title: Sequential double-guidewire technique and transpancreatic precut sphincterotomy for difficult biliary cannulation.
abstract: OBJECTIVE
  The double-guidewire technique (DGT) and transpancreatic precut sphincterotomy (TPS) are introduced as alternative biliary cannulation techniques for difficult biliary cannulation. This study aimed to evaluate the sequential use of DGT and TPS compared with a needle-knife precut papillotomy (NK).
  
  
  METHODS
  Six hundred and thirty-five consecutive patients with naοve papilla and who underwent endoscopic retrograde cholangiopancreatography (ERCP) for biliary cannulation from March 2010 to April 2014 in a single institute were analyzed. When standard techniques were unsuccessful, DGT or NK was performed. TPS was sequentially performed if DGT failed.
  
  
  RESULTS
  DGT and NK were attempted in 65 and 58 patients, respectively. A sequential DGT-TPS was performed in 38 patients after a failed DGT. Biliary cannulations were successful in 42%, 74%, and 66% of the DGT, sequential DGT-TPS, and NK patients, respectively (P = 0.002). The cannulation rate was higher in the DGT ± TPS patients (85%) than in the NK patients (P = 0.014). Post-ERCP pancreatitis (PEP) developed in 26% of the successful DGT patients, 37% of the sequential DGT-TPS patients, and 10% of the NK patients (P = 0.008). Of the sequential DGT-TPS patients, the incidence of PEP was significantly reduced in patients with a pancreatic duct (PD) stent compared with patients without a PD stent (24% vs. 62%, P = 0.023).
  
  
  CONCLUSIONS
  Sequential DGT-TPS is a useful alternative method compared with NK for patients in whom biliary cannulation is difficult. In the sequential DGT-TPS patients, the incidence of PEP was significantly reduced with the use of a PD stent.
authors: Chang W
authors: CW
authors: Kim
authors: Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.
authors: Jae H
authors: JH
authors: Chang
authors: Tae H
authors: TH
authors: Kim
authors: Sok W
authors: SW
authors: Han
mesh_terms: D000368:Aged; D001662:Biliary Tract Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D002404:Catheterization / Q000379:methods*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000379:methods*; D015331:Cohort Studies; D003135:Common Bile Duct / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010195:Pancreatitis / Q000209:etiology; D011446:Prospective Studies; D012189:Retrospective Studies; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects / Q000379:methods*; D015607:Stents; D016896:Treatment Outcome