Strategies for Successful Difficult Biliary Cannulation: Insights from a University Hospital Experience

Aims The aim of our study is to report the techniques used at our center and their effectiveness.

Methods This is a retrospective study covering a four-year period (2019 to March 2024) involving patients admitted for ERCP. A cannulation is considered difficult if one or more of the following criteria are met: more than five attempts at cannulating the papilla, unintentional passage of the guidewire or opacification of the Wirsung duct.

Results The study included 414 patients, of which 28.7% (n=118) were classified as having undergone difficult cannulation. The mean age was 61.5 years, with a slight male predominance (51.5%). The main indications for ERCP were predominantly malignant tumors (51%, n=60) and biliary stones (36%, n=43).The techniques used in our study were as follows:

• Pre-cut techniques, such as papillotomy, fistulotomy, or infundibulotomy, were performed in 92 patients (78%), with a success rate of 89% and failure in 10 cases. Complications included minor bleeding in 3 cases (treated with compression and vasoactive drug injection), and one case requiring radiological embolization. One case of severe acute pancreatitis was observed following this technique.

• Biliary cannulation with a pancreatic guidewire in place (double guidewire technique) was performed in 18 patients (15.25%), with success in 14 patients and failure in 4. One case of severe pancreatitis occurred as a complication.

• Septotomy (trans-pancreatic sphincterotomy) was performed in 5 cases (4.2%), with 100% success and no major post-procedure complications.

• Use of a fibroscope was necessary in one patient with difficult papilla localization, accessed by duodenoscope, with successful outcome.

• Percutaneous rendezvous technique was employed in one patient with post-traumatic bile duct stenosis, with successful cannulation.

• Duodenal stent placement was used in one patient to access the papilla, but failed to achieve successful cannulation.

Conclusions ERCP is a procedure where each step presents a challenge for the operator. It requires a high level of expertise and continuous commitment to skill refinement to ensure optimal outcomes and patient safety. The choice of technique mainly depends on the operator’s expertise and available equipment.

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Artikel online veröffentlicht:
27. März 2025