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Dr. Nishino is currently working as gastroenterologist at Southern TOHOKU General Hospital. Dr. Nishino graduated Jichi Medical University in 1987. He then worked at Southern TOHOKU General Hospital as director of gastroenterology. He has authored several publications in various journals and books. His publications reflect his research interests in pancreaticobiliary disease and diagnosis by Abdominal xerography. Dr. Nishino is serving as a fellow in The Japanese Society of Gastroenterology, Japan Gastroenterological Endoscopy Society, The Japanese Biliary Association.
ERCP requires delicate and sophisticated manipulation to perform, moreover secure and fair procedure without complication of pancreatitis. Our mission to lead ERCP is to perform perfectly. Although there is no answer to make it possible yet.
Now wire guided cannulation (WGC) is the current standard strategy to perform ERCP. However WGC could not even make it possible, it is a blind technique, the rates of successful access to bile duct (BD) estimate up to 90-95% on some Randomized studies. The difficult cases of ERCP as rest 5-10% still remained unknown.
We evaluate the cause of difficulty to access BD. We here present the superiority of contrast-assisted cannulation (CAC). Visualized images of the intra-ampullary anatomy reveal the causes for any difficulties to access BD.
In our hospital, we perform every ERCP with CAC, and evaluate accessibility to the BD inspiring both ampullary morphology and intra-ampullary biliary anatomy. We are able to observe unusual pathways, and we demonstrate how to access the BD using an original ‘sawing technique’, which refers to delicate and progressive manipulation using a catheter only, without a guide wire (GW). Co-ordinated manipulation of a scope with a catheter could make passing through unusual bifurcations and difficult angles possible.
Out of a total of 4039 cases over a 13-year period in our facility, 2177 were naïve papilla. The success rate in accessing the BD was 97.9%, and 1.6% of the naïve papilla cases had post-ERCP pancreatitis. In the naïve papilla cases, we evaluated the difficulty of cannulation, taking three factors into consideration. First is whether the papilla has an ovoid appearance similar in shape to a ‘long nose’. Second is the angle; whether the intra-ampullary BD rises perpendicularly from the pancreatic duct. The final factor is the presence or absence of tiny cysts within the papilla.
This article is not basic and foundamental but essential and universal. The anatomy of intra-ampulla has many variations; therefore, we have to respond flexibly to adapt to these variations. Contrast medium will always visualize all possible routes to the BD; however, it can be difficult to follow these routes. Therefore, CAC is a superior strategy to WGC in terms of safety and reliability when performing ERCP.