Optimal timing for discontinuation of ERCP in cases of difficult selective biliary cannulation

Abstract

Background and study aims

Prolonged cannulation during endoscopic retrograde cholangiopancreatography (ERCP) increases risk of complications, particularly post-ERCP pancreatitis (PEP). This study aimed to determine optimal timing to discontinue ERCP when selective biliary cannulation (SBC) cannot be easily achieved.

Patients and methods

Patients with naïve papilla who underwent ERCP between January 2021 and December 2021 were analyzed. The primary outcome was to determine optimal timing for discontinuing ERCP based on cannulation success rate and complication rate.

Results

A total of 272 patients with naïve papilla underwent ERCP. Trainees did not participate in any of the procedures. Median age was 71 years, and 152 patients (55.9%) were male. The most common indication for ERCP was choledocholithiasis (60.7%), followed by malignant obstruction (24.3%) and benign stricture (4.8%). SBC was achieved in 249 patients (91.5%). After excluding patients with pre-procedure amylase elevation or preexisting pancreatitis, 232 patients were analyzed for complications. Eighteen patients (6.7%) experienced complications, with PEP occurring in 15 patients (5.5%). SBC success was achieved in 50% of cases at 3.3 minutes and in 90% at 12.1 minutes. In contrast, the PEP rate reached 10% after 7.9 minutes and 14.5% after 12.1 minutes. Multivariate analysis identified distal biliary stricture and age over 70 as significant predictors of difficult SBC.

Conclusions

In cases of difficult SBC, discontinuing attempts at around 8 minutes may minimize risk of PEP. However, extending attempts up to 12 minutes can be justified to achieve higher success rates. Beyond 12 minutes, likelihood of successful SBC diminishes significantly.

Keywords

Pancreatobiliary (ERCP/PTCD) - ERC topics - Stones - Strictures

Publikationsverlauf

Eingereicht: 05. Dezember 2024

Angenommen nach Revision: 30. Januar 2025

Accepted Manuscript online:
10. Februar 2025

Artikel online veröffentlicht:
04. April 2025

• References

• 1 Testoni PA, Mariani A, Aabakken L. et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2016; 48: 657-683
• 2 Chen PH, Tung CF, Peng YC. et al. Duodenal major papilla morphology can affect biliary cannulation and complications during ERCP, an observational study. BMC Gastroenterol 2020; 20: 310
• 3 Fugazza A, Troncone E, Amato A. et al. Difficult biliary cannulation in patients with distal malignant biliary obstruction: An underestimated problem?. Dig Liver Dis 2022; 54: 529-536
• 4 Tabak F, Ji GZ, Miao L. Impact of periampullary diverticulum on biliary cannulation and ERCP outcomes: a single-center experience. Surg Endosc 2021; 35: 5953-5961
• 5 Lou L, Wang X, Zhang Y. et al. Prolonged cannulation time is an independent risk factor for moderate-to-severe post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis: a large cohort study. Ann Transl Med 2023; 11: 188
• 6 Mandai K, Uno K, Fujii Y. et al. Number of endoscopic retrograde cholangiopancreatography procedures required for short biliary cannulation time. Gastroenterol Res Pract 2017; 2017: 1515260
• 7 Cotton PB, Lehman G, Vennes J. et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-393
• 8 Kiriyama S, Kozaka K, Takada T. et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci 2018; 25: 17-30
• 9 Wong Kee Song LM, Baron TH. Endoscopic management of procedure-related bleeding. Gastrointest Intervention 2012; 1: 43-52
• 10 Haraldsson E, Lundell L, Swahn F. et al. Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study. United European Gastroenterol J 2017; 5: 504-510
• 11 Domagk D, Oppong KW, Aabakken L. et al. Performance measures for ERCP and endoscopic ultrasound: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2018; 50: 1116-1127
• 12 Faulx AL, Lightdale JR. ASGE Standards of Practice Committee. et al. Guidelines for privileging, credentialing, and proctoring to perform GI endoscopy. Gastrointest Endosc 2017; 85: 273-281
• 13 Saito H, Kadono Y, Shono T. et al. Synergistic effect of independent risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis: a multicenter retrospective study in Japan. Clin Endosc 2024; 57: 508-514
• 14 Lee YS, Cho CM, Cho KB. et al. Difficult biliary cannulation from the perspective of post-endoscopic retrograde cholangiopancreatography pancreatitis: Identifying the optimal timing for the rescue cannulation technique. Gut Liver 2021; 15: 459-465
• 15 Haraldsson E, Kylanpaa L, Gronroos J. et al. Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP. Gastrointest Endosc 2019; 90: 957-963
• 16 Yue P, Zhu KX, Wang HP. et al. Clinical significance of different periampullary diverticulum classifications for endoscopic retrograde cholangiopancreatography cannulation. World J Gastroenterol 2020; 26: 2403-2415
• 17 Cagir Y, Durak MB, Simsek C. et al. Comparison of ERCP outcomes and complication risk between elderly and younger patients: A large single-center study. J Clin Med 2024; 13: 6112
• 18 Tabak F, Wang HS, Li QP. et al. Endoscopic retrograde cholangiopancreatography in elderly patients: Difficult cannulation and adverse events. World J Clin Cases 2020; 8: 2988-2999
• 19 Day LW, Lin L, Somsouk M. Adverse events in older patients undergoing ERCP: a systematic review and meta-analysis. Endosc Int Open 2014; 2: E28-E36
• 20 Yang JH LW, Si XK, Zhang JX. et al. Efficacy and safety of therapeutic ERCP in the elderly: A single center experience. Surg Laparosc Endosc Percutan Tech 2018; 28: e44-e48
• 21 Chan T-T, Chew M, Tang R. Troubleshooting difficult bile duct access: Advanced ERCP cannulation techniques, percutaneous biliary drainage, or EUS-guided rendezvous technique?. Gastroenterology Insights 2021; 12: 405-422
• 22 Dumonceau JM, Andriulli A, Elmunzer BJ. et al. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – updated June 2014. Endoscopy 2014; 46: 799-815