Efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis

doi:10.16139/j.1007-9610.2023.06.010

Abstract

Abstract:

Objective To assess the comparative efficacy of different methods for difficult biliary cannulation in endoscopic retrograde cholangio-pancreatography (ERCP) through a network meta-analysis. Methods Randomized controlled trials (RCTs) that compared the efficacy of different adjunctive methods (early or late needle-knife technique, pancreatic guidewire-assisted technique, pancreatic stent-assisted technique, transpancreatic sphincterotomy, persistent standard cannulation technique) for difficult biliary cannulation with each other were identified. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) were the outcomes of interest. Pairwise and network meta-analysis and ranking according to surface under the cumulative ranking curve(SUCRA) for all methods were performed. Results Eighteen RCTs were identified according to selection criteria, and 2 033 patients were enrolled. The use of transpancreatic sphincterotomy over persistent standard cannulation technique (RR=1.34, 95% CI: 1.02-1.77) and over pancreatic guidewire-assisted technique（RR=1.26, 95% CI: 1.00-1.60）significantly increased the success rate of biliary cannulation. Based on SUCRA ranking, transpancreatic sphincterotomy followed by early needle-knife techniques were ranked highest in terms of increasing the success rate of biliary cannulation. Only early needle-knife technique significantly decreased PEP rate when compared with persistent standard cannulation technique (RR=0.53, 95％CI: 0.30-0.94), whereas both early needle-knife techniques and transpancreatic sphincterotomy led to lower PEP rates as compared with pancreatic guidewire-assisted technique (RR=0.41， 95％CI: 0.17-0.99; RR=0.49， 95％CI: 0.25-0.96; respectively). Based on SUCRA ranking, early needle-knife technique followed by transpancreatic sphincterotomy were ranked highest for decreasing the PEP rate of biliary cannulation. Conclusions Transpancreatic sphincterotomy increases the success rate of difficult biliary cannulation in ERCP; early needle-knife technique and transpancreatic sphincterotomy are superior to other interventions in decreasing PEP rates and should be considered as a choice of difficult biliary cannulation.

Key words: Endoscopic retrograde cholangio-pancreatography, Difficult biliary cannulation, Network meta-analysis

CLC Number:

QI Yang, YAO Wenfei, LI Qianyi, YAO Wei, KONG Lei, XU Ruiyun, WU Yuquan, LI Nengping. Efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis[J]. Journal of Surgery Concepts & Practice, 2023, 28(06): 540-550.

