Introduction A range of techniques have been described to achieve successful cannulation at ERCP, and when training in ERCP it is often difficult to select the optimum approach.1 There are potential advantages to a wire-led approach and we have evaluated this in our unit in a training setting.
Aim To evaluate cannulation success rates for trainers and trainees using a wire-led technique as the default approach.
Methods A prospective evaluation was done with 2 experienced trainers and 2 trainees (previous experience of 50–100 ERCPs each). The sphincterotome was pre-loaded with a hydrophilic wire (in limited cases loop tip wire was used) and cannulation started with the wire extending 3–5 mm out of cannula. Attempts were then made to advance the wire deep into the bile duct before injecting any contrast or pushing the cannula through the ampulla. Trainees were allowed 6 min for cannulation attempts. If the wire-led approach failed then other techniques were used. Wire-led cannulation was considered successful only if no other techniques were required. Only cases with a ‘virgin ampulla’ were including in this study.
Results 85 cases were included over a 4 month period. Trainees were present in 51/85 (60%) cases. Overall biliary cannulation success was 78/85 (92%). Success rate was 45/51 (88%) if a trainee was present and 33/34 (97%), if no trainee was present. Independent success for trainees was 25/51 (49%), mostly using the wire-led technique (21/25) 84%. In cases where a trainer took over from a trainee, the wire-led approach was still successful in 13/26 (50%).
Overall success with the wire-led approach alone was 57/85(67%); other approaches used in remaining cases included pre-cut sphincterotomy, locked PD wire, and PD stent. A peri-ampullary diverticulum was the most common cause for failure of wire-led technique; other common causes included stricture, floppy ampulla, or an impacted stone.
Median cannulation time was 6.5 min (IQR 4–10 min) overall and 5 min (IQR 3–10 min) for consultant-only cases. Immediate complications included false passage of wire (1 case, no further clinical events) and late complications: post ERCP pancreatitis (1 case, hospital stay 3 days, no further clinical events).
Conclusion Wire-led biliary cannulation, with selective usage of additional techniques, may allow a cannulation rate of >90% in cases with a virgin ampulla. The technique appears to be a useful training tool and has a low complication rate.
Gastrointest Endoscopy Clin N Am 2012 Jul;22(3):417–34
Disclosure of Interest None Declared.
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