Antegrade Wire, Rendezvous Cannulation of the Biliary Tree May Reduce the Incidence of Post-ERCP Pancreatitis

Ryan M Juza, MD, Randy S Haluck, MD, Ann M Rogers, MD, Jerome R LynSue, MD, Eric M Pauli, MD. Penn State Milton S. Hershey Medical Center.

Introduction: Post-procedural pancreatitis (PPP) is a common serious complication of therapeutic and diagnostic endoscopic retrograde cholangiopancreatography (ERCP) with a reported incidence of up to 10%. Multiple cannulation attempts, as well as mechanical trauma and injection of the pancreatic duct are causative factors for the development of PPP. Preventative strategies for PPP minimize these events. To efficiently access the biliary tree and minimize inadvertent trauma to the pancreatic duct, we have begun utilizing an Antegrade Wire, Rendezvous Cannulation (AWRC) technique in patients undergoing laparoscopic cholecystectomy (LC) with an indication for ERCP.

Methods: Eight patients underwent AWRC during LC in the setting of acute cholecystitis and choledocholithiasis with or without preoperative biliary pancreatitis. Informed consent was obtained for both procedures (LC and ERCP) pre-operatively. Under general anesthesia in supine position, patients underwent standard 4 port LC with routine intraoperative cholangiography. Following confirmation of a biliary filling defect not able to be cleared with flush and glucagon administration, a 0.035” 450cm flexible tip guidewire was inserted in an antegrade fashion through the cystic ductotomy into the common bile duct, through the duodenal papilla and into the duodenum. A therapeutic duodenoscope (TJF-160VR , Olympus, Center Valley, PA) was then inserted and advanced until the duodenal papilla and wire were identified. A standard polypectomy snare was used to grasp the guidewire and withdraw it through the accessory channel of the duodenoscope. Over this guidewire a biliary sphincterotome was backloaded and the biliary tree directly cannulated. The antegrade wire was subsequently removed and a new 0.035” 260cm flexible tip guidewire was positioned retrograde beyond the hepatic duct bifurcation. Subsequent retrograde cholangiography, biliary sphincterotomy, balloon extraction of choledocholithiasis and stent insertion were performed as indicated using a short-wire ERCP method. The LC was completed in standard fashion.

Results: Eight patients (2M:6F), age range 20-74, underwent intraoperative ERCP with stone extraction utilizing an AWRC technique during LC. Two patients had their ERCP performed via a transgastric route because of a previous history of Roux-en-Y gastric bypass. Average operative time for all patients was 208 min with a range of 107-295min. Median length of stay was 2.5 days with a range of 1-12days. There were no wire cannulations or injections of the pancreatic duct. There were no intra-operative or postoperative complications and no patients developed PPP. One patient with severe biliary pancreatitis preoperatively had no evidence of worsening pancreatitis postoperatively. She had gradual resolution of her symptoms with supportive care. There were no hospital readmissions and all patients had uncomplicated outpatient biliary stent removal.

Conclusion: AWRC is a novel technique for efficient cannulation of the biliary tree for therapeutic ERCP in the setting of choledocholithiasis at the time of LC. Our report demonstrates good results with this technique with no identified PPP in eight consecutive patients. Although this represents a small case series, we believe the AWRC technique holds merit for reducing the incidence of PPP following therapeutic ERCP.

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