A RETROSPECTIVE ANALYSIS TO ASSESS THE IMPORTANCE OF DOING A BILIARY SPHINCTEROTOMY TO INCREASE AND SIMPLIFY CANNULATION SUCCESS RATE OF THE MAIN PANCREATIC DUCT

Aims:

MPD cannulation is the prime requisite for any pancreatic endotherapy during an ERCP. Very few techniques are described for selective pancreatic duct cannulation. When doing primary pancreatic therapy in cases where MPD cannulation is difficult, if we could get the wire into the CBD first, then doing a wide biliary sphincterotomy is shown to increase the success of cannulation of the MPD without using any more sophisticated techniques.

Methods:

Our data of all cases (1206) for pancreatic ERCP from October 2008 to May 2018 was studied. All cases were done by a single operator. All cases where MPD could not be cannulated in three attempts, or MPD not cannulated directly in 10 minutes or CBD cannulated first were studied. When MPD cannulation failed we tried to cannulate the CBD first or when CBD was first cannulated, instead of trying MPD cannulation again we did a wide biliary sphincterotomy, separated the biliary and pancreatic orifices and then cannulated the MPD with a cannula and glide wire.

Results:

• Number of ERP: 1206

• Successful direct MPD cannulation: 982 (81.4%)

• Difficult Cannulation: 224 (18.6%)

• CBD cannulated first: 199 out of 224 (88.9%)

• Biliary Sphincterotomy done: 199 (100%)

• Successful MPD Cannulation after biliary sphincterotomy: 185 (92.9%)

• Failed MPD cannulation after biliary sphincterotomy: 14 (7.03%)

• Pancreas Divisum found: 10/14 failed cannulations (71.4%)

• Failed MPD cannulation overall: 25 out of 1206 (2.07%).

Conclusions:

If direct MPD cannulation is difficult, cannulating the CBD first and doing a biliary sphincterotomy improves the MPD cannulation success rate significantly- Increase success from 81.4% to 92.9%.

Failed MPD cannulation even after biliary sphincterotomy, 71.4% had divisum.

Lavage therapy after failed cannulation would be EUS guided drainage or surgery.