John G. Lee, MD The Difficult Cannulation ACG Western Regional Course, 2013 John G. Lee, MD Professor of Clinical Medicine Division of Gastroenterology University of California, Irvine Medical Center Selective cannulation 1. Identify the ampulla 1. Access the ampulla 2. Identify major and minor papilla 2. Identify the desired orifice 1. Biliary 2 Duct of Wirsung 2. 3. Duct of Santorini DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 1 John G. Lee, MD Ideal access for cannulation • Shorten scope to ~70-80cm • Ampulla at 12 O’clock or in center • Scope under the ampulla – Big wheel down/push in scope • Lock both controls • Flush/glucagon • ‘Mini maneuvers’ DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Access Pancreatitis / cancer Post esophagectomy 3 year old with malrotation 90 year old DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 2 John G. Lee, MD If you must cannulate long… DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal The missing ampulla DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 3 John G. Lee, MD Access • Use native anatomy when ever possible • Short position – If not get short as soon as possible • Look proximally if ampulla ll nott ffound d • Look for air cholangiogram DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Selective cannulation 1. Identify the ampulla 1. Access the ampulla 2. Identify major and minor papilla 2. Identify the desired orifice 1. Biliary 2 Duct of Wirsung 2. 3. Duct of Santorini DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 4 John G. Lee, MD Identification of major papilla • Medial wall D2 70 i i • ~70cm att incisors • Look for – Bile flow – Transverse fold – Intraduodenal segment – Diverticulum DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Identification of minor papilla • Right and proximal i • Di Divisum – Prominent papilla – Failed pancreatic cannulation – Easy biliary cannulation • Access – Long position DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 5 John G. Lee, MD Selective cannulation 1. Identify the ampulla 1. Access the ampulla 2. Identify major and minor papilla 2. Identify the desired orifice 1. Biliary 2 Duct of Wirsung 2. 3. Duct of Santorini DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Position of biliary / pancreatic orifice • Biliary – left upper • Pancreatic – right lower DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 6 John G. Lee, MD Study the papilla first! DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Orifice in peri-ampullary diverticulum DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 7 John G. Lee, MD Post sphincterotomy • Left upper S t orifice ifi • Separate • Supra papillary DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Why did this fail? • Biliary orifice always proximal • Very safe DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 8 John G. Lee, MD Identification of minor orifice • Secretin • Methylene Blue DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Technique of selective Cannulation • Positioning (ACCESS) • Orientation (AXIS) • 12 maneuvers to position scope in relation to papilla • Impact tip in the orifice • Try wire while changing h i di direction ti • Cannulate with 1cm of wire DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 9 John G. Lee, MD Devices • Sphincterotome • 2, 3 lumens • Short nose • 25mm monofilament wire • Hydrophilic guidewire DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Axis ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology 10 John G. Lee, MD Altering axis by changing access DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Cannulation technique •Ampulla at 12 o’clock or center •Aim to left upper •Push out sphincterotome and bow •Impact tip in ampulla and push wire •Push P h outt wire i and d ttry cannulation l ti with ith tip of wire •Repeat with slight change in R/L or U/D knobs DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 11 John G. Lee, MD Cannulation technique • Stay close to papilla • Approach from below • Cannula directed at 11- 12 o’clock position • Steps • Big wheel down • Elevator up • Push catheter • Push scope in while pushing in catheter and relaxing elevator DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Selective Cannulation: Pancreatic Duct • Cannula perpendicular to duodenal wall • Aim at 1-2 o’clock direction • “Drop” the cannula by relaxing up angulation or lower elevator • Withdraw tip of scope • Hydrophilic guide wire DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 12 John G. Lee, MD Guidewire versus conventional contrast cannulation of the common bile duct for the prevention of postERCP pancreatitis: a systematic review and meta-analysis Meta-analysis of primary bile duct cannulation success during ERCP with the initial technique for Guidewire versus Contrast Cheung J et al. Guidewire versus conventional contrast cannulation of the common bile duct for the prevention of postERCP pancreatitis: a systematic review and meta-analysis. Gastrointest Endosc, 2009 Dec;70(6):1211-9. DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Guidewire versus conventional contrast cannulation of the common bile duct for the prevention of postERCP pancreatitis: a systematic review and meta-analysis Pancreatitis among patients with inadvertent PD manipulation for Guidewire versus Contrast cannulation Cheung J et al. Guidewire versus conventional contrast cannulation of the common bile duct for the prevention of postERCP pancreatitis: a systematic review and meta-analysis. Gastrointest Endosc, 2009 Dec;70(6):1211-9. DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 13 John G. Lee, MD Why is cannulation difficult ? • Problems with axis – Repeated PD access – Unable to access either duct • Problems with access – Difficult sedation – Pathologically altered access – Surgically altered access DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Double Guide Wire Cannulation • Insert guidewire into mid pancreatic duct and locked the wire, this helps to straighten the common channel • Selective CBD cannulation with second guide wire DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 14 John G. Lee, MD Double wire technique DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Double-guidewire technique for difficult bile duct cannulation: a multicenter randomized, controlled trial Successful cannulation rate in the SCT and DGT groups (per intention to treat and per protocol analysis) SCT group, no. (%) SC Intent to treat n = 91 51 (56) Per protocol n = 87 47 (54) DGT G group, no. (%) O (95% OR ( %C CI)) n = 97 46 (47) 0.85 (0.64-1.12) n = 76 27 (35) 0.66 (0.46-0.94) SCT, Standard cannulation technique; DGT, double-guidewire technique; OR, odds ratio; CI, confidence interval Herreros de Teiada A et al, Gastrointest Endosc2009 Oct;70(4):700-9. DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 15 John G. Lee, MD Double-guidewire technique for difficult bile duct cannulation: a multicenter randomized, controlled trial Complications in randomized patients according to protocol SCT group (n = 87), no. (%) DGT group (n = 76), no. (%) P value Acute pancreatitis 7 (8) 13 (17) .079 Mild Moderate Severe Bleeding Acute cholangitis 4 (5) 2 (2) 1 (1) 5 (6) 0 9 (12) 2 (2.5) 2 (2.5) 0 0 .095 — Acute cholecystitis 1 (1) 0 1.00 1 (1) 0 1.00 1.00 Perforation 1 (1) Death related to ERCP 1 (1) SCTM, Standard cannulation technique; DGT, double-guidewire technique Herreros de Teiada A et al, Gastrointest Endosc2009 Oct;70(4):700-9. DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Precut sphincterotomy • Fistulotomy • Cut diagonally layer by layer until – Flash of bile – Sphincter muscle – Bleeding – 5-10 strokes • Probe with guidewire • Repeat as needed DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 16 John G. Lee, MD Precut after pancreatic access • Stent and needle knife – ?safer than double wire • Septotomy – Cut to the left DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Minor precut sphincterotomy • Landmarks • Size – Limited to needle knife • Risk of stenosis – Multiple cuts • Stenting St ti – Mandatory DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 17 John G. Lee, MD Can early precut implementation reduce endoscopic retrograde cholangiopancreatography - related complication risk? Meta-analysis of randomized controlled trials Six RCT comparing cannulation rates of the early precut (EPC) implementation and of persistent attempts (PA) by the standard approach The pooled analysis of all selected studies yielded an OR of 1.20 (95 %CI 0.54-2.69). The statistical tests showed presence of between-study heterogeneity (P = 0.04; I2 = 56.6 %) Cennamo V, et al. Can early precut implementation reduce endoscopic retrograde cholangiopancreatography-related complication risk? Meta-analysis of randomized controlled trials. Endoscopy 2010 May;42(5):381-8 DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Can early precut implementation reduce endoscopic retrograde cholangiopancreatography - related complication risk? Meta-analysis of randomized controlled trials Post-ERCP pancreatitis developed in 2.5 % of patients (11 out of 442) randomized to the early precut groups and in 5 5.3 3 % of patients (28 out of 524) randomized to the persistent attempts groups. The pooled analysis yielded an OR of 0.47 (95 %CI 0.24-0.91). EPC, early precut group; PA, persistent attempts group. Cennamo V, et al. Can early precut implementation reduce endoscopic retrograde cholangiopancreatography-related complication risk? Meta-analysis of randomized controlled trials. Endoscopy 2010 May;42(5):381-8 DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 18 John G. Lee, MD Should you quit? • • • • • Patient stable? Indicated? Urgent? Ampulla accessed? Orifice located? No DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ Heal Alternatives • Do nothing • Another day, another endoscopist • PTBD or surgery – Combined procedure • EUS guided rendezvous DiscoverDiscover ▪ Teach▪ Teach ▪ Heal▪ ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology Heal 19 John G. Lee, MD Th k you Thank ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology 20
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