Advances in Biliary Access
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ENDOSCOPY AND SURGERY (S KOMANDURI, SECTION EDITOR)
Advances in Biliary Access Abdul H. El Chafic 1 & Janak N. Shah 1 Accepted: 16 October 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose of Review Bile duct cannulation using conventional techniques fails in up to 16% of endoscopic retrograde cholangiopancreatography (ERCP) procedures. Advanced techniques to gain biliary access include ERCP-based maneuvers, and newer endoscopic ultrasound (EUS)–guided interventions. In this article, we review the evidence supporting the use of various ERCP and EUS techniques for biliary access, as well as studies comparing these different techniques. Recent Findings In comparative studies, biliary access after failed conventional cannulation was more successful with EUSrendezvous compared to precut papillotomy. EUS-guided drainage compares favorably with percutaneous drainage with respect to clinical success, safety profile, and cost-efficiency. Recent randomized trials comparing EUS to ERCP drainage in malignant obstruction have found similar success rates between these techniques. Summary EUS-guided techniques compare favorably to ERCP-based methods for biliary access and drainage. The advent of newer technologies to facilitate interventional EUS may further change current treatment approaches. Keywords Endoscopic retrograde cholangiopancreatography (ERCP) . Endoscopic ultrasound (EUS) . Biliary access . Bile duct cannulation . Biliary drainage
Introduction
Advanced ERCP Biliary Access Techniques
Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice for minimally invasive treatment of bile duct disorders. Deep biliary access is the first and key component of successful ERCP. Standard techniques for bile duct access usually include attempts using a cannula or papillotome, with or without a wire. Unfortunately, bile duct cannulation using these conventional techniques fails in up to 16%, even in expert hands. [1–3] Difficult cannulation can be defined as the inability to achieve selective biliary cannulation by these standard ERCP techniques within 10 min or up to 5 cannulation attempts. [4] In such cases, endoscopists should consider the use of advanced techniques to facilitate successful endobiliary therapy. These advanced techniques include ERCP-based maneuvers, and newer EUS-guided interventions.
Commonly used, ERCP-based, advanced access techniques include the use of pancreatic guidewire-assisted cannulation and precut techniques. The specific choice of the next-line modality for biliary access when standard cannulation fails is highly dependent on the endoscopist’s preference, level of training, and personal expertise. However, with the popularity of wire-based standard cannulation techniques, the pancreatic duct is often inadvertently accessed during cannulation attempts. In such cases, the pancreatic guidewire-assisted technique is likely the most commonly used advanced technique given its simplicity and the ability to immediately place a pancreatic
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