Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist

Transpancreatic Sphincterotomy After Double Guidewire Technique Was Noninferior to Primary Transpancreatic Sphincterotomy in Difficult Biliary Cannulation

BACKGROUND

When unintentional pancreatic duct access occurs during difficult biliary cannulation, the double guidewire (DGW) or transpancreatic sphincterotomy (TPS) may be utilized. DGW can be easily switched to TPS due to the existing guidewire in the pancreatic duct. However, the efficacy of TPS after DGW, named sequential DGW-TPS technique, versus primary TPS has not been assessed.

AIMS

Our aim was to compare the benefits and adverse events of sequential DGW-TPS technique and primary TPS.

METHODS

We performed a comparative retrospective cohort study that enrolled a total of 117 patients with native papillae. The patients were divided into one of 2 groups according to the primary bile duct access technique (sequential DGW-TPS or primary TPS), both with pancreatic stenting.

RESULTS

Between November 2017 and May 2023, a total of 84 patients were grouped into sequential DGW-TPS and 33 into primary TPS. The overall post-ERCP pancreatitis (PEP) rate was 4.3% in the entire cohort, with no statistical differences were observed between the groups in terms of PEP rates (P = 0.927), PEP severity (P = 1.000), first biliary cannulation success (P = 0.621), overall cannulation success (P = 1.000), hyperamylasemia incidence (P = 0.241), elevated amylase levels (P = 0.881), and postoperative hospital stay (P = 0.185). Furthermore, these results remained consistent in multivariable regression analysis.

CONCLUSIONS

The sequential DGW-TPS technique showed a comparable safety and biliary cannulation success rate to primary TPS in difficult biliary cannulation. Given the potential long-term complications associated with TPS, DGW should be first if inadvertent pancreatic access occurs, with TPS serving as second only if DGW fails.

Morphology of the papilla can predict procedural safety and efficacy of ERCP-a systematic review and meta-analysis

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary therapeutic procedure for pancreaticobiliary disorders, and studies highlighted the impact of papilla anatomy on its efficacy and safety. Our objective was to quantify the influence of papilla morphology on ERCP outcomes. We systematically searched three medical databases in September 2022, focusing on studies detailing the cannulation process or the rate of adverse events in the context of papilla morphology. The Haraldsson classification served as the primary system for papilla morphology, and a pooled event rate with a 95% confidence interval was calculated as the effect size measure. Out of 17 eligible studies, 14 were included in the quantitative synthesis. In studies using the Haraldsson classification, the rate of difficult cannulation was the lowest in type I papilla (26%), while the highest one was observed in the case of type IV papilla (41%). For post-ERCP pancreatitis, the event rate was the highest in type II papilla (11%) and the lowest in type I and III papilla (6-6%). No significant difference was observed in the cannulation failure and post-ERCP bleeding event rates between the papilla types. In conclusion, certain papilla morphologies are associated with a higher rate of difficult cannulation and post-ERCP pancreatitis.

Analysis of the Effectiveness of Second Attempt Endoscopic Retrograde Cholangiopancreatography (ERCP) 24 Hours (Second Day) After Primary Failure

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive intervention that has established itself as the gold standard therapeutic option for various pancreaticobiliary conditions. Deep cannulation of the common bile duct (CBD) is essential in ERCP. However, cannulation is not possible in approximately 20% of the cases with the usual techniques even when performed by highly trained professionals or at major healthcare institutions. In case of failure on the first attempt, alternative choices include redoing the procedure (on the second attempt) or moving on to more proficient endoscopic methods such as endoscopic ultrasound (EUS) or radiology-aided techniques (rendezvous procedures), totally percutaneous approaches, or surgical treatments.

OBJECTIVE

To analyze the effectiveness of the second attempt ERCP 24 hours (second day) after primary failure.

METHODOLOGY

This analytical study was conducted to check the outcomes of second attempt ERCP in patients with prior failed cannulation, from June 20, 2023, to November 20, 2023, at the Department of Gastroenterology, Lady Reading Hospital, Peshawar. Patients of either sex, aged >16 years with failed biliary cannulation, and who were otherwise clinically stable were included in the study. Patients with surgically modified anatomy, an unidentified main duodenal papilla, or a history of sphincterotomy at another setup were excluded. Outcomes were assessed in terms of gaining deep biliary access (cannulation) using a therapeutic duodenoscope and endoscopy system supported by a fluoroscope while using a wire-guided sphincterotome. Factors linked to second ERCP cannulation success or failure were analyzed using SPSS version 24.

RESULTS

Ninety-four patients were enrolled including 61 (64.9%) males and 33 (35.10%) females. The mean age of the participants was 39.01±14.831 years. The most common indication for the intervention was CBD stones, which were present in 70 (74.5%) patients. Successful cannulation on the second attempt was achieved in 72 (76.6%) patients. Experienced endoscopists achieved a greater proportion of successful cannulation (86.8%) compared to 33.3% by endoscopists with lower experience (p-value: <0.001). Logistic regression analysis was conducted to predict the outcomes (cannulation), which revealed an odds ratio for endoscopist experience of 33.604 (95% confidence interval: 6.948-162.52).

CONCLUSION

A second ERCP attempt 24 hours after the primary failed attempt appears to be the best course of action for the majority of clinically stable patients.