Figures/Tables 10

Fig 1

Tab 1

Basic information of the included studies

Serial number	Author (date of publication)	Experimental group	Control subject	Number of cases	Nation	Devise	Definition of difficult bile duct cannulation	Gender (M/F)	Age (y)	Etiology	Difficult cannulation rate (%)	Pancreatic duct stent application
1	Maeda^[11] (2003)	Pancreatic guidewire assisted technique	Persistent standard technique	27/26	Japan	Single-center	10 min	23/30	64 vs. 64	Unreported	49.50	Not use
2	Catalano^[12] (2004)	Transpancreatic sphincterotomy	Early needle- knife technique	31/32	United States of America	Single-center	30 min; multiple intra-pancreatic ductal injections of contrast media	38/25	68	11 cases of bile duct stones, 32 cases of obstructive jaundice, 15 cases of abdominal pain with abnormal liver function, 4 cases of SOD, 1 case of tumor	1.40	Selected cases
3	Tang^[13] (2005)	Early needle-knife technique	Persistent standard technique	32/30	Canada	Single-center	12 min	29/31	64.6 vs. 67.2	There were 23 cases of choledochal dilatation, 11 cases of choledochal stone, 21 cases of tumor, 12 cases of biliary pancreatitis, 34 cases of abdominal pain, 34 cases of jaundice, 40 cases of liver function abnormality, 5 cases of cholangitis.	9.70	Not use
4	Zhou^[14] (2006)	Early needle-knife technique	Persistent standard technique	43/48	China	Single-center	10 min; 3 accidental guidewire entries into pancreatic ducts	55/36	62.7 vs. 64.3	28 cases of choledochal dilatation, 20 cases of choledochal stones, 15 cases of acute cholangitis, 25 cases of tumor, 3 cases of gastrectomy type B-Ⅱ	9.60	Not use
5	Manes^[15] (2009)	Early needle-knife technique	Persistent standard technique	77/74	Italy	Multicenter	10 min; 5 accidental guidewire entries into pancreatic ducts	98/53	66 vs. 65	72 cases of choledocholithiasis, 56 cases of tumors, 4 cases of benign bile duct stenosis, 5 cases of bile leakage, 2 cases of SOD cholecystitis, 5 cases of choledocholithiasis, 2 cases of choledochal cyst, 5 cases of recurrent pancreatitis	9.50	Not use
6	Cennamo^[16] (2009)	Early needle-knife technique	Late needle-knife technique	36/32	Italy	Single-center	5 min; 3 accidental guidewire entries into pancreatic ducts	31/37	68 vs. 69	47 cases of bile duct stones, 21 cases of tumor	17.3	Not use
7	Herreros de Tejada^[17] (2009)	Pancreatic guidewire-assisted technique	Persistent standard technique	97/91	Spain	Multicenter	5 unsuccessful cannulations	76/112	69.5 vs. 65.8	100 cases of bile duct stones, 38 cases of tumor, 9 cases of acute cholangitis, 5 cases of benign bile duct stenosis, 12 cases of others, 27 cases of abnormal liver function, 7 cases of SOD	22.2	Selected cases
8	Cote^[18] (2012)	Pancreatic guidewire-assisted technique	Pancreatic stent-assisted technique	42/45	United States of America	Multicenter	6 min; 3 accidental guidewire entries into pancreatic ducts	Unreported	58.1 vs. 57.4	Unreported	19.7	Selected cases
9	Angsuwatcharakon^[19] (2012)	Pancreatic guidewire-assisted technique	Early needle- knife technique	23/21	Thailand	Single-center	10 min	23/21	66.1 vs. 64.1	23 cases of choledochal stones, 4 cases of gallbladder stones, 2 cases of Mirrizi's syndrome, 1 case of benign stenosis, 1 case of bile leakage, 13 cases of tumor	8.2	Not use
10	Swan^[20] (2013)	Early needle-knife technique	Persistent standard technique	39/34	Australia	Single-center	5 min; 5 cannulations; 2 accidental guidewire entries into pancreatic ducts	23/50	59 vs. 57	46 cases of choledocholithiasis, 8 cases of SOD, 6 cases of obstructive jaundice, 9 cases of benign bile duct stenosis, 4 cases of bile leaks	15.7	Selected cases
11	Yoo^[21] (2013)	Pancreatic guidewire-assisted technique	Transpancreatic sphincterotomy	34/37	South Korea (Republic of Korea)	Single-center	10 min; 10 unsuccessful cannulation	41/30	67 vs. 63.7	30 cases of choledochal stones, 13 cases of gallbladder stones, 18 cases of tumors, 10 cases of other	7.4	Not use
12	Zang^[22] (2014)	Transpancreatic sphincterotomy	Early needle-knife technique	73/76	China	Single-center	10 min; 5 accidental guidewire entries into pancreatic ducts	71/78	53.7 vs. 54.6	127 cases of choledocholithiasis, 17 cases of benign bile duct obstruction, 5 cases of bile leakage	13.9	Not use
13	Mariani^[23] (2016)	Early needle-knife technique	Persistent standard technique	185/190	Italy	Multicenter	5 min; 3 accidental guidewire entries into pancreatic ducts	165/210	70.4 vs. 68.2	223 cases of bile duct stones, 139 cases of tumors, 33 cases of cholangitis, 18 cases of SOD, 18 cases of benign bile duct stenosis, 12 cases of bile leaks, 11 cases of other	9.5	Not use
14	Zagalsky^[24] (2016)	Early needle-knife technique	Persistent standard technique	50/51	Argentina	Multicenter	8 min; 3 accidental guidewire entries into pancreatic ducts	31/70	52 vs. 49	Choledocholithiasis 78% vs. 82.3%, tumor 22% vs. 17.7%, acute pancreatitis 6% vs. 13.7%, recurrent pancreatitis 2% vs. 2%, others 14% vs. 15.7	8.7	Selected cases
15	Sugiyama^[25] (2018)	Transpancreatic sphincterotomy	Pancreatic guidewire-assisted technique	34/34	Japan	Single-center	15 min; 3 accidental guidewire entries into pancreatic ducts	37/31	69.8 vs. 67.3	18 cases of choledocholithiasis, 34 cases of tumor, 9 cases of benign bile duct stenosis, 3 cases of hepatocellular carcinoma, 1 case of SOD, 3 cases of other	25.8	All cases
16	Eminler^[26] (2019)	Pancreatic guidewire-assisted technique	Pancreatic stent-assisted technique	50/50	Istanbul	Single-center	5 min; 5 accidental guidewire entries into pancreatic ducts	40/60	56 vs. 52.9	76 cases of choledochal stones, 13 cases of tumors, 5 cases of benign strictures, and 6 cases of bile leaks	11	All cases
17	Tabak^[27] (2021)	Early needle knife technique	Transpancreatic sphincterotomy	43/43	China	Single-center	5 min; 5 unsuccessful cannulations; 2 guidewire entries into pancreatic ducts	51/35	61 vs. 59.4	57 cases of biliary stones, 16 cases of tumors, 18 cases of benign strictures, 3 cases of cholangitis, 5 cases of biliary pancreatitis	12.8	Selected cases
18	Kylanpaa^[28] (2021)	Transpancreatic sphincterotomy	Pancreatic guidewire-assisted technique	104/99	Finland, Denmark, Norway, Sweden	Multicenter	5 min; 5 unsuccessful cannulations	98/105	66 vs. 68	87 cases of choledocholithiasis, 91 cases of stricture, 12 cases of primary sclerosing cholangitis, and 17 cases of bile leakage, 20 cases of other	17.1	Selected cases

Tab 1

Fig 2

Fig 3

Tab 2

Fig 4

Fig 5

Tab 3

Fig 6

Fig 7

References 32

[1]	TSE F, YUAN Y, MOAYYEDI P, et al. Guidewire-assisted cannulation of the common bile duct for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis[J]. Cochrane Database Syst Rev, 2012, 12(12):CD009662.
[2]	WILLIAMS E J, TAYLOR S, FAIRCLOUGH P, et al. Are we meeting the standards set for endoscopy?Results of a large-scale prospective survey of endoscopic retrograde cholangiopancreatograph practice[J]. Gut, 2007, 56(6):821-829. doi: 10.1136/gut.2006.097543 URL
[3]	TESTONI P A, MARIANI A, AABAKKEN L, et al. Papillary cannulation and sphincterotomy techniques at ERCP:European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline[J]. Endoscopy, 2016, 48(7):657-683. doi: 10.1055/s-00000012 URL
[4]	HALTTUNEN J, MEISNER S, AABAKKEN L, et al. Difficult cannulation as defined by a prospective study of the scandinavian association for digestive endoscopy (SADE) in 907 ERCPs[J]. Scand J Gastroenterol, 2014, 49(6):752-758. doi: 10.3109/00365521.2014.894120 URL
[5]	LIAO W C, ANGSUWATCHARAKON P, ISAYAMA H, et al. International consensus recommendations for difficult biliary access[J]. Gastrointest Endosc, 2017, 85(2):295-304. doi: 10.1016/j.gie.2016.09.037 URL
[6]	FREEMAN M L, DISARIO J A, NELSON D B, et al. Risk factors for post-ERCP pancreatitis: a prospective, multicenter study[J]. Gastrointest Endosc, 2001, 54(4):425-434. doi: 10.1067/mge.2001.117550 pmid: 11577302
[7]	WANG P, LI Z S, LIU F, et al. Risk factors for ERCP-related complications: a prospective multicenter study[J]. Am J Gastroenterol, 2009, 104(1):31-40. doi: 10.1038/ajg.2008.5 pmid: 19098846
[8]	PÉCSI D, FARKAS N, HEGYI P, et al. Transpancreatic sphincterotomy has a higher cannulation success rate than needle-knife precut papillotomy da meta-analysis[J]. Endoscopy, 2017, 49(9):874-887. doi: 10.1055/s-0043-111717 URL
[9]	PUHAN M A, SCHÜNEMANN H J, MURAD M H, et al. A GRADE Working Group approach for rating the qua-lity of treatment effect estimates from network meta-analysis[J]. BMJ, 2014, 349:g5630. doi: 10.1136/bmj.g5630 URL
[10]	HIGGINS J P, ALTMAN D G, GØTZSCHE PC, et al. The cochrane collaboration’s tool for assessing risk of bias in randomised trials[J]. BMJ, 2011, 343:d5928. doi: 10.1136/bmj.d5928 URL
[11]	MAEDA S, HAYASHI H, HOSOKAWA O, et al. Prospective randomized pilot trial of selective biliary cannulation using pancreatic guide-wire placement[J]. Endoscopy, 2003, 35(9):721-724. pmid: 12929017
[12]	CATALANO M F, LINDER J D, GEENEN J E. Endoscopic transpancreatic papillary septotomy for inaccessible obstructed bile ducts:comparison with standard pre-cut papillotomy[J]. Gastrointest Endosc, 2004, 60(4):557-561. doi: 10.1016/S0016-5107(04)01877-2 URL
[13]	TANG S J, HABER G B, KORTAN P, et al. Precut papillotomy versus persistence in difficult biliary cannulation:a prospective randomized trial[J]. Endoscopy, 2005, 37(1):58-65. doi: 10.1055/s-2004-826077 URL
[14]	ZHOU P H, YAO L Q, XU M D, et al. Application of needle-knife in difficult biliary cannulation for endoscopic retrograde cholangiopancreatography[J]. Hepatobiliary Pancreat Dis Int, 2006, 5(4):590-594.
[15]	MANES G, DI GIORGIO P, REPICI A, et al. An analysis of the factors associated with the development of complications in patients undergoing precut sphincterotomy: a prospective, controlled, randomized, multicenter study[J]. Am J Gastroenterol, 2009, 104(10):2412-2417. doi: 10.1038/ajg.2009.345 pmid: 19550413
[16]	CENNAMO V, FUCCIO L, REPICI A, et al. Timing of precut procedure does not influence success rate and complications of ERCP procedure: a prospective rando-mized comparative study[J]. Gastrointest Endosc, 2009, 69(3):473-479. doi: 10.1016/j.gie.2008.09.037 URL
[17]	HERREROS DE TEJADA A, CALLEJA J L, DÍAZ G, et al. Double-guidewire technique for difficult bile duct cannulation: a multicenter randomized,controlled trial[J]. Gastrointest Endosc, 2009, 70(4):700-709. doi: 10.1016/j.gie.2009.03.031 URL
[18]	COTÉ G A, MULLADY D K, JONNALAGADDA S S, et al. Use of a pancreatic duct stent or guidewire facilitates bile duct access with low rates of precut sphinctero-tomy: a randomized clinical trial[J]. Dig Dis Sci, 2012, 57(12):3271-3278. doi: 10.1007/s10620-012-2269-2 URL
[19]	ANGSUWATCHARAKON P, RERKNIMITR R, RIDTITID W, et al. Success rate and cannulation time between precut sphincterotomy and double-guidewire technique in truly difficult biliary cannulation[J]. J Gastroenterol Hepatol, 2012, 27(2):356-361. doi: 10.1111/jgh.2012.27.issue-2 URL
[20]	SWAN M P, ALEXANDER S, MOSS A, et al. Needle knife sphincterotomy does not increase the risk of pancrea-titis in patients with difficult biliary cannulation[J]. Clin Gastroenterol Hepatol, 2013, 11(4):430-436. doi: 10.1016/j.cgh.2012.12.017 URL
[21]	YOO Y W, CHA S W, LEE W C, et al. Double guidewire technique vs. transpancreatic precut sphincterotomy in difficult biliary cannulation[J]. World J Gastroenterol, 2013, 19(1):108-114. doi: 10.3748/wjg.v19.i1.108 URL
[22]	ZANG J, ZHANG C, GAO J. Guidewire-assisted transpancreatic sphincterotomy for difficult biliary cannulation: a prospective randomized controlled trial[J]. Surg Laparosc Endosc Percutan Tech, 2014, 24(5):429-433. doi: 10.1097/SLE.0000000000000062 pmid: 24910935
[23]	MARIANI A, DI LEO M, GIARDULLO N, et al. Early precut sphincterotomy for difficult biliary access to reduce post-ERCP pancreatitis: a randomized trial[J]. Endoscopy, 2016, 48(6):530-535. doi: 10.1055/s-0042-102250 pmid: 26990509
[24]	ZAGALSKY D, GUIDI M A, CURVALE C, et al. Early precut is as efficient as pancreatic stent in preventing post-ERCP pancreatitis in high-risk subjectsda rando-mized study[J]. Rev Esp Enferm Dig, 2016, 108(9):558-562.
[25]	SUGIYAMA H, TSUYUGUCHI T, SAKAI Y, et al. Transpancreatic precut papillotomy versus double-guidewire technique in difficult biliary cannulation:prospective randomized study[J]. Endoscopy, 2018, 50(1):33-39.
[26]	EMINLER A T, PARLAK E, KOKSAL A S, et al. Wire-guided cannulation over a pancreatic stent method increases the need for needle-knife precutting in patients with difficult biliary cannulations[J]. Gastrointest Endosc, 2019, 89(2):301-308. doi: 10.1016/j.gie.2018.08.034 URL
[27]	TABAK F, WANG F, JI G Z, et al. Propensity score-matched analysis for comparing transpancreatic sphincterotomy and needle-knife precut in difficult biliary cannulation[J]. Sci Rep, 2021, 11(1):6059. doi: 10.1038/s41598-021-84655-2 pmid: 33723297
[28]	KYLÄNPÄÄ L, KOSKENSALO V, SAARELA A, et al. Transpancreatic biliary sphincterotomy versus double guidewire in difficult biliary cannulation:a randomized controlled trial[J]. Endoscopy, 2021, 53(10):1011-1019. doi: 10.1055/a-1327-2025 URL
[29]	PÉCSI D, FARKAS N, HEGYI P, et al. Transpancreatic sphincterotomy is effective and safe in expert hands on the short term[J]. Dig Dis Sci, 2019, 64(9):2429-2444. doi: 10.1007/s10620-019-05640-4
[30]	CHEN J, WAN J H, WU D Y, et al. Assessing quality of precut sphincterotomy in patients with difficult biliary access: an updated metaanalysis of randomized controlled trials[J]. J Clin Gastroenterol, 2018, 52(7):573-578. doi: 10.1097/MCG.0000000000001077 URL
[31]	JANG S I, KIM D U, CHO J H, et al. Primary needle-knife fistulotomy versus conventional cannulation method in a high-risk cohort of post-endoscopic retrograde cho-langiopancreatography pancreatitis[J]. Am J Gastroenterol, 2020, 115(4):616-624. doi: 10.14309/ajg.0000000000000480 URL
[32]	李谦益, 姚文飞, 祁洋, 等. 胰管支架表面括约肌预切开在ERCP困难胆管插管中的应用效果[J]. 肝胆胰外科杂志, 2022, 34(3):129-133.
	LI Q Y, YAO W F, QI Y, et al. Efficacy of precut over a pancreatic duct stent for difficult biliary cannulation in ERCP[J]. J Hepatopancreatobiliary Surg, 2022, 34(3):129-133.

Cannulation techniques	SUCRA (%)	PrBest (%)	MeanRank
Transpancreatic sphincterotomy	95.3	82.2	1.2
Early needle-knife technique	67.2	5.8	2.6
Pancreatic guidewire-assissted technique	50.7	1.7	3.5
Standard technique	35.8	0.7	4.2
Late needle-knife technique	27.2	6.3	4.6
Pancreatic stent-assisted technique	23.7	3.2	4.8

Cannulation techniques	SUCRA (%)	PrBest (%)	MeanRank
Early needle-knife technique	88	62.3	1.5
Transpancreatic sphincterotomy	75.2	28.5	2
Persistent standard technique	40.8	0.7	3.4
Pancreatic guidewire-assissted technique	23.2	0.2	4.1
Pancreatic stent-assisted technique	22.8	8.3	4.1