Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

Pier Alberto Testoni, Alberto Mariani, Lars Aabakken, Marianna Arvanitakis, Erwan Bories, Guido Costamagna, Jacques Devière, Mario Dinis-Ribeiro, Jean Marc Dumonceau, Marc Giovannini, Tibor Gyokeres, Michael Hafner, Jorma Halttunen, Cesare Hassan, Luis Lopes, Ioannis S. Papanikolaou, Tony C. Tham, Andrea Tringali, Jeanin Van Hooft, Earl J. Williams

Research output: Contribution to journalReview article

Abstract

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It provides practical advice on how to achieve successful cannulation and sphincterotomy at minimum risk to the patient. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations 1 ESGE suggests that difficult biliary cannulation is defined by the presence of one or more of the following: more than 5 contacts with the papilla whilst attempting to cannulate; more than 5 minutes spent attempting to cannulate following visualization of the papilla; more than one unintended pancreatic duct cannulation or opacification (low quality evidence, weak recommendation). 2 ESGE recommends the guidewire-assisted technique for primary biliary cannulation, since it reduces the risk of post-ERCP pancreatitis (moderate quality evidence, strong recommendation). 3 ESGE recommends using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation is difficult and repeated unintentional access to the main pancreatic duct occurs (moderate quality evidence, strong recommendation). ESGE recommends attempting prophylactic pancreatic stenting in all patients with PGW-assisted attempts at biliary cannulation (moderate quality evidence, strong recommendation). 4 ESGE recommends needle-knife fistulotomy as the preferred technique for precutting (moderate quality evidence, strong recommendation). ESGE suggests that precutting should be used only by endoscopists who achieve selective biliary cannulation in more than 80% of cases using standard cannulation techniques (low quality evidence, weak recommendation). When access to the pancreatic duct is easy to obtain, ESGE suggests placement of a pancreatic stent prior to precutting (moderate quality evidence, weak recommendation). 5 ESGE recommends that in patients with a small papilla that is difficult to cannulate, transpancreatic biliary sphincterotomy should be considered if unintentional insertion of a guidewire into the pancreatic duct occurs (moderate quality evidence, strong recommendation). In patients who have had transpancreatic sphincterotomy, ESGE suggests prophylactic pancreatic stenting (moderate quality evidence, strong recommendation). 6 ESGE recommends that mixed current is used for sphincterotomy rather than pure cut current alone, as there is a decreased risk of mild bleeding with the former (moderate quality evidence, strong recommendation). 7 ESGE suggests endoscopic papillary balloon dilation (EPBD) as an alternative to endoscopic sphincterotomy (EST) for extracting CBD stones

Original languageEnglish
Pages (from-to)657-683
Number of pages27
JournalEndoscopy
Volume48
Issue number7
DOIs
Publication statusPublished - Jul 1 2016

ASJC Scopus subject areas

  • Gastroenterology

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  • Cite this

    Testoni, P. A., Mariani, A., Aabakken, L., Arvanitakis, M., Bories, E., Costamagna, G., Devière, J., Dinis-Ribeiro, M., Dumonceau, J. M., Giovannini, M., Gyokeres, T., Hafner, M., Halttunen, J., Hassan, C., Lopes, L., Papanikolaou, I. S., Tham, T. C., Tringali, A., Van Hooft, J., & Williams, E. J. (2016). Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy, 48(7), 657-683. https://doi.org/10.1055/s-0042-108641