Risk factors for post‑retrograde cholangiopancreatography pancreatitis in patients with common bile duct stones: A meta‑analysis

Endoscopic retrograde cholangiopancreatography (ERCP) has become a common treatment method for common bile duct stones. However, ERCP is also associated with a high risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Identification of risk factors is essential for reducing the incidence of PEP. The present study aimed to summarize the risk factors for PEP by performing a meta-analysis. Therefore, studies published between 2000 and 2022 were screened in PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang Digital Periodicals and the Weipu Database, with no language restrictions. Newcastle-Ottawa Scale was used to assess the quality of the included studies. Stata 17.0 software was utilized for the meta-analysis of 14 possible risk factors. Overall, 15 high-quality studies were included into the present meta-analysis. The results showed that female [odds ratio (OR), 1.42; 95% CI, 1.23-1.64), age <60 years (OR, 1.53; 95% CI, 1.06-2.21), difficult intubation (OR, 4.87; 95% CI, 2.73-8.68), ≥3 cannulation attempts (OR, 9.64; 95% CI, 4.16-22.35), cannulation time ≥10 min (OR, 2.37; 95% CI, 1.67-3.35), history of pancreatitis (OR, 2.95; 95% CI, 1.06-5.51), pancreatic duct visualization (OR, 3.63; 95% CI, 2.47-5.34) and sphincter of Oddi dysfunction (OR, 5.72; 95% CI, 1.80-18.24) are potential risk factors for PEP (P<0.05). In conclusion, the present meta-analysis suggests that PEP can be affected by several risk factors, particularly the technique-related factors such as the frequency and time of cannulation. Therefore, effective precautions should be taken as early as possible to reduce the incidence of PEP.

The volume of ERCP per endoscopist is associated with a higher technical success and a lower post-ERCP pancreatitis rate. A prospective analysis

INTRODUCTION

conflicting results have been reported regarding the influence of the annual volume of endoscopic retrograde cholangiopancreatography (ERCP) on outcome.

OBJECTIVE

to evaluate the influence of case volume on ERCP outcomes.

PATIENTS AND METHODS

an analysis of a prospective database was performed, comparing the outcomes of ERCP in three consecutive periods defined by the number of endoscopists performing ERCP: five endoscopists in period I (P1), four in period II (P2) and three in period III (P3). Only patients with biliary ERCP in accessible and naïve papilla were included. Primary variables were cannulation rates and adverse effects (AE). The American Society of Gastrointestinal Endoscopy (ASGE) complexity grades III and IV were considered as highly complex procedures.

RESULTS

a total of 2,561 patients were included: 727 (P1), 972 (P2) and 862 (P3). There were no differences in age and sex between groups (p > 0.05). The cannulation rate was significantly higher in P2 and P3: 92.4 % vs 93.3 % vs 93 % (p = 0.037). The AE rate was 13.8 %, 12.6 % and 10.3 % (p > 0.05), respectively. The rate of post-ERCP pancreatitis was significantly lower in P3: 8.5 %, 7.3 % and 5 % (p = 0.01). The rate of complex procedures was 12 %, 14.8 % and 27 % (p < 0.0001), respectively. Two endoscopists participated in all periods and only one had significantly improved outcomes. Cannulation and post-ERCP pancreatitis rates remained significantly better in P3 after adjusting for sex, complexity and endoscopist.

CONCLUSION

a higher annual volume of ERCP per endoscopist was associated with a higher rate of cannulation and a lower rate of post-ERCP pancreatitis, despite the greater complexity of the procedures. These beneficial effects seem to differ between endoscopists.

The Relation between Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis and Different Cannulation Techniques: The Experience of a High-Volume Center from North-Eastern Romania

BACKGROUND

Despite numerous advances that have aimed to increase the safety of endoscopic retrograde cholangiopancreatography (ERCP), post-ERCP pancreatitis (PEP) still remains a major issue. We aimed to assess the rate of PEP as well as the relation to the cannulation techniques in our unit, a high-volume center in north-eastern Romania.

METHODS

ERCPs performed in our unit from March to August 2022 were retrospectively included. Data concerning demographic information, presence of difficult cannulation, the technique used for cannulation, as well as immediate complications, were gathered from the electronic database.

RESULTS

233 ERCPs were included. PEP was diagnosed in 23 (9.9%) of cases. Precut sphincterotomy (PS), transpancreatic sphincterotomy (TPBS), and a combination of TPBS and PS were performed in 6.4%, 10.3%, and 1.7% of cases, respectively, while an Erlangen precut papillotomy was performed in one case. Both in patients with PS and TPBS the rate of PEP was 20%. When the two techniques were associated, the rate of PEP was 25%. TPBS and PS represented risk factors for PEP (OR 1.211 for a CI of 0.946-1.551, p = 0.041, and OR 1.124 for a CI of 0.928-1.361, p = 0.088, respectively). No PEP-associated deaths were found.

CONCLUSIONS

Both PS and TPBS presented a similar risk of PEP.

Association between type of major duodenal papilla and difficult biliary cannulation at first endoscopic retrograde cholangiopancreatography in adults: a cross-sectional study with bootstrap method

Background

The type of major duodenal papilla could be associated with difficult biliary cannulation at first endoscopic retrograde cholangiopancreatography (ERCP) in adults.

Methods

This retrospective cross-sectional study included patients undergoing ERCP for the first time by an expert endoscopist. We defined the type of papilla according to the endoscopic classification of Haraldsson in type 1-4. The outcome of interest was difficult biliary cannulation, defined according to the European Society of Gastroenterology. To assess the association of interest, we calculated crude and adjusted prevalence ratios (PRc and PRa, respectively) and their respective 95% confidence intervals (CI) using Poisson regression with robust variance models, employing bootstrap methods. For the adjusted model we included the variables age, sex, and indication for ERCP, according to an epidemiological approach.

