Use of a pancreatic duct stent or guidewire facilitates bile duct access with low rates of precut sphincterotomy: a randomized clinical trial.
OBJECTIVE
Among cases of difficult biliary cannulation, alternatives include use of a pancreatic duct stent (PDS) or guidewire (PDW) to facilitate access. We compared the effectiveness of a PDS versus a PDW to facilitate common bile duct (CBD) cannulation.


METHODS
We conducted a randomized, crossover trial at two endoscopy referral centers, limited to patients undergoing ERCP without a history of biliary sphincterotomy. After meeting predefined criteria for difficult cannulation, patients were randomized to using a PDS or PDW to facilitate CBD cannulation. Outcomes included cannulation rate within 6 min, overall cannulation rate, frequency of precut, and complication rates.


RESULTS
Among 442 eligible patients, 87 (19.7 %) met criteria for difficult cannulation. Forty two were randomized to PDW, 54 to PDS (including 9 PDW patients crossed over to PDS). The rate of CBD cannulation within 6 min was similar in the PDW (38.1 %) and PDS (51.9 %) groups (p = 0.18). In a secondary analysis limited to patients who successfully underwent PDW or PDS deployment, the rate was also comparable (PDW 59.3 %, PDS 65.1 %; p = 0.62). The overall frequency of CBD cannulation was 66.7 % in PDW and 90.7 % in PDS patients. Precut was required in 9.5 % of PDW and 25.9 % of PDS patients. Complication rates were similar, with 4 (4.6 %) patients having post-ERCP pancreatitis and 1 (1.1 %) having post-ERCP pain without confirmation of pancreatitis.


CONCLUSIONS
Use of a PDS or PDW facilitates CBD cannulation while maintaining a low complication rate and reducing the need for precut sphincterotomy in the majority of cases.
Washington University School of Medicine in St. Louis, 660 S. Euclid Avenue, Campus Box 8124, St. Louis, MO 63110, USA.
Gregory A
GA
Coté
Daniel K
DK
Mullady
Sreenivasa S
SS
Jonnalagadda
Rajesh N
RN
Keswani
Sachin B
SB
Wani
Christine E
CE
Hovis
Tarek
T
Ammar
Abed
A
Al-Lehibi
Steven A
SA
Edmundowicz
Sri
S
Komanduri
Riad R
RR
Azar
D000328:Adult; D000368:Aged; D001649:Bile Duct Diseases / Q000601:surgery*; D001652:Bile Ducts / Q000601:surgery*; D002404:Catheterization; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009803:Sphincter of Oddi / Q000601:surgery; D016717:Sphincterotomy, Endoscopic / Q000295:instrumentation*; D015607:Stents