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

Abstract

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 χ 2 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). Needleknife 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.

Suprapapillary Needle Knife Fistulotomy Versus Conventional Precut Sphincterotomy in Difficult Biliary Cannulation: A Retrospective Comparative Study

“…Since NKF is suitable in patients with bulging and properly configured papilla,14 although not supported by literature, the tendency of CPS use in malignant biliary strictures might have resulted from the observation that bulging papillary morphology is less often in those patients irrespective of the stricture localization. In this patient group, NKF and CPS were equally effective in biliary cannulation by previous studies 27,29. In the presented study, while all 23 patients with malignant stricture in the NKF group had successful biliary cannulation in the first ERCP session, 21 (72.4%) of 29 patients with malignant stricture in the CPS group could only be cannulated.…”

“…In this patient group, NKF and CPS were equally effective in biliary cannulation by previous studies. 27,29 In the presented study, The use of NKF was less frequent than CPS in the presence of perivaterian diverticulum in the presented study. This could be explained by the perivaterian diverticula's alteration in papillary configuration and, thus, loss of conformity to NKF.…”

“…It has been demonstrated that the frequency of difficult biliary cannulation is increased in patients with malignant strictures. 27,28 In the presented study, 52 (50.5%) out of 103 patients having malignant stricture required precut cannulation correlatively. In addition, it was observed that CPS was more preferred than NKF in this patient group (P = 0.019).…”

Predictive factors of needle-knife pre-cut papillotomy failure in patients with difficult biliary cannulation

“…Endoscopists’ experience is another important factor in initial NKP failure 30 . Like ERCP, it is difficult for beginners to master the skills required for NKP.…”