Results

We included 230 patients. The most frequent type of papilla was type 1 (43.5%), and 101 (43.9%) of the patients presented difficult biliary cannulation. The results were consistent between the crude and adjusted analyses. After adjusting for age, sex, and ERCP indication, the prevalence of difficult biliary cannulation was highest in patients with papilla type 3 (PRa 3.66, 95%CI 2.49-5.84), followed by patients with papilla type 4 (PRa 3.21, 95%CI 1.82-5.75), and patients with papilla type 2 (PRa 1.95, 95%CI 1.15-3.20) compared to patients with papilla type 1.

Conclusion

In adults undergoing ERCP for the first time, patients with papilla type 3 had a greater prevalence of difficult biliary cannulation than patients with papilla type 1.

Is percutaneous drainage better than endoscopic drainage in the management of patients with malignant obstructive jaundice? A meta-analysis of RCTs

To compare the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangial drainage (PTCD) in the treatment of malignant obstructive jaundice, a systematic review and meta-analysis of published studies was undertaken to assess the differences between the two procedures in terms of efficacy and safety. From November 2000 to November 2022, the Embase, PubMed, MEDLINE, and Cochrane databases were searched for randomized controlled trials (RCTs) on the treatment of malignant obstructive jaundice with ERCP or PTCD. Two investigators independently assessed the quality of the included studies and extracted the data. Six RCTs, including 407 patients, were included. The results of the meta-analysis showed that the overall technical success rate in the ERCP group was significantly lower than that in the PTCD group (Z=3.19, P=0.001, OR=0.31 (95% CI: 0.15-0.64)), but with a higher overall procedure-related complication incidence rate (Z=2.57, P=0.01, OR=0.55 (95% CI: 0.34-0.87)). The incidence of procedure-related pancreatitis in the ERCP group was higher than that in the PTCD group (Z=2.80, P=0.005, OR=5.29 (95% CI: 1.65-16.97)), and the differences were statistically significant. No significant difference was observed between the two groups when the clinical efficacy, postoperative cholangitis, and bleeding rate were compared.Both treatments for malignant obstructive jaundice were efficacious and safe. However, the PTCD group had a greater technique success rate and a lower incidence of postoperative pancreatitis.The present meta-analysis has been registered in PROSPERO.

Correlation between Pancreatic Duct Variation and Related Diseases: An Effective Method Observing the Dual-Energy CT with Low-keV Monoenergetic Images

PURPOSE

Pancreatic duct variation can affect the secretory function of the pancreas. We aimed to explore the pancreatic duct variation, observed using low-keV monoenergetic images [MEI (+)] of dual-energy CT (DECT), and its relationship with related diseases. We further sought to compare pancreatic duct imaging using low-keV MEI (+) of DECT and magnetic resonance cholangiopancreatography (MRCP).

MATERIALS AND METHODS

The DECT and MRCP images of 854 patients were evaluated retrospectively. The 808 patients' pancreatic duct types were classified according to the anatomy and the opening of the pancreatic ducts, and the correlation with related diseases was analyzed. The DECT and MRCP images of 852 patients were graded according to the sharpness of the pancreatic ducts for evaluation.

RESULTS

A higher prevalence of acute pancreatitis (AP), chronic pancreatitis (CP), and duodenal papillary carcinoma (DPC) was observed in the variant group. Of the 27 AP cases in the variant group, 9 patients (33.3%) were Type 3c. Additionally, Type 4a was significantly correlated with AP and CP (p < 0.05). Low-keV MEI (+) of DECT outperformed the MRCP images in the sharpness of the pancreatic ducts in 852 patients.

CONCLUSIONS

Pancreatic duct variation is associated with AP, CP, and DPC. Low-keV MEI (+) DECT is an effective method to observe the pancreatic duct system.

Propensity score-matched analysis of physician-controlled wire-guided cannulation as an effective technique against difficult cannulation in endoscopic retrograde cholangiopancreatography: A retrospective study

BACKGROUND

Advanced endoscopic retrograde cholangiopancreatography (ERCP) cannulation strategies for difficult cases could replace conventional techniques, in which assistants control guidewires. We aimed to compare the safety and efficacy of a new salvage cannulation strategy, physician-controlled wire-guided cannulation (PCWGC), with those of a conventional strategy.

METHODS

This retrospective study included patients with naïve papillae who underwent ERCP between January 2018 and December 2020. Patients, divided into two groups, received initial cannulation using a conventional catheter. After failed cannulation, the second attempt used PCWGC and double-guidewire technique (DGT) in the new and conventional strategy groups, respectively. Propensity score-matching (PSM) analysis compared outcomes between groups. Primary outcome included overall success rate, while secondary outcomes included cannulation time, adverse events, and cannulation difficulty subgroup analysis.

RESULTS

The new strategy group comprised 255 (47.6%) of 536 patients who underwent ERCP. The total cannulation success rate was 98.4% (vs. 97.2%, p = 0.318), with similar post-ERCP pancreatitis (PEP) (1.8% vs. 2.4%, p = 0.64) rates. Following 1:1 PSM, 219/438 patients were allocated to both the conventional and new strategy groups, and 46 patients from the difficult cannulation subgroup were distributed evenly among groups. No difference in overall cannulation success rate existed between the groups before (97.2% vs. 98.4%) and after PSM (96.8% vs. 98.2%). The primary cannulation success rate was higher in the conventional strategy group, while the secondary cannulation success rate was higher in the new strategy group. However, the difficult cannulation subgroup PSM results showed that only the salvage cannulation success rate was significant (9/23, 39.1% vs. 18/23, 78.3%, p = 0.007). In the difficult cannulation subgroup, the salvage cannulation success rate for PCWGC was four times higher than DGT (95% confidence interval; 1.129-14.175), with no significant difference in PEP rate (p = 0.571).

