Biliary cannulation can be facilitated by pancreatic stent insertion

Biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP) remains challenging in 1 %–10 % of cases [1]. A variety of sphincterotomes and cannulation techniques have been developed. Complications including pancreatitis remain a significant concern, particularly if repeated instrumentation or pancreatic duct injection or precut techniques are used.

Pancreatic duct stenting reduces the incidence of post-ERCP pancreatitis by up to 20 % [2]. Stent placement is technically feasible in about 95 % of cases, although there is an increased risk of pancreatitis when placement fails. Placement of a pancreatic duct stent to facilitate biliary access has been described as a useful adjunct to biliary cannulation in difficult cases [3] ([Fig. 1]).

Fig. 1 Pancreatic stent used to aid biliary cannulation.

We placed a 5 cm 5 Fr Wilson Cook (Winston-Salem, North Carolina, USA) pancreatic stent with an external phalange to facilitate common bile duct (CBD) cannulation in five consecutive patients in whom standard techniques for CBD cannulation (excluding precut sphincterotomy) had failed. The reason for cannulation failure appeared to be due to a combination of factors including angulation of the distal CBD and an abnormal appearing papilla. Pancreatic stent placement was successful in four patients, and subsequent biliary cannulation using the pancreatic stent as a guide was successful in 4 / 5 with a standard sphincterotome. The fifth patient required a precut sphincterotomy over the pancreatic stent to facilitate biliary cannulation. None of the five patients suffered any ERCP-related complications.

Pancreatic duct stent placement for prophylaxis of post-ERCP pancreatitis has become standard practice for higher-risk patients in many centers, including our own. Stent placement to facilitate biliary cannulation has been suggested to be safe and effective [3]. The pancreatic stent most likely facilitates biliary cannulation by straightening distal CBD angulation but possibly also by overcoming difficulties posed by a short common channel [4]. We suggest that pancreatic stent placement to facilitate biliary cannulation in difficult cases may be preferable to initial precut techniques, although further prospective study is required.

Endoscopy_UCTN_Code_TTT_1AR_2AB

References

• 1 Freeman M L. Cannulation techniques for ERCP: one size does not fit all.  Gastrointest Endosc. 2007;  65 132-133
• 2 Freeman M L, Guda N. Prevention of post-ERCP panceatitis: a comprehensive review.  Gastrointest Endosc. 2004;  57 845-864
• 3 Goldberg E, Titus M, Haluszka O, Darwin P. Pancreatic-duct stent placement facilitates difficult common bile duct cannulation.  Gastrointest Endosc. 2005;  62 592-596
• 4 HJ K im, HS C hoi, JH P ark. et al . Factors influencing the technical difficulty of endoscopic clearance of bile duct stones.  Gastrointest Endosc. 2007;  66 1154-1160