The large working channel of a new generation of duodenoscopes permits side-by-side
double guide wire placements, which can facilitate both cannulation and drainage during
pancreaticobiliary procedures [1]. The use of two guide wires in one duct can make therapeutic endoscopy easier during
drainage procedures. It is employed by many endoscopists for bilateral drainage of
strictures in the biliary duct [1]
[2]. A similar method for stent insertion, employing a double guide wire, can also be
applied during cystoenterostomies [3].
The “double guide wire technique” can also facilitate cannulation of the biliary tract
in difficult endoscopic retrograde cholangiopancreatography (ERCP) procedures. If
selective cannulation of the common bile duct has not been successful, we pass a 0.035-inch
Teflon guide wire (Wilson-Cook, Winston-Salem, North Carolina, USA) distally into
the main pancreatic duct, to prevent repeated overfilling and pancreatitis. It is
advisable to suck the contrast medium out of the pancreas beforehand. A standard sphincterotome
is then passed into the working channel of the endoscope (JFT10, Olympus, Hamburg,
Germany). The tip of the papillotome is positioned against the first wire placed in
the pancreatic duct, and its curve is altered; this usually makes it easy to introduce
a second guide wire into the common bile duct (Figure [1]). If not, then the guide wire placed in the pancreatic duct is pushed downwards;
this may straighten the distorted prepapillary part of the common bile duct and facilitate
guidance to the choledochus.
Figure 1 One guide wire has been passed into the pancreatic duct and another is being moved
in the direction of the bile duct through the papillotome inserted into the ampulla.
This method was first described by Dumenceau et al. [4], but was used in only one patient, who had a Billroth I anastomosis. A similar idea
was reported by Slivka et al. [5], who used temporary short pancreatic polyethylene stents to facilitate access into
the bile duct.
We have routinely used this double guide wire technique in all our difficult cases
for more than 3 years, because we believe that unwanted cannulation and repeated filling
of the pancreatic duct run the risk of provoking pancreatitis. During recent months
in our department, we performed 75 ERCPs followed by endoscopic sphincterotomy for
biliary conditions. We used the double guide wire technique for cannulation in 24
difficult cases (32 %). (Patients who underwent precutting are excluded.) All the
interventions were carried out by two endoscopists. The complication rate did not
differ significantly between the group of patients in whom cannulation was easy and
the group in whom the double guide wire was used (mild pancreatitis 7.8 % vs. 8.3
%; slight bleeding 5.8 % vs. 4.1 %). A similar method can be applied if cannulation
of the pancreatic duct is attempted but only biliary access is achieved initially.
It is feasible to insert separate guide wires into the two ducts for complex endoscopic
treatment of chronic pancreatitis. Pancreatic sphincterotomy using a needle-knife
papillotome is then safer if it is applied between the two guide wires placed in the
pancreatic and biliary ducts (Figure [2]).
Figure 2 Septotomy using a needle-knife papillotome, between separate guide-wires inserted
into the pancreatic and biliary ducts.
All of the abovementioned techniques are aimed at assisting the endoscopist, shortening
the duration of procedures, and decreasing the risk of complications. Another advantage
is safety even during the clinician's learning curve for the procedures [1], when repeated cannulation and overfilling of the pancreatic duct is a real danger,
and correction of failed attempts is difficult because of papillary damage.
Acknowledgement
Presented at the IAP 2000 meeting, Chicago: Pancreas 2000; 21: 4, 439 (A).
