Early use of double-guidewire technique to facilitate selective bile duct cannulation: the multicenter randomized controlled EDUCATION trial.

Background and study aims: There are no guidelines for the timing of conversion from a singleguidewire to a double-guidewire technique to facilitate selective bile duct cannulation and reduce post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), when using wireguided cannulation. We investigated whether early conversion to the double-guidewire method, at first unintentional insertion of a guidewire into the pancreatic duct, facilitated selective bile duct cannulation and reduced PEP compared with repeated single-guidewire attempts. Patients and methods: A multicenter prospective randomized controlled trial included 274 patients with a naive papilla, undergoing endoscopic retrograde cholangiography (ERC) using wireguided cannulation in whom there was unintentional insertion of the guidewire into the pancreatic duct. With the guidewire still in the duct, patients were randomly assigned to undergo the double-guidewire technique or repeated singlewire cannulation. Main outcomes were success rates for selective bile duct cannulation and PEP frequency. Results: Success rates for selective bile duct cannulation within 10 attempts and 10 minutes were 75% and 70%, respectively, for the early double- guidewire (EDG) and repeated single-guidewire (RSG) cannulation groups (relative rate 1.07, 95% confidence interval [95 %CI] 0.93-1.24, P= 0.42). Corresponding final selective bile duct cannulation rates were 98% and 97% (relative rate 1.01, 95%CI 0.97-1.05, P=1.00). PEP rates were 20% and 17%, respectively, for the EDG and RSG cannulation groups (relative risk 1.17, 95%CI 0.71-1.94, P=0.53). Double-guidewire cannulation was more effective in patients with malignant biliary stricture (relative rate 1.36, 95%CI 1.05-1.77, P=0.02). Conclusions: During therapeutic ERC using wire guided cannulation, converting to a double-guidewire technique neither facilitated selective bile duct cannulation nor decreased PEP incidence compared with repeated use of a single-wire technique. [ABSTRACT FROM AUTHOR]