Impact of periampullary diverticulum on biliary cannulation and ERCP outcomes: a single-center experience

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

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.

Development of a Scoring System for Predicting the Difficulty of Bile Duct Cannulation and Selecting the Appropriate Cannulation Method

BACKGROUND

Selective biliary cannulation in endoscopic retrograde cholangiopancreatography can be challenging due to factors like papillary morphology. Various patterns indicate cannulation difficulty, but the combinations causing difficulty and the optimal cannulation method for each scenario are unclear.

AIMS

This study aimed to identify cannulation difficulty patterns and develop a predictive scoring system for selecting the appropriate cannulation method.

METHODS

We retrospectively compared 776 patients with naïve papilla, dividing them into conventional contrast cannulation (N = 510) and salvage technique (N = 266) groups. The salvage group included patients using pancreatic duct guidewire placement and/or wire-guided cannulation due to difficulties with the contrast method. Papillary morphology (Haraldsson's classification), periampullary diverticulum (PAD), and scope operability were analyzed using multiple regression to identify risk factors for cannulation difficulties. Factors were scored based on hazard ratios to access combinations causing difficulties.

RESULTS

The salvage group had more older patients and higher frequencies of type 2 (small), type 3 (protruding or pendulous), type 4 (creased or ridged) papillae, PAD, and poor scope operability. Significant risk factors in the multivariate analysis included type 2 [odds ratio (OR) 6.88], type 3 (OR 7.74), type 4 (OR 4.06) papillae, PAD (OR 2.26), and poor scope operability (OR 4.03). Pattern recognition scores were significantly higher in the salvage group (1.31 vs. 3.43, P < 0.0001).

CONCLUSIONS

Type 2-4 papillae, PAD, and poor scope operability are significant risk factors for cannulation difficulty. Pattern recognition scores based on these factors can predict cannulation difficulty and aid in selecting between conventional and salvage methods.

Pancreatic stent improves the success rate of needle-knife papillotomy in patients with difficult biliary cannulation

BACKGROUND

Needle-knife precut papillotomy (NKP) is typically performed freehand. However, it remains unclear whether pancreatic stent (PS) placement can improve the outcomes of NKP.

AIM

To explore whether PS placement improves the success rate of NKP in patients with difficult biliary cannulation.

METHODS

This single-center retrospective study included 190 patients who underwent NKP between January 2017 and December 2021 after failed conventional biliary cannulation. In cases with incidental pancreatic duct cannulation during conventional biliary cannulation, the decision for pre-NKP PS placement was made at the endoscopist's discretion. The primary outcome was the difference in the NKP success rate between patients with and without PS placement; the secondary outcome was the adverse event rate.

RESULTS

Among the 190 participants, 82 received pre-NKP PS (PS-NKP group) whereas 108 did not [freehand or freehand NKP (FH-NKP) group]. Post-NKP selective biliary cannulation was successful in 167 (87.9%) patients, and the PS-NKP had a significantly higher success rate than the FH-NKP group (93.9% vs 83.3%, P = 0.027). The overall adverse event rates were 7.3% and 11.1% in the PS-NKP and FH-NKP groups, respectively (P = 0.493). A periampullary diverticulum (PAD) and significant intraoperative bleeding during NKP were independently associated with NKP failure; however, a pre-NKP PS was the only predictor of NKP success. Among the 44 participants with PADs, the PS-NKP group had a non-significantly higher NKP success rate than the FH-NKP group (87.5% and 65%, respectively; P = 0.076).

CONCLUSION

PS significantly improved the success rate of NKP in patients with difficult biliary cannulation.

Comparison of ERCP Outcomes and Complication Risk between Elderly and Younger Patients: A Large Single-Center Study

Objectives: The current study compared potential risks, complications, and the impact on clinical outcomes among elderly and younger patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Methods: Procedure-related complications, risk factors, and clinical outcomes following complications in elderly patients (aged ≥75 years) and younger who underwent biliary ERCP were evaluated. Results: Median age of 63 (48-74) of 1164 patients who underwent biliary ERCP for the first time, and 266 (22.8%) were elderly. Comorbidities were statistically significant (81 [30.5%] versus 78 [8.7%], p < 0.001), and periampullary diverticulum (PAD) was detected more commonly in the elderly group (79 [29.7%] vs. 103 [11.5%], p < 0.001). There was no statistical difference in cannulation technique, cannulation time, and cannulation success in both groups, while the total ERCP procedure time was higher in the elderly group (22 [16-29] vs. 20 [14-29], p = 0.030). Regarding the procedure-related complications, there was no statistically significant difference between the two groups (26 [9.8%] vs. 71 [7.9%], p = 0.292). In the case of complications, the length of hospitalization stay was statistically longer in the elderly group. Moreover, the elderly had a longer length of hospitalization, experiencing pancreatitis and a higher probability of developing moderate/severe pancreatitis. In multivariate and univariate analysis, prolonged cannulation time was found to be an independent risk factor in patients ≥75 years of age. Conclusions: This study showed that while ERCP-related complication rates in elderly patients are comparable to younger patients, it can be associated with worse outcomes following the complication and prolonged length of hospitalization.

The impact of periampullary diverticula on cannulation and adverse events in endoscopic retrograde cholangiopancreatography

Background

Periampullary diverticulum (PAD) is commonly encountered in endoscopic retrograde cholangiopancreatography (ERCP) procedures.

Objectives

We sought to determine whether PADs are associated with a lower success rate of cannulation and an increased risk of adverse events.

Design

A retrospective cohort study was conducted using prospectively gathered nationwide registry data.

Methods

Using the Swedish registry for gallstone surgery and ERCP, we analyzed a cohort of 66,974 prospectively registered ERCP procedures performed in 2006-2021. The presence of PAD was divided into two groups based on the PAD type: Boix type 1 (the papilla located inside the PAD) and Boix types 2-3 (the papilla located either at the edge of the PAD or immediately adjacent to the PAD). The primary outcomes were the success rate of cannulation and overall adverse events within 30 days.

Results

PADs were registered in 8130 (12.1%) of ERCPs included in the study population. In total, 2114 (3.9%) patients had Boix type 1 PAD, while 5035 (8.2%) patients had Boix type 2 or 3 PAD. The chance of successful cannulation was lower in patients with type 1 PAD compared to no PAD (80.1% vs 88.7%; odds ratio: 0.42, 95% confidence interval: 0.38-0.46). No differences were seen in overall adverse events or post-ERCP pancreatitis. Adverse events occurred in 14.6% of patients with PAD type 1 and 16.0% of patients with PAD type 2 or 3, compared to 16.5% of patients without a PAD.

Conclusion

Cannulation appears less successful during ERCP when the papilla is located in the PAD (i.e., type 1). Adverse events seem not to increase with the presence of a PAD, but they could theoretically be influenced by the inability to cannulate.

Impact of periampullary diverticula on the rates of successful cannulation and ERCP complications: An up-to-date systematic review and meta-analysis

OBJECTIVES

Periampullary diverticulum (PAD) is usually incidentally discovered during abdominal imaging, gastrointestinal endoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). The influence of PAD on ERCP outcomes is unclear. The aim of this systematic review and meta-analysis was to provide an up-to-date evaluation of the impact of PAD on cannulation and ERCP-related complications.

METHODS

PubMed, Web of Science, Cochrane Library and EMBASE databases were searched for relevant articles published up to October 31, 2023. The rates of successful cannulation and post-ERCP complications were compared between the PAD and non-PAD groups. The quality of the studies was evaluated with the Newcastle-Ottawa Scale (NOS). The meta-analysis was conducted using Review Manager 5.3.

RESULTS

Twenty-eight articles were included. Non-PAD was associated with a relatively high cannulation success rate (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.54-0.97, p = 0.03). However, after 2015, PAD was not correlated with cannulation failure (OR 0.81, 95% CI 0.59-1.11, p = 0.20). Compared with intradiverticular papilla (IDP), non-IDP had a higher successful cannulation rate (OR 0.42, 95% CI 0.25-0.72, p = 0.002), while IDP increased the difficult cannulation rate (OR 1.60, 95% CI 1.05-2.44, p = 0.03). Additionally, PAD increased the incidence of ERCP-related pancreatitis (OR 1.24, 95% CI 1.10-1.40, p = 0.0006) and bleeding (OR 1.34, 95% CI 1.03-1.73, p = 0.03).

CONCLUSIONS

Although PAD, especially IDP, decreased the cannulation success rate, PAD was no longer considered a significant obstacle to cannulation after 2015. PAD increased the incidence of post-ERCP pancreatitis and bleeding.

The usefulness of traction-assisted endoscopic papillectomy for ampullary early tumors(with video)

Objective Endoscopic papillectomy(EP) is a minimally invasive treatment for early ampullary tumors. However, the optimal method is unclear. The aim of this study is to explore the efficacy and safety of traction-assisted EP treatments for ampullary early tumors.Methods We retrospective analyzed the patients with ampullary adenoma or early adenocarcinoma underwent endoscopic papillectomy between January 2010 and August 2023, including patient characteristics, lesion size, papilla type, pathological diagnosis and lesion surrounding conditions, en-bloc resection rate, complete resection rate, procedure time, complications, recurrences.Results During the study period, a total of 106 patients with ampullary adenoma or early adenocarcinoma underwent EP. The number of patients in traction group (clip combined with dental floss traction, CDT-EP) and non-traction group (hot snare papillectomy, HSP or endoscopic mucosal resection, EMR) were 45 and 61 respectively. The traction group has a higher en-bloc resection rate and complete resection rate than the non-traction group (92.86% vs. 68.85%, p = 0.003; 90.48% vs. 60.66%, p = 0.001), and the procedure time is slightly shorter[(1.57 ± 1.93)min vs. (1.98 ± 1.76)min, p = 0.039]. The complications and recurrence in the traction group were lower than those in the non-traction group (7.14% vs. 19.72%, p = 0.076; 7.14% vs. 11.78%, p = 0.466), and all complications were successfully treated by endoscopy or conservative medical treatment. There was no statistical difference between the two groups in terms of patient characteristics, papilla type, pathological diagnosis and lesion surrounding conditions (p > 0.050), but there were differences in lesion size[(13 ± 1.09)mm vs. (11 ± 1.65)mm, p = 0.002]. The recurrence rate of the traction group is lower than that of the non-traction group, but the difference is not significant(7.14% vs. 13.11%, p = 0.335), and the non-traction group mainly has early recurrence. Further analysis shows that the size of the lesion, whether en-bloc resection or not, and the method of resection as independent risk factors for incomplete resection (OR = 1.732, p = 0.031; OR = 3.716, p = 0.049; OR = 2.120, p = 0.027).Conclusions CDT- EP, HSP and EMR are all suitable methods for the treatment of ampullary adenoma or early adenocarcinoma. Assisted traction technology can reduce the operation difficulty of large and difficult