Clinical usefulness of double‐guidewire technique for difficult biliary cannulation in endoscopic retrograde cholangiopancreatography

Background and Aim Although biliary cannulation with pancreatic guidewire placement ( P ‐ GW ) is useful for difficult cases in endoscopic retrograde cholangiopancreatography ( ERCP ), the clinical significance of wire‐guided cannulation with P ‐ GW (double‐guidewire technique: DGT ) has not been clarified. The aim of the present study was to evaluate the usefulness of DGT for difficult biliary cannulation after unsuccessful biliary cannulation using a cannula/sphincterotome under guidance of injected contrast with P ‐ GW (single‐guidewire technique: SGT ). Methods One‐hundred and forty‐six patients with difficult biliary cannulation who underwent SGT were included in this retrospective study. DGT was carried out if SGT was unsuccessful. Pancreatic duct ( PD ) stenting was attempted to prevent post‐ ERCP pancreatitis ( PEP ) in all patients. The success rate of cannulation and the risk factors for PEP were investigated. Results Biliary cannulation with SGT was achieved in 70%. DGT was carried out in 25 patients with unsuccessful SGT , biliarycannulation being successful in 72%. Of the 13 patients who underwent precut sphincterotomy, biliary cannulation was achieved in 46%. The incidence of PEP in patients who had undergone SGT , DGT , and precut sphincterotomy was 8% (12: mild, 8; moderate, 3; severe, 1), 4% (mild, 1), and 0%, respectively. PD stenting was successfully carried out in 86%. Multivariate analysis revealed unsuccessful PD stenting to be the only risk factor for PEP ( OR 8.3, 95% CI 2.3–30). Conclusions DGT may replace SGT or become the salvage procedure in cases of unsuccessful SGT as a result of its high success rate with an acceptable incidence of PEP . Failed pancreatic duct stenting in these techniques was frequently associated with PEP .