The Analysis Of Treatment Strategies Of Difficult Biliary Cannulation In Endoscopic Retrograde Cholangiopancreatography (ERCP)

Background:Nowadays, endoscopic retrograde cholangiopancreatography (ERCP) is a mature and widely used technology which combines endoscope (duodenoscopy) and Interventional Radiology technology. It is essential for ERCP examination and related treatment technology to select and insert into the bile duct accurately and quickly of casting requires accurate, it is not only a key to a successful ERCP, but also the precise the duodenum advocate nipple intubation technique can prevent the occurrence of the ERCP postoperative complications (such as pancreatitis, gastrointestinal bleeding, perforation, etc.).However the conventional and standard biliary cannulation technology can not meet all the cannula cases needs because of the abnormal duodenal papilla size position and direction of exception in some congenital abnormal anatomy of duodenal papilla, papilla beside diverticulum or in diverticulum, choledocholithiasis incarcerated, duodenal ampullary tumors and so on,standard bile duct intubation techniques already cannot satisfy the intubation of all cases need. And about 5-15% of cases of normal bile duct intubation techniques cannot succeed. Repeat operation for a long time can increases the probability of occurrence of ERCP related complications and fail to even enter the bile duct.Objective:To analyze and summarize the operating skills that can be applied in difficult biliary cannulation (BC) in ERCP and its effectiveness and security.Methods:Row a retrospective analysis of the clinical data of difficult biliary cannulation in ERCP which was operated in Shandong Provincial Hospital and summarize the skills applied in those cases. The difficult biliary cannulation (BC) is defined as:the operator using conventional methods can not enter the bile duct or go into the pancreatic duct repeatedly by the guide wire within 10-15 minutes and has touched duodenal papilla more than 5 times just because of the deformity of duodenal papilla such as papilla oblique, edema of papilla, small papilla, papilla opening being not clear, papilla next to diverticulum nipple/nipple diverticulum, tumor invasion of the nipple or gastrectomy surgery and other factors. Make statistical analysis of the each case difficult biliary cannulation success rate and incidence of post-ERCP-related complications. What’s more, the cases of difficult biliary cannulation (DBC) are divided into four groups including:group of papilla inclination; group of swelling papilla; group of small papilla; group of normal papilla, by the size position and angle of papilla. Compare the differences among the three ways of difficult biliary cannulation in every group.Results:There are 106 cases of difficult biliary cannulation of the total 1859 cases in the latest 6 years, and the total success rate is 92.45%(98/106).(1)precut sphincterotomy (success rate 86.11%); double guidewire technique (DGT) (success rate 55.17%); The method of long duodenoscope body (intubation with a catheter assisted) (success rate 57.14%)(P<0.05) There is a statistically significant difference among the three groups. Adjust the test level and then make the intergroup comparison show that: ① precut group vs DGT group:P= 0.000< 0.0167 (0.05/3);② recut group vs long duodenoscope body group:P= 0.005< 0.0167; ③ DGT group vs long duodenoscope body group:P= 0.633> 0.0167. Subgroup analysis in the precut components show:needle knife precut sphincterotomy (NKPS) group (success rate 84.62%); transpancreatic sphincterotomy (TPS) group (success rate 80.49%) (P>0.05).(2)①Dgroup of papilla inclination P=0.015:precut group(success rate 91.67%) vs DGT group (success rate 50.00%):P= 0.009<0.167 (0.05/3); precut group(success rate 91.67%) vs long duodenoscope body group (success rate 53.33%):P= 0.015< 0.167; DGT group (success rate50.00%) vs long duodenoscope body group (success rate 53.33%):P= 1. Subgroup analysis in the precut components show:needle knife precut sphincterotomy (NKPS) group (success rate 100%) vs transpancreatic sphincterotomy (TPS) group (success rate 85.71%) P>0.05.②group of swelling papilla P>0.05;③group of small papilla P>0.05;group of normal papilla P> 0.05.(3) The complications of post-ERCP include:1 hyperamylasemia:33 cases, the incidence rate was 34.25%, no significant difference among the three groups (P> 0.05); 2 post-ERCP pancreatitis (PEP):8 cases, the incidence rate was 7.50%, no differences among the groups (P>0.05); 3 infection:18 cases, the incidence rate of 16.67%, no difference among the groups (P>0.05);.4 without complications:49 cases, accounting for 41.67%, no difference (P>0.05). All the difficult biliary cannulation cases have not occurred gastrointestinal perforation or bleeding.Conclusion:Pre-cut technique (including needle knife precut sphincterotomy,NKPS and transpancreatic sphincterotomy,TPS), double guidewire technique (DGT), long duodenoscope body technique (intubation with a catheter assisted) are safe and effective. They can improve the success rate of difficult biliary cannulation. Particularly, pre-cut technique is superior to the other two techniques (double guidewire technique (DGT) and long duodenoscope body technique). No statistical difference among the groups of postoperative complications. We should promote the use of this technology especially in the cases of papilla inclination. Percut technique can be divided into NKPS and TPS, and there is no statistical difference between the two groups.