Failed biliary cannulation: clinical and technical outcomes after tertiary referral endoscopic retrograde cholangiopancreatography

Abstract

Aim: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center.

Methods: Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP.

Results: Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary cannulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identifiable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 naïve papilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or post-ERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017).

Conclusion: Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.

Keywords: Biliary cannulation; Failed biliary cannulation; Failed endoscopic retrograde cholangiopancreatography; Needle knife sphincterotomy; Post endoscopic retrograde cholangiopancreatography pancreatitis; Precut sphincterotomy; Tertiary referral endoscopic retrograde cholangiopancreatography; Unsuccessful biliary cannulation.

Figure 1

Technique of conventional/freehand/deroofing precut needle knife sphincterotomy. Case of previously failed biliary cannulation without an identifiable cause. A: Normal papillary appearance; B: After we were unable to cannulate selectively the biliary orifice after several pancreatic duct wire cannulations, a pancreatic stent was inserted; C: Precut needle knife sphincterotomy was performed with a cut directed from the ampullary orifice towards the 12 o’clock position. Biliary epithelium and bile noted (arrowpoint) at apex of the cut; D: Bile duct selectively cannulated with wire and sphincterotomy performed.