Endoscopic salvage therapy after failed biliary cannulation using advanced techniques: A concise review

Abstract

Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) begins with successful biliary cannulation. However, it is not always be successful. The failure of the initial ERCP is attributed to two main aspects: the papilla/biliary orifice is endoscopically accessible, or it is inaccessible. When the papilla/biliary orifice is accessible, bile duct cannulation failure can occur even with advanced cannulation techniques, including double guidewire techniques, transpancreatic sphincterotomy, needle-knife precut papillotomy, or fistulotomy. There is currently no consensus on the next steps of treatment in this setting. Therefore, this review aims to propose and discuss potential endoscopic options for patients who have failed ERCP due to difficult bile duct cannulation. These options include interval ERCP, percutaneous-transhepatic-endoscopic rendezvous procedures (PTE-RV), and endoscopic ultrasound-assisted rendezvous procedures (EUS-RV). The overall success rate for interval ERCP was 76.3% (68%-79% between studies), and the overall adverse event rate was 7.5% (0-15.9% between studies). The overall success rate for PTE-RV was 88.7% (80.4%-100% between studies), and the overall adverse event rate was 13.2% (4.9%-19.2% between studies). For EUS-RV, the overall success rate was 82%-86.1%, and the overall adverse event rate was 13%-15.6%. Because interval ERCP has an acceptably high success rate and lower adverse event rate and does not require additional expertise, facilities, or other specialists, it can be considered the first choice for salvage therapy. EUS-RV can also be considered if local experts are available. For patients in urgent need of biliary drainage, PTE-RV should be considered.

Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the clinical presentation and outcomes?

“…First, MBO is frequently associated with anatomical alterations, and this leads to a lower success rate of ERCP, as shown in this study[ 17 ]. Patients who fail ERCP require salvage therapy to relieve bile duct obstruction, thereby prolonging LOHS[ 20 ]. Second, following ERCP, MBO patients may require additional treatment for the underlying disease.…”

Impact of papillary morphology and diverticular type on needle-knife precut sphincterotomy in patients with periampullary diverticulum with difficult biliary cannulation

“…For patients encountering di culty with conventional cannulation methods due to PAD, guidelines propose precut sphincterotomy as an alternative cannulation technique 9 . However, needle-knife precut sphincterotomy (NKPS), which includes needle-knife papillotomy (NKP) and needle-knife stulotomy (NFK), does not consistently achieve SBC 10,11 . Our previous study indicated a signi cant association between PAD and NKP failure in univariate analysis, although not in multivariate analysis 12 .…”

Predictive factors of failure of main bile duct cannulation during endoscopic treatment of biliary lithiasis: about 498 cases

“…In univariate analysis, we identified eleven predictive factors for failure of CBD catheterization: age>65 years (p=0.001), cytolysis (p=0.011), elevated alkaline phosphatase levels (p=0.029), hyperbilirubinemia (p=0.007), small papilla (p<0.001), protruding papilla (p<0.001), hidden papilla (p<0.001), difficult orientation of the papilla (p<0.001), intradiverticular papilla (p=0.047), difficult CBD cannulation as defined by the European Society of Gastrointestinal Endoscopy (ESGE) criteria (5-5-1) (p<0,001) and the use of advanced catheterization techniques (p<0.001). On multivariate analysis, four factors were found to be predictive of failed cannulation : small papilla (p=0.032, OR=6 ), hidden papilla (p=0.005, OR=13,1), difficult orientation of the papilla (p=0.01, OR=13,3), and the use of advanced catheterization techniques (p<0.001, OR=12,7) 1 2 3 4 .…”