Endoscopic Retrograde Cholangiopancreatography after a Liquid Fatty Meal: Effect on Deep Common Bile Duct Cannulation Time

Background and Study Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is an important gastrointestinal endoscopic procedure in the study and treatment of pancreaticobiliary diseases. The critical step of the procedure is cannulation of the common bile duct (CBD) and/or the pancreatic duct. Cannulation can be a technical challenge at times. Fat is a natural stimulator for bile secretion and relaxation of the sphincter of Oddi. The objective of this study was to determine the effect of a liquid fatty meal on deep CBD cannulation during ERCP.
Patients and Methods: We performed a randomized double-blind study in 84 patients to examine the effect of a liquid fatty meal on deep CBD cannulation during ERCP, in a teaching medical center. In the study group, each patient had a liquid fatty meal orally about 1 hour before the procedure. In the control group, each patient had the same volume of a non-fat meal. The appearance of the major papilla, the cannulation rate, the cannulation time, and the fluoroscopy time during cannulation were compared for the two groups.
Results: The orifice of the CBD/pancreatic duct was much more easily identified in the group who ingested the fatty meal. Compared with the non-fat meal group, in the fatty meal group the mean and the median deep CBD cannulation times were shorter, at 8.0 minutes vs. 14.7 minutes (P = 0.005) and 8.0 minutes vs. 11.5 minutes (P = 0.008), respectively. Additionally, in the fatty meal group, the mean and the median fluoroscopy times during deep CBD cannulation were lower, at 3.3 minutes vs. 6.1 minutes (P = 0.040) and 2.5 minutes vs. 3.9 minutes (P = 0.013), respectively. There were no complications, such as aspiration, associated with the liquid meals given shortly before the ERCP procedure.
Conclusions: To avoid prolonged cannulation and unnecessary radiation exposure, patients should have a liquid fatty meal before ERCP procedures.