CONCLUSIONS

PCWGC demonstrated greater efficacy than the conventional salvage technique. PCWGC could be a safe and useful technique, especially for difficult biliary cannulation.

Predictive factors of difficult biliary cannulation: An experience of a tunisian tertiary center

Introduction

Selective biliary cannulation is a prerequisite for a successful endoscopic retrograde cholangiopancreatography (ERCP). However, conventional biliary access can be difficult. The aims of our study were to determine the prevalence of difficult biliary cannulation (DBC) and its associated factors and to describe the efficiency and safety of used standard and advanced cannulation techniques.

Methods

We conducted a single-center retrospective study including all patients with naïve papilla who had an ERCP procedure in Gastroenterology department of Mohamed Taher Maamouri Hospital from June 2019 to December 2021. Efficiency was defined as successful selective deep biliary cannulation. DBC was defined based on the presence of one or more of the European Society of Gastrointestinal Endoscopy (ESGE) criteria (5-5-1): more than five cannulation attempts, more than 5 min before cannulation and more than one accidental passage in the wirsung. Prevalence was measured using ESGE 5-5-1 cutoffs and chinese set cutoffs 15-10-2. Predictors of DBC were sought by univariate and multivariate analysis (SPSS software, p significant if < 0.05).

Results

We included 664 patients (mean age 62 years and sex ratio M/W = 0.8). Main indication for ERCP was choledocholithiasis (67%, n = 442) followed by malignant biliary stenosis (21%, n = 138). Based on ESGE criteria, prevalence of DBC was 42.62% (n = 283). Prevalence was 21.15% when 15-10-2 cutoffs are applied in trainee-involved procedure. Cumulative biliary success rate was 96.46%. Standard cannulation method achieved access in 98.2% while advanced methods permitted success in 92.2% in fistulotomy, 94.1% in papillotomy and 77.3% in transpancreatic sphincterotomy. Independent predictive factors of DBC in multivariate analysis were: Trainee presence OR 1.80 [1.24-2.65], SOD OR 4.71 [1.11-19.88], biliary stenosis found on imaging examinations (OR 2.53 [1.63-3.92], small papilla OR 4.09 [1.82-9.17] and difficult orientation of the papilla OR 14.90 [3.28-67.62].

Conclusion

DBC is a frequent endoscopic situation. Predictors of DBC can be related to trainee involvement in the procedure, anatomical and clinical factors. A thorough understanding of these factors can actively contribute to ERCP management plans.

One-stage approach to cholecystocholedocholithiasis treatment: a feasible surgical strategy for emergency settings and frail patients

BACKGROUND

Cholecystocholedocholithiasis (CCL) occurs in up to 18% of patients undergoing laparoscopic cholecystectomy (LC). The two-stage treatment using endoscopic retrograde cholangiopancreatography (ERCP) followed by LC is the treatment of choice for CCL. However, only 10 to 60% of patients have common bile duct (CBD) stones at the time of ERCP, thus exposing patients to unnecessary ERCPs, causing 3 to 15% of post-interventional pancreatitis. One-stage laparoscopic-endoscopic rendezvous (LERV) is an alternative for the treatment of CCL. Given the selective top-to-bottom CBD cannulation, LERV reduces the risk of pancreatitis and failed CBD cannulation. Additionally, LERV is performed exclusively in patients presenting CBD stones at intraoperative cholangiography, avoiding unnecessary ERCPs. Despite its advantages, considering the logistical burden of coordinating different specialties, LERV is performed in few centers. Here, we present the largest retrospective series of LERVs performed at our department, analyzing elective and emergency procedures.

METHODS

All consecutive patients undergoing LERV for CCL between January 2014 and December 2021 were included. LERV success rate, operative time, biliary outflow restoration rate, postoperative complications (POC), length of hospital stay (LOS), and recurrences were analyzed.

RESULTS

181 patients were included (61 elective LERVs, 120 emergency LERVs). We reported a 100% LERV success rate, a 97.79% biliary outflow restoration rate, a 0% conversion rate, a mean intraoperative time of 120.17 ± 31.35 min, and LOS of 4.00 ± 2.82 days. POC included 7 Clavien-Dindo type 1, 11 type 2, and 3 type 3 cases. Seven patients presented with CBD stone recurrence: 2 within 30 days after discharge, 3 within 6 months after discharge, and 2 patients at 1 year. No statistically significant difference was found between elective and emergency patients.

CONCLUSION

LERV is safe, representing a valid option even in emergency settings, thus enabling the management of CCL within a single procedure, consequently sparing additional anesthesia and decreasing post-ERCP complications.

The Safety and Efficacy of an Unflanged 4F Pancreatic Stent in Transpancreatic Precut Sphincterotomy for Patients with Difficult Biliary Cannulation: A Prospective Cohort Study

Prophylactic pancreatic stenting effectively reduces the rate and severity of post-ERCP pancreatitis (PEP) in the precut technique; however, studies on the optimal type and duration of the stent are still lacking. This prospective study evaluated the incidence and severity of PEP and the rate of spontaneous stent dislodgement in patients undergoing transpancreatic precut sphincterotomy (TPS) accompanied by prophylactic pancreatic stenting with an unflanged plastic stent (4F × 5 cm) for difficult biliary cannulation. A total of 247 patients with naïve papilla were enrolled in this study, and data were collected prospectively. In the final analysis, 170 and 61 patients were included in the standard cannulation technique and TPS groups, respectively. The incidence of PEP in the standard cannulation technique and TPS groups was 3.5% and 1.6% (p = 0.679), respectively. The technical success rate of selective biliary cannulation in the TPS group was 91.8%. The spontaneous dislodgement rate of the prophylactic plastic stent was 98.4%. In conclusion, an unflanged pancreatic stent (4F × 5 cm) placement in TPS for patients with failed standard cannulation technique is a safe and effective measure due to low adverse events and few additional endoscopic procedures for removing the pancreatic duct (PD) stent.

"Salvage techniques" are the key to overcome difficult biliary cannulation in endoscopic retrograde cholangiopancreatography

Although the efficacy and safety of salvage techniques for biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) have been reported, few reports analyzed the choice of techniques and their clinical outcomes in large cohorts. This study aimed to evaluate the outcomes of biliary cannulation in patients with native papillae. We retrospectively identified 1021 patients who underwent initial ERCP from January 2013 to March 2020. We investigated background factors, treatment details, cannulation success rates, and adverse event rates. Then we analyzed a series of treatment processes, including salvage techniques such as double guidewire technique (DGT), needle knife pre-cutting (NKP), and transpancreatic pre-cut papillotomy (TPPP). The initial ERCP success rate using standard technique alone was 62.8%, which increased to 94.3% including salvage techniques. Salvage techniques were frequently required in patients with long oral protrusions (OR 2.38; 95% CI 1.80–3.15; p < 0.001). A total of 503 cases (49.3%) had long oral protrusions, 47.5% of which required the salvage techniques, much higher than 27.5% of not-long cases. Patients with long oral protrusions had a higher frequency of NKP. In conclusion, patients with long oral protrusions frequently required salvage techniques. Salvage techniques may help to overcome many difficult biliary cannulation cases.

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

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.

FACTORS ASSOCIATED WITH DIFFICULT BILIARY CANNULATION IN A TRAINING CENTER FOR ENDOSCOPIC INTERVENTION OF THE BILIARY TRACT

ABSTRACT Background This paper aims to determine factors associated with difficult biliary cannulation (DBC) that are identifiable before procedures. Methods This is a nested case-control study within a historical cohort in adult patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) from 2015-2019 in the Hospital Universitario San Ignacio, Colombia. This study assessed the associations among variables that could be identified before or at the beginning of procedures and the probability of DBC. These associations were evaluated through a bivariate and multivariate analysis. The study used criteria for DBC defined by the European Society of Gastrointestinal Endoscopy. Results A total of 498 ERCP performed in 376 patients were analyzed. Of all procedures, 144 (29%) fulfilled criteria for DBC. The multivariate analysis showed an association between DBC and the acute care hospital setting (OR:2.92; CI95% 1.70-5.01; P<0.001), redundant papilla (OR:7.26; CI95% 3.38-15.61; P<0.001), or peridiverticular papilla (OR:2.45; CI95% 1.38-4.36; P=0.002). No association was found between DBC and endoscopist’s experience, bilirubin levels, or dilation of the biliary tract. Conclusion The DBC is a frequent event. Alterations in the papilla and ERCP performed in the acute care hospital setting are the principal factors associated with DBC. This information might be useful to predict DBC and establish healthcare and administrative strategies to reduce its implications.

Safety and efficacy of different techniques in difficult biliary cannulation at endoscopic retrograde cholangiopancreatography

BACKGROUND

Adverse events (AEs) are commonly seen at endoscopic retrograde cholangiopancreatography (ERCP) during difficult biliary cannulation (DBC). Therefore, attaining the right technique is essential to have improved outcomes.

METHODS

Patients who had DBC over a 3-year period were assessed for outcomes. The protocol included double guidewire (DGW) technique, wire-guided cannulation (WGC) after pancreatic stent, precut sphincterotomy/fistulotomy, and EUS-guided rendezvous (RV). The success of various techniques and AE was studied.

RESULTS

As per available case analysis, a total of 3680 patient details were assessed out of which DBC was noted in 471 (12.8%) patients with a mean (SD) age of 51.5 (17.4) years; majority being 330 (70.1%) males. Most patients underwent precut sphincterotomy 230 (48.8%); however, it was not successful in the first attempt in 10 (2.1%) patients with the success rate of 220 (95.6%). The success rate of DGW cannulation was 120 (95.2%), WGC after pancreatic stent was 64 (94.1%), EUS-RV was 34 (97.1%), and wire-guided repeat ERCP after 48 h was 10 (98.3%). AEs were noted in 52 (11.1%) patients. After precut, 32 (13.9%) patients developed AE out of which post-ERCP pancreatitis was noted in 20 (8.7%). Twenty-three patients had failed biliary access after all methods and 20 (86.9%) of those received successful percutaneous transhepatic biliary drainage.

CONCLUSION

Repeat ERCP after 48 h and EUS-RV appear prudent for DBC. Precut remains one of the preferred choices for most endoscopists when there is no entrance to PD. Further utilizing an algorithmic approach can contribute to higher success rates without compromising safety.

Factors Predicting Difficult Biliary Cannulation during Endoscopic Retrograde Cholangiopancreatography for Common Bile Duct Stones

Background/Aims

Difficult biliary cannulation is an important risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Therefore, this study aimed to identify the factors that predict difficult cannulation for common bile duct stones (CBDS) to reduce the risk for PEP.

Methods

This multicenter retrospective study included 1,406 consecutive patients with native papillae who underwent ERCP for CBDS. Factors predicting difficult cannulation for CBDS were identified using univariate and multivariate analyses.

Results

Univariate analysis showed that six factors significantly predicted difficult cannulation: ERCP performed by non-expert endoscopists, low-volume center, absence of acute cholangitis, normal serum bilirubin, intradiverticular papilla, and type of major duodenal papilla. Multivariate analysis identified ERCP performed by non-expert endoscopists (odds ratio [OR], 2.5; p<0.001), low-volume center (OR, 1.6; p<0.001), intradiverticular papilla (OR, 1.3; p=0.007), normal serum bilirubin (OR, 1.3; p=0.038), and absence of acute cholangitis (OR, 1.3; p=0.049) as factors significantly predicting difficult cannulation for CBDS.

Conclusions

Initial cannulation by an experienced endoscopist, early rescue cannulation, or early takeover by an experienced endoscopist should be considered when performing ERCP for CBDS in the presence of factors predicting difficult cannulation.

Is Cholecystectomy a cause of difficult biliary cannulation in endoscopic retrograde cholangiopancreatography?

BACKGROUND AND STUDY AIM

In European Society of Gastrointestinal Endoscopy guidelines, biliary cannulation of naive papillae is defined as difficult in the presence of more than 5 papilla contacts, more than 5min cannulation time or more than one unintended pancreatic duct cannulation or opacification. It is not known whether cholecystectomy is a cause of difficult biliary cannulation. This study aimed to investigate whether cholecystectomy (CCY) is a cause of difficult biliary cannulation in patients who have undergone Endoscopic Retrograde Cholangiopancreatography (ERCP) for choledocholithiasis.

PATIENTS AND METHODS

Adult patients with naive papillae and those who underwent ERCP for common bile duct stones and/or sludge were included in this retrospective study. Patient demographics, clinical presentation (acute cholangitis, biliary pancreatitis or biliary colic), periprocedural data including laboratory and radiological findings and ERCP results were compared between no-CCY and post-CCY groups.

RESULTS

438 patients were included in the present study and 347 of these patients were in the no-CCY group and 91 patients were in post-CCY group. A statistically significant difference was found in the number of patients with difficult cannulation in the post-CCY group (n=30, 33.0%) patients compared to the no- CCY group (n=67, 19.3%) (p=0.011). According the multivariate analyses results, presence of history of cholecystectomy was found an independent risk factor of difficult cannulation (Odds ratio: 2.014; 95 % Cl 1.205-3.366; p=0.008).

CONCLUSIONS

The results showed that biliary cannulation was significantly more difficult in patients with cholecystectomy who underwent ERCP for common bile duct stones.

Safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients aged 85 years and older: A single center experience

Objective: To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients (≥85 years old).

Material and Methods: Patients who underwent ERCP for any reason within 12 months were evaluated. Patients undergoing ERCP were classified as the elderly group aged 85 years and older or the controls under the age of 85 years.

Results: A total of 1225 patients, 504 males and 721 females, were included in the study. Length of hospital stay, the number of patients in whom pre- cut sphincterotomy was performed in ERCP, and mortality rate showed similar characteristics compared to the control group in patients with advanced age (≥85 years old). Except for pancreatitis, there was no significant difference between the groups in terms of complications related to the procedure. Post ERCP pancreatitis was observed significantly less in the elderly group (p= 0.042). Pre-cut sphincterotomy was required in a total of 191 (15.5%) patients. In patients who underwent pre-cut sphincterotomy and patients with cholangitis, post ERCP complication rates were not significant between the groups.

Conclusion: ERCP is a safe procedure for older patients (≥85 years old) as well as young patients.

Best practices for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Acute pancreatitis is of one the most common gastroenterology-related indications for hospital admissions worldwide. With the widespread reliance on endoscopic retrograde cholangiopancreatography (ERCP) for the management of pancreaticobiliary conditions, post-ERCP pancreatitis (PEP) has come to represent an important etiology of acute pancreatitis. Despite many studies aiming to better understand the pathogenesis and prevention of this iatrogenic disorder, findings have been heterogeneous, and considerable variation in clinical practice exists. Herein, we review the literature regarding PEP with the goal to raise awareness of this entity, discuss recent data, and present evidence-based best practices. We believe this manuscript will be useful for gastrointestinal endoscopists as well as other specialists involved in the management of patients with PEP.

Artificial intelligence-assisted analysis of endoscopic retrograde cholangiopancreatography image for identifying ampulla and difficulty of selective cannulation

The advancement of artificial intelligence (AI) has facilitated its application in medical fields. However, there has been little research for AI-assisted endoscopy, despite the clinical significance of the efficiency and safety of cannulation in the endoscopic retrograde cholangiopancreatography (ERCP). In this study, we aim to assist endoscopists performing ERCP through automatic detection of the ampulla and the identification of cannulation difficulty. We developed a novel AI-assisted system based on convolutional neural networks that predict the location of the ampulla and the difficulty of cannulation to the ampulla. ERCP data of 531 and 451 patients were utilized in the evaluation of our model for each task. Our model detected the ampulla with mean intersection-over-union 64.1%, precision 76.2%, recall 78.4%, and centroid distance 0.021. In classifying the cannulation difficulty, it achieved the recall of 71.9% for the class of easy cases and that of 61.1% for that of difficult cases. Remarkably, our model accurately detected AOV with varying morphological shape, size, and texture on par with the level of a human expert and showed promising results for recognizing cannulation difficulty. It demonstrated its potential to improve the quality of ERCP by assisting endoscopists.

Palliative endoscopic retrograde biliary drainage for malignant biliary obstruction in Korea: A nationwide assessment

BACKGROUND

Malignant biliary obstruction (MBO) is usually caused by biliary tract cancer or pancreatic cancer. This study was performed to summarize the current situation regarding palliative endoscopic retrograde biliary drainage (ERBD) for MBO in Korea and to determine its clinical significance by analyzing representative nationwide data.

METHODS

Patients that underwent palliative ERBD for MBO between 2012 and 2015 were identified using the Health Insurance Review and Assessment database, which covers the entire Korean population. We assessed clinical characteristics and complications and compared the clinical impacts of initial metal and plastic stenting in these patients.

RESULTS

A total of 9,728 subjects (mean age, 65 ± 11.4 years; male, 61.4%) were identified and analyzed. The most common diagnosis was malignant neoplasm of liver and intrahepatic bile ducts (32.1%) and this was followed by extrahepatic or Ampulla of Vater cancer and pancreatic cancer. Initial plastic stent(s) placement was performed in 52.9% of the study subjects, and metal stent(s) placement was performed in 23.3%. The number of sessions of endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD) was significantly higher in patients that underwent initial plastic stenting than in patients that underwent metal stenting (2.2 ± 1.7 vs 1.8 ± 1.4, P < 0.0001), but rates of post-ERCP pancreatitis, hospital days, and time to second ERCP or PTBD were not significantly different.

CONCLUSION

This nationwide assessment study suggests that initial metal stenting is associated with fewer sessions of total ERCP or PTBD following the initial procedure, despite the preference for initial plastic stenting in Korea.

Biliary Cannulation in Endoscopic Retrograde Cholangiography: How to Tackle the Difficult Papilla

BACKGROUND

In the setting of a naïve papilla, biliary cannulation is a key step in successfully performing endoscopic retrograde cholangiography. Difficult biliary cannulation (DBC) is associated with an increased risk of post-ERCP pancreatitis and failure of the whole procedure.

SUMMARY

Recommendations for biliary cannulation can be divided into (a) measures to reduce the likelihood of a difficult papilla situation a priori and (b) rescue techniques in case the endoscopist is actually facing DBC. (a) Careful inspection of the papillary anatomy and optimizing its accessibility by scope positioning is fundamental. A sphincterotome in combination with a soft-tip hydrophilic guidewire rather than a standard catheter with a standard guidewire should be used in most situations. (b) The most important rescue techniques are needle-knife precut, double-guidewire technique, and transpancreatic sphincterotomy. In few cases, anterograde cannulation techniques are needed. To this regard, the EUS-guided biliary drainage followed by rendezvous is increasingly used as an alternative to percutaneous transhepatic biliary drainage. Key Messages: Biliary cannulation can be accomplished with alternative retrograde or less frequently by salvage anterograde techniques, once conventional direct cannulation attempts have failed. Considering recent favorable data for the early use of transpancreatic sphincterotomy, an adopted version of the 2016 European Society for Gastrointestinal Endoscopy (ESGE) algorithm on biliary cannulation is proposed.

Causes and Countermeasures of Difficult Selective Biliary Cannulation: A Large Sample Size Retrospective Study

OBJECTIVE

Selective biliary cannulation is a difficult part of endoscopic retrograde cholangiopancreatography (ERCP). Therefore, endoscopists have focused on how to improve the cannulation success rate and reduce the postoperative complication rate. This study aims to provide practical advice on safe operation for endoscopists.

MATERIALS AND METHODS

Data from the ERCP database of our medical center from January 2008 to December 2017 were retrospectively reviewed. All patients underwent ERCP for the first time. Data pertaining to diseases, anatomic factors, difficult cannulation rates, cannulation success rates, and postoperative complication rates for various assistive cannulation techniques were analyzed by using the Pearson χ2 tests and Fisher exact tests.

RESULTS

The difficult cannulation rate was 8.1%. The main influencing factors were benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy. The postoperative complication rates and overall cannulation success rates of 7 assistive techniques were not statistically different (P>0.05), but the overall complication rates were statistically different (P<0.05). Needle-knife precut sphincterotomy had the highest rate of complications.

CONCLUSIONS

Benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy were the main factors of difficult selective biliary cannulation. The overall incidence of needle-knife precut sphincterotomy complications was higher than that of other techniques, but various assistive techniques were safe and effective in our single center.

Dormia basket impacted during ERCP, resolved by laparoscopic bile duct approach: Case report

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice for treating and removing common bile duct (CBD) stones with high success rates. Among the adverse effects, impaction of the Dormia basket when removing the stones is an unusual complication.

CASE PRESENTATION

Two cases of choledocholithiasis with endoscopic treatment by ERCP and Dormia basket impaction, resolved by a laparoscopic approach to the bile duct.

DISCUSSION

Laparoscopic common bile duct exploration (LCBDE) has been developed as a technique to treat choledocholithiasis and simultaneously vesicular lithiasis by laparoscopy. LCBDE can be by means of a transcystic approach or by choledochotomy. The success of the treatment depends on surgical experience and the availability of adequate equipment, with high effectiveness to eliminate CBD stones and a success rate greater than 95%, it is equally effective for the resolution of adverse events during ERCP.

CONCLUSION

LCBDE provides an alternative therapy where there is no other type of treatment for the resolution of complications of ERCP. It is a safe, effective and reliable technique with high success rates, which offers the benefits of a minimally invasive approach.

A Proposed Algorithm for Endoscopic Ultrasound-Guided Rendezvous Technique in Failed Biliary Cannulation

Background: The selection of an approach route in endoscopic ultrasound-guided rendezvous (EUS-RV) for failed biliary cannulation is complicated. We proposed an algorithm for EUS-RV. Methods: We retrospectively evaluated consecutive EUS-RV cases between April 2017 and July 2020. Puncturing the distal extrahepatic bile duct (EHBD) from the duodenal second part (D2) (DEHBD/D2 route) was attempted first. If necessary, puncturing the proximal EHBD from the duodenal bulb (D1) (PEHBD/D1 route), puncturing the left intrahepatic bile duct (IHBD) from the stomach (LIHBD/S route), or puncturing the right IHBD from the D1 (RIHBD/D1 route) were attempted in this order. Results: A total of 16 patients were included. The DEHBD/D2 route was used in 10 (62.5%) patients. The PEHBD/D1 route was attempted in five (31.3%) patients, and the biliary puncture failed in one patient in whom the RIHBD/D1 route was used because of tumor invasion to the left hepatic lobe. The LIHBD/S route was applied in one (6.3%) patient. Successful biliary cannulation was achieved in all patients eventually. The time from the puncture to the guidewire placement in the DEHBD/D2 route (3.5 min) was shorter than that in other methods (14.0 min) (p = 0.014). Adverse events occurred in one (6.3%) patient with moderate pancreatitis. Conclusions: The proposed algorithm might be useful for the selection of an appropriate approach route in EUS-RV.

Predicting cannulation difficulty in endoscopic retrograde cholangiopancreatography using CT image findings: a decision-tree analysis

BACKGROUND

Difficult cannulation during endoscopic retrograde cholangiopancreatography (ERCP) is associated with increased complications; therefore, its prediction is important.

PURPOSE

To identify radiologic risk factors of difficult cannulation during ERCP based on computed tomography (CT) findings and to develop a predictive model for a difficult cannulation.

MATERIAL AND METHODS

A total of 171 patients with native papilla who underwent both enhanced CT and ERCP were recruited. Two radiologists independently measured the distal common bile duct (CBD) diameter and choledochoduodenal (CD) angle and analyzed CT images for presence of CBD stone and papilla bulging, size and type of periampullary diverticulum (PAD), and duodenal segment in which major papilla was located. Multivariate logistic regression analysis and decision-tree analysis were performed to identify risk factors for difficult cannulation.

RESULTS

Thirty-nine patients underwent a difficult cannulation. The multivariate logistic regression analysis revealed that a smaller CBD diameter, presence of papilla bulging, location of the major papilla other than the descending duodenum, a smaller CD angle, and a higher worrisome PAD score were statistically relevant factors for difficult cannulation (P < 0.049). In the decision-tree analysis, a higher worrisome PAD score was the strongest predictor of difficult cannulation, followed by the presence of papilla bulging, smaller CD angle, and a smaller CBD diameter. The predictive model had an 82.5% overall predictive accuracy.

CONCLUSION

The CT findings-based decision-tree analysis model showed a high accuracy in predicting cannulation difficulty and may be helpful for making pre-ERCP strategy.

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

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.

Methods

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.

Endosonographic finding of the simultaneous depiction of bile and pancreatic ducts can predict difficult biliary cannulation on endoscopic retrograde cholangiopancreatography

Thus far, no curved linear array endoscopic ultrasound (CLAEUS) findings were established as predictors of difficult selective bile duct cannulation (SBDC). This study aimed to identify CLAEUS findings to predict endoscopic retrograde cholangiopancreatography (ERCP) cases with difficult SBDC. This single-center, retrospective cohort study was conducted between July 2014 and June 2017. This study included all consecutive patients who underwent CLAEUS prior to naïve ERCP. A CLAEUS finding of the simultaneous depiction of bile and pancreatic ducts at the second portion of the duodenum (D2) (simultaneous depiction) was selected as a possible predictor of difficult SBDC, and the κ values in the evaluation of inter- and intra-observer variabilities for “simultaneous depiction” were 0.65 and 0.77, respectively, with substantial correlation. Among the 986 patients who underwent ERCP, 80 patients were relevant for evaluation. Logistic regression analysis revealed strong association between “simultaneous depiction” and difficult SBDC (odds ratio 15.4, 95% confidence interval 4.2–56.0; p<0.001). Among patients who underwent CLAEUS prior to naïve ERCP, a strong correlation was observed between “simultaneous depiction” and the risk of difficult SBDC. An endoscopist can prepare for difficult SBDC by “simultaneous depiction.” The finding enables pertinent planning when performing ERCP, such as setting time limits and selecting alternative devices, techniques, and skilled endoscopists, for difficult SBDC with minimal complications including post-ERCP pancreatitis. However, a future prospective study is necessary to establish the procedure algorithm for suspected difficult SBDC cases based on CLAEUS.

Anatomy of Major Duodenal Papilla Influences ERCP Outcomes and Complication Rates: A Single Center Prospective Study

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) has been one of the most intensely studied endoscopic procedures due to its overall high complication rates when compared to other digestive endoscopy procedures. The safety and outcome of such procedures have been linked to multiple procedure- or patient-related risk factors. The aim of our study is to evaluate whether the morphology of the major duodenal papilla influences the ERCP outcomes and complication rates.

METHODS

A total of 322 patients with a native papilla have been included in the study over an eight month period. Morphology of the papilla has been classified into normal papilla and four anatomical variations (Type I-IV). All patients have been prospectively monitored over a 15 day period after ERCP. Procedural outcomes and complication rates have been registered.

RESULTS

Morphology of the papilla influences both overall complication rates (95%CI, p = 0.0066) and post-ERCP pancreatitis rates (95%CI, p = 0.01001) in univariate analysis. Type IV papillae have proven to be independent risk factors for post-ERCP pancreatitis in multivariate analysis (OR = 12.176, 95%CI, p = 0.005). Type I papillae have been significantly linked to difficult cannulation (AUC = 0.591, 95%CI, p = 0.008); Conclusions: In the monitored cohort morphology of the major duodenal papilla has significantly influenced both ERCP outcomes and post-procedural complication rates.