Difficult Biliary Cannulation: Should We Always Try a Second Ercp After a Failed Needle-Knife Fistulotomy?

Abstract

BACKGROUND: A successful bile duct cannulation is a prerequisite for the realization of endoscopic retrograde cholangiopancreatography (ERCP). When biliary cannulation is not possible, needle-knife fistulotomy (NKF) can be performed. However, when biliary access is not successfully achieved even after performing NKF, it is possible to interrupt the procedure, and repeat the ERCP after a short interval. OBJECTIVE: The aim of this study is to analyze if repeating an ERCP after a short interval of 48 hours is effective in achieving biliary access after an initial NKF was unsuccessfully performed. METHODS: A total of 1024 patients with a naive papilla, that underwent ERCP between the years of 2009-2019, were retrospectively reviewed. Difficult biliary cannulation was identified in 238 of these cases and NKF was performed. Success of biliary cannulation, NKF success at the first and second ERCPs, the associations between the type of the papilla, biliary dilatation, and overall success of NKF and adverse events rates were evaluated. RESULTS: Biliary access was initially achieved in 183 (76.8%) cases. Of the 55 (23.1%) remaining cases a second attempt was performed after 48 hours, and biliary access was successfully achieved in 46 (83.6%) of them. The overall success of NKF after the first and second ERCP, the success rate was 96.2%. Papilla located out of its normal position was related to a minor chance of success at NKF (P<0.05). CONCLUSION: We conclude that when biliary access is not achieved after the performance of a NKF, a second attempt is safe and effective and should be attempted.

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

“…Studies have shown that experienced endoscopists using a needle-knife have improved the cannulation success rate to between 85% and 99%; however, the matter of selecting the best substitute among the available options in the event of initial ERCP failure still holds interest [1,11]. A subsequent ERCP within a few days is an effective and safe therapy for patients who are clinically stable, with a success rate of 68%-79% [2,12,13]. The results of the current study reveal an overall success rate of 76.6%, which supports the validity and vitality of a second ERCP.…”

“…Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive intervention that has established itself as the gold standard therapeutic option for various pancreaticobiliary conditions [1]. Nonetheless, there are times when ERCP is ineffective, even when performed by highly trained professionals or at major healthcare institutions [2].…”

Enlarged fistulotomy of the papilla as access to the biliary tract during ERCP

“…According to Flumignan [ 18 ] and Deng [ 19 ], a second fistulotomy attempt is feasible, and safe, and can be attempted after a short 48-hour interval if the first ERCP attempt is unsuccessful.…”

Enlarged fistulotomy of the papilla as access to the biliary tract during ERCP

“…Methods This was a cross-sectional study, with retrospective data collection from 2233 ERCP exams with 528 EFP procedures, conducted from November 2006 to August 2022 analysis of results regarding cannulation success and complications. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19…”