References

• 1 Cotton P B. Cannulation of papilla of Vater by endoscopy and retrograde cholangiopancreatography.  Gut. 1972;  13 1014-1025
• 2 Cotton P B. ERCP.  Gut. 1977;  18 316-341
• 3 Sherman S, Lehman G A. Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy and stone removal, and endoscopic biliary and pancreatic drainage. In: Yamada T, et al. (eds.) Textbook of gastroenterology. 3rd edn.  Philadelphia: Lippincott, Williams &. Wilkins ;  1999 2718-2746
• 4 National Institutes of Health, State of Science Conference Statement .Endoscopic retrograde cholangiopancreatography for diagnosis and therapy. 2002. http://www.nic.gov
• 5 Himal H S. Common bile duct stones: the role of preoperative, intraoperative, and postoperative ERCP.  Semin Laparosc Surg. 2000;  7 237-245
• 6 Golf J S. Long-term experience with the transpancreatic sphincter pre-cut approach to biliary sphincterotomy.  Gastrointest Endosc. 1999;  50 642-645
• 7 Wehrmann T, Schmitt T, Stergiou N. et al . Topical application of nitrates onto the papilla of Vater: manometric and clinical results.  Endoscopy. 2001;  33 323-328
• 8 Devereaux B M, Lehman G A, Seymour F. et al . Facilitation of pancreatic duct cannulation using a new synthetic porcine secretin.  American Journal of Gastroenterology. 2002;  97 2279-2281
• 9 Hashiba K, D’Assuncao M A, Amellini S. et al . Endoscopic suprapapillary blunt dissection of the distal common bile duct in cases of difficult cannulation: a pilot series.  Endoscopy. 2004;  36 317-321
• 10 Kumar S, Sherman S, Hawes R H, Lehman G A. Success and yield of second attempt ERCP.  Gastrointest Endosc. 1995;  41 445-447
• 11 Siegel J H. Precut papillotomy: a method to improve success of ERCP and papillotomy.  Endoscopy. 1981;  12 130-133
• 12 Silivka A. A new technique to assist in bile duct cannulation [letter].  Gastrointest Endosc. 1996;  44 636
• 13 Goff J S. Common bile duct pre-cut sphincterotomy: transpancreatic approach.  Gastrointest Endosc. 1995;  41 502-505
• 14 Silvis S E, Meier P B. Techniques for endoscopic retrograde cholangiopancreatography. In: Silvis SE, Rohrmann CA jr, Nael HJ, eds Text and atlas of endoscopic retrograde cholangiopancreatography. New York; Igaku-Shoin Medical Publishers 1994: 22-50
• 15 Freeman M L. Adverse outcomes of endoscopic retrograde cholangiopancreatography: avoidance and management.  Gastrointest Endosc Clin N Am. 2003;  13 775-789
• 16 Wehbi M, Obidden M K, Shaukat A, Cai Q. Deep cannulation of the common bile duct - how challenging is it?.  Gastrointest Endosc. 2004;  59 AB186
• 17 Weston A P. Sincalide: a cholecystokinin agonist as an aid in endoscopic retrograde cholangiopancreatography - a prospective assessment.  J Clin Gastroenterol. 1997;  24 227-230
• 18 Thompson J N, Gupta S, Murray J K. et al . A randomized double-blind trial of cholecystokinin during ERCP [letter].  Endoscopy. 1986;  18 251
• 19 Igarashi Y, Tada T, Shimura J. et al . A new cannula with a flexible tip (Swing Tip) may improve the success rate of endoscopic retrograde cholangiopancreatography.  Endoscopy. 2002;  34 628-631
• 20 Cortas G A, Mehta S N, Abraham N S, Barkun A N. Selective cannulation of the common bile duct: a prospective randomized trial comparing standard catheters with sphincterotomes.  Gastrointest Endosc. 1999;  50 775-779
• 21 Fogel E L, Sherman S, Lehman G A. Increased selective biliary cannulation rate in the setting of periampullary diverticula: main pancreatic duct placement followed by pre-cut biliary sphincterotomy.  Gastrointest Endosc. 1998;  47 396-400
• 22 Weisbrodt N W. Bile production, secretion, and storage. In: Johnson LR, et al (ed) Gastrointestinal physiology.  6th edn.. Mosby;  2001 107-118
• 23 Bockus H L. Timed biliary drainage. In: Bockus HL (ed). Bockus gastroenterology. 2nd edn.  WB Saunders:. Philadelphia;  1965 664-665
• 24 Matthews J NS. An introduction to randomized controlled trials. London; Arnold 2000
• 25 Hopman W P, Jansen J B, Rosenbusch G, Lamers C B. Effect of equimolar amounts of long-chain triglycerides and medium-chain triglyceride on plasma cholecystokinin and gallbladder contraction.  Am J Clin Nutr. 1984;  39 356-359
• 26 Isaacs P E, Ladas S, Forgacs I C. et al . Comparison of effects of ingested medium- and long-chain triglyceride on gallbladder volume and release of cholecystokinin and other gut peptides.  Dig Dis Sci. 1987;  32 481-486
• 27 Mclaughlin J, Grazia Luca M, Jones M N. et al . Fatty acid chain length determines cholecystokinin secretion and effect of human gastric motility.  Gastroenterology. 1999;  116 46-53
• 28 Jonkers I J, Ledeboer M, Steens J. et al . Effects of very long chain versus long chain triglycerides on gastrointestinal motility and hormone release in humans.  Dig Dis Sci. 2000;  45 1719-1726
• 29 Obideen M K, Wehbi M, Shaukat A, Cai Q. The effect of magnesium sulfate and a fatty meal on human gallbladder volume.  Am J Gastroenterol. 2004;  99 S47
• 30 Rosner B. Fundamentals of biostatistics. 5th edn. Pacific Grove, California; Duxbury Press 2000
• 31 Faigel D O, Eisen G M, Baron T H. et al . Standards of Practice Committee. American Society for Gastroenintestinal Endoscopy. Preparation of patients for GI endoscopy.  Gastrointest Endosc. 2003;  57 446-450
• 32 Soreide E. Preoperative fasting.  Br J Surg. 2003;  90 400-406
• 33 American Society of Anesthesiology . Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures.  Anesthesiology. 1999;  90 896-905
• 34 Poon R T, Fan S T. Antisecretory agents for prevention of post-ERCP pancreatitis: rationale for use and clinical results.  JOP J Pancreas (online). 2003;  4 33-40
• 35 Vandervoort J, Soetikno R M, Tham T C. et al . Risk factors for complication after performance of ERCP.  Gastrointest Endosc. 2002;  56 652-656
• 36 Heyd R I, Kopecky K K, Sherman S. et al . Radiation exposure to patients and personnel during interventional ERCP at a teaching institution.  Gastrointest Endosc. 1996;  44 287-292
• 37 Cohen R V, Aldred M A, Paes W S. et al . How safe is ERCP to the endoscopist?.  Surg Endosc. 1997;  11 615-617
• 38 Larkin C J, Workman A, Wright R E, Tham T C. Radiation doses to patients during ERCP.  Gastrointest Endosc. 2001;  53 161-164
• 39 Buls N, Pages J, Mana F, Osteaux M. Patient and staff exposure during endoscopic retrograde cholangiopancreatography.  Br J Radiol. 2002;  75 435-443
• 40 Tsalafoutas I A, Paraskeva K D, Yakoumakis E N. et al . Radiation doses to patients from endoscopic retrograde cholangiopancreatogaphy examination and image quality considerations.  Radiat Prot Dosimetry. 2003;  106 241-246
• 41 Aufrichtig R, Xue P, Thomas C W. et al . Perceptual comparison of pulsed and continuous fluoroscopy.  Med Phys. 1994;  21 245-256
• 42 Bushberg J T. Essential physics of medical images. 2nd edn. Philadelphia; Lippincott Williams & Wilkins 2002
• 43 USDA .Search the USDA national nutrient database for standard reference.  http://www.nal.usda.gov/fnic/foodcomp/search
• 44 Walsh J H. Gastrointestinal hormones. In: Johnson LR (ed) Physiology of the gastrointestinal tract. New York; Raven Press 1987: 195-206
• 45 Lai K H, Peng N J, Lo G H. et al . Does a fatty meal improve hepatic clearance in patients after endoscopic sphincterotomy?.  J Gastroenterol Hepatol. 2002;  17 337-341
• 46 Bar-Meir S, Halpern Z, Bardan E, Gilat T. Frequency of papillary dysfunction among cholecystectomized patients.  Hepatology. 1984;  4 328-330