Duodenal major papilla morphology can affect biliary cannulation and complications during ERCP, an observational study

Abstract

Background We investigated whether duodenal major papilla morphology could be a risk factor for failure of selective biliary cannulation (SBC) and post endoscopic retrograde cholangiography and pancreatography (ERCP) complications.Method A prospectively recorded database was reviewed retrospectively. Patients were included if they received therapeutic ERCP and had naïve major duodenal papilla. We used Haraldsson’s classification for papilla morphology, as follows: Regular (Type 1), Small (Type 2), Protruding or Pendulous (Type 3) and Creased or Ridged (Type 4). Risk factors for failing SBC and post-ERCP complications were analyzed by multivariate analysis.Results A total of 286 cases were included. Age, gender, indications and therapeutic procedures were not different among the four types of papillae. The failure rates of SBC with Type 3 papilla and Type 4 papilla were 11.11% and 6.25%, respectively. In the multivariate analysis, Type 2 papilla (odd ratio 7.18, p= 0.045) and Type 3 papilla (odd ratio 7.44, p= 0.016) were associated with greater SBC failure compared with Type 1 papilla. Malignant obstruction compared to stone (odds ratio 4.45, p=0.014) and age (odd ratio=1.06, p=0.010) were also risk factors for cannulation failure. Type 2 papilla was correlated with a higher rate of post-ERCP pancreatitis (20%, p=0.020) compared to the other types of papilla However, papilla morphology was not a significant risk factor for any complications in the multivariate analysis.Conclusion Small papilla and protruding or pendulous papilla are more difficult to cannulate compared to regular papilla. Small papilla is associated with a higher rate of post-ERCP pancreatitis.

Second endoscopic retrograde cholangiopancreatography after failure of initial biliary cannulation: A single institution retrospective experience

“…In the present retrospective study, all of the ERCP procedures were performed by one experienced endoscopist, which may limit possible confounding factors resulting from the varying skill of the operators. However, patient factors, including abnormal duodenal papilla, twisting or stenosis of the distal bile duct, fast bowel motility, intradivertiucular or peridiverticular papilla and surgically altered anatomy, usually directly increase the operating difficulty, which may result in a decreased success rate (5)(6)(7)18,38). The present study found that preoperative normal serum bilirubin level was a risk factor that correlated with failure in a second ERCP (OR= 6.702, P= 0.034) by multivariate analysis.…”

“…'Expert endoscopist' was defined as one having performed >1,000 ERCPs during their career and who could perform procedures equivalent to Grade 3 of the grading scale for the difficulty of ERCP, based on the ERCP core curriculum, without assistance (17)(18)(19)(20).…”

Salvage Techniques for Difficult Biliary Cannulation: A Retrospective Study of 1021 Endoscopic Retrograde Cholangiopancreatography Cases in a Tertiary Referral Center

“…Many studies have reported the results of individual salvage techniques such as pre-cuts or compared 2 or 3 techniques in a limited small number of patients [5,[11][12][13][14][15][16][17][18][19][20]. There are also several studies analyzing the di cult factors of biliary cannulation [21][22][23][24][25]. On the other hand, no reports have clearly shown the stream of the procedure based on a particular strategy, which cases were di cult, and which salvage techniques were used successfully or not in all the patients.…”

“…Several studies reported success rates and adverse events of each technique, although the analysis of all reports extracted only cases in which each salvage technique was performed [5,[11][12][13][14][15][16][17][18][19][20]. On the other hand, several articles have reported the factors that make biliary cannulation di cult in ERCP [21][22][23][24][25]. However, few of them have described how di cult cases were addressed using salvage techniques.…”

Difficult Biliary Cannulation in Endoscopic Retrograde Cholangiopancreatography: Definitions, Risk Factors, and Implications

“…53 Small papillae are often more difficult to identify (discussed further below), especially when there is significant duodenal oedema, inflammation, or redundant mucosal folds, and thereafter cannulate. 54 A small papilla increases the odds of the sphincterotome coming in contact with the septum instead of insertion into the bile duct, especially if highly compressible, and may make it more difficult to make adjustments to the position of the sphincterotome without losing contact with the papilla. On the other hand, a large papilla may be more relaxed and floppy, providing less stability during cannulation.…”