Background During endoscopic retrograde cholangiopancreatography (ERCP), access to the common bile duct (CBD) can be problematic after unintentional insertion of the guidewire into the pancreatic duct. We conducted a prospective, randomized study in order to compare biliary cannulation success rates of early double-guidewire (EDG) and repeated single-guidewire (RSG) techniques in patients with inadvertent passage of the guidewire into the pancreatic duct. Methods Patients with a native papilla were randomly assigned to either the EDG or RSG groups after unintentional insertion of the guidewire into the pancreatic duct. The primary outcome was successful selective CBD cannulation within 10 minutes. The secondary outcomes were successful final selective bile duct cannulation, time to bile duct cannulation, and frequency of post-ERCP pancreatitis (PEP). Results 142 patients were randomized and selective bile duct cannulation was achieved in 57/68 patients (84%) in the EDG group and in 37/74 patients (50%) in the RSG group within 10 minutes (relative risk 1.34; 95% confidence interval 1.08-6.18; P <0.001). The overall final selective bile duct cannulation rate was 99.3%. The time to access the CBD was shorter using the EDG technique (6.0 vs. 10.4 minutes; P =0.002). Mild PEP was not observed more frequently in the EDG group than in the RSG group. Conclusion The EDG technique significantly increased the success rate of biliary duct cannulation within 10 minutes compared with an RSG approach.

Auteur(s) : Leila Kanafi1, Catherine Tauzin2, Barbara Bonnefoy1, Ramuntxo Arotcarena1, Philippe Berthelemy1, Alexandre Pariente1 1Unite d’hepatogastroenterologie, centre hospitalier de Pau, boulevard Hauterive, 64046 Pau cedex, France 2Service d’imagerie medicale, centre hospitalier de Pau, boulevard Hauterive, 64046 Pau cedex, France La periode d’attente de la transplantation hepatique est souvent fertile en complications, parfois generatrices de difficultes diagnostiques [...]

Introduction: Self-expandable metal stent (SEMS) are used to treat malignant colorectal obstruction (MCRO). SEMS may be used as bridge to surgery or as a palliative treatment. This study aims to evaluate the use of SEMS for MCRO in a single university endoscopic practice center. Aims and Methods: A total of 135 colorectal SEMS were inserted during a 6 years period (July 2001 to February 2008). This retrospective study was realised in a single university hospital center with three senior gastroenterology and four trainees. The included patients presented MCRO with differents clinics symptoms: total or partial obstructive syndrome, others symptoms. The outcome measures where the technical and clinical success and possible differences according to several groups of patients (peritoneal carcinosis; indications; clinical symptoms; using fluoroscopy or not to control the insertion of the stent, length of the stenosis, endoscopic features). Results: Median patients age was 78 years (27 to 98 years). 60% were men and 40% women. The median length of the stenosis was 5 cm. The site of obstruction was: the rectum in 21%, rectosigmoid in 61%, splenic flexure in 6%, transverse in 6%, right colon in 6%. Successful placement was achieved in 123 patients (91,1%) and colonic decompression was achieved in 118 patients (87,4%). SEMS was inserted as a bridge to surgery in 31% and as a palliative treatment in 69%. There where no difference when the stent was inserted before surgery (89%) or as a palliative treatment (90%). The median delay before surgery was 7.5 days. There was differences between several sub-group, clinical success was: 67% for patients with peritoneal carcinosis, 78,9% for patients with complete obstructive symptoms; 89,3% with partial obstructive symptoms. The stent was inserted by endoscopy alone in 66,7% and 33,3% by endoscopy with control by fluoroscopy. Clinical success for the group who had the stent inserted by endoscopy with a fluoroscopic control in 93,2% And with endoscopic control alone in 84,1%The major complication was perforation in 4 patients (4%) and lead to death in 2 patients (1,6%). There where less severe complications in 16%. Median survival after the stent placement was 69 days (one day to 3 years). Conclusions: SEMS placement and colonic decompression in MCRO is safe and effective without serious complications. It appears that SEMS are more effective in patient without peritoneal carcinosis and symptomatic partial colonic obstruction and when it is inserted by endoscopy with a fluoroscopic control.