision
was made to discontinue the procedure. In a repeat ERCP
later, a conventional guidewire cannulation method was
successful. Thus, all the papillas with a double-guidewire
cannulation attempt could be eventually cannulated.
The cannulation times and duration of the entire ERCP
procedure, the findings, the number of diagnostic and
therapeutic procedures, and the complications experienced
by patients with an attempted double-guidewire-assisted
biliary ERCP are shown in Table 2. In addition to the
minor needleknife-induced bleeding and the PEP of mod-
erate severity after successful double-guidewire cannula-
tion, no other complications were encountered.
Discussion
Most often, the success rate for cannulation in ERCP is not
satisfactory at the overall national level. For example, the
recent large-scale prospective survey of ERCP practice in
the United Kingdom showed achievement of overall deep
biliary cannulation for only 2,684 (84%) of 3,210 patients
undergoing their first ever ERCP [13]. This is not the case
in expert centers with high volumes. For example, in the
survey by Fukatsu et al. [14], the total success rate for
biliary cannulation was as high as 99% (497 of 501
patients).
Recently, we described our indications, techniques, and
results for 1,703 consecutive first-time ERCPs [9]. The
overall success rate for bile duct cannulation was 97% in
our records. The aforementioned figures emphasize that
although every cannulation may be challenging and the
results are not satisfactory at the national level, high rates
of success for biliary cannulation can be reached in high-
volume centers due to routine practice of alternative can-
nulation methods in difficult cases.
Thus, when selective biliary cannulation cannot be
achieved using standard cannulation methods, alternative
methods such as double-guidewire and various precutting
techniques should be used. In expert hands, deep access to
the bile ducts usually can be achieved. Furthermore, if all
the endoscopic cannulation techniques prove unsuccessful
with patients for whom endoscopic diagnosis and therapy
are crucial, a rendezvous procedure definitely should be
considered [15].
The current series of 50 patients treated with the double-
guidewire technique is one of the largest presented to date
in the literature [2–8]. The original reports describing the
method were case reports by Dumonceau et al. [2] and
Gotoh et al. [3] based on 1 patient only. Next, followed
case series by Gyo ¨keres et al. [4] (24 patients), Draganov
et al. [5] (12 patients), and Ito et al. [6] (113 patients). In
these case series, the success rates for biliary cannulation
were relatively high (83% [5] and 73% [6]; no rates are
reported in Ref. [4]).
These high success rates, most obviously involving
multiple cannulation attempts, may be associated with a
relatively high rate of PEP reported in two of these studies
(8% [4] and 12% [6]). No PEPs were encountered in the
small study (12 patients) of Draganov et al. [5].
In the current series, with its success rate of 66% for the
double-guidewire technique for biliary cannulation, the rate
for PEP remained as low as 2%. The overall success rate
for difficult biliary cannulation was, however, eventually as
high as 98% in the current series. Therefore, we find that to
keep the PEP rate as low as possible and the overall can-
nulation rate still as high as possible, it is important to
proceed to alternative cannulation techniques if the double-
guidewire technique appears troublesome. Prophylactic
pancreatic stenting is reported to decrease the risk for PEP
after double-guidewire cannulation [6]. No pancreatic
stents were inserted in our series.
As for the two published prospective randomized trials
on the role of the double-guidewire cannulation [7, 8], both
were designed to compare the performance of the double-
guidewire technique with standard cannulation techniques.
In the single-center pilot trial of Maeda et al. [7], the
success rate for the double-guidewire technique (27
Table 2 Cannulation time and duration of the entire endoscopic
retrograde cholangiopancreatography (ERCP) procedure as well as
the findings, number of diagnostic and therapeutic procedures, and
complications in 50 patients with an attempt at double-guidewire-
assisted biliary ERCP
Median cannulation time: min (range)8 (1–31)
Median duration of the entire procedure: min (range)23 (11–60)
Findings: n (%)
Bile duct stones17 (34)
Bile duct stricture11 (22)
Bile duct dilation only5 (10)
Others16 (32)
Failure1 (2)
Nature: n (%)
Diagnostic5 (10)
Therapeutic44 (90)
Complications: n (%)
Bleeding1 (2)
Post-ERCP pancreatitis1 (2)
Others0
Mortality0
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patients) was significantly higher than that for the con-
ventional technique (93% vs 58%), and no PEP occurred in
this pilot study.
In contrast, de Tejada et al. [8] concluded in their
multicenter trial (97 patients) that the double-guidewire
technique was not superior to standard cannulation tech-
nique (success rates of 47% and 56%, respectively) and
might be associated with a higher risk for PEP (17% and
8%, respectively). In their multicenter study from six
centers, with a mean of only 16 patients in each during the
2-year study period, the success rate for the double-
guidewire-assisted cannulation was rather low (47%), but
the rate for PEP still was surprisingly high (17%).
The former results suggest that too many low-volume
centers were participating because a high success rate for
biliary cannulation with a low complication rate can be
reached only in high-volume centers that use alternative
cannulation methods routinely in difficult cases. Also, the
median cannulation time was 16 min in the former multi-
center study [8], clearly longer than in the current study
(8 min). All these results support the policy of centralizing
ERCP procedures in high-volume centers.
The limitation of the current study is that it was not a
randomized study comparing the double-guidewire-assis-
ted cannulation method with the other cannulation tech-
niques. Instead, it was a thorough and accurate prospective
data collection of consecutive biliary ERCP procedures at
our experienced tertiary referral center during 1 year.
The strong element of the current study was the rela-
tively large number of double-guidewire cannulations
performed by very experienced ERCP endoscopists in a
single relatively high-volume tertiary referral center, min-
imizing the impact of variable expertise and case volumes
that can play a role in multicenter studies. We conclude
that in expert hands, the double-guidewire technique is a
feasible and safe method in difficult biliary cannulation
with a low rate of PEP. To increase the success rate of
biliary ERCP procedures, ERCP endoscopists, particularly
those who prefer noninvasive cannulation methods to
precutting techniques, should be aware of the double-
guidewire-assisted cannulation method.
Disclosures
sen, Simo Laine, Jukka Karvonen, and Paulina Salminen have no
conflicts of interest or financial ties to disclose.
Juha M. Gro ¨nroos, Hanna Vihervaara, Risto Gullich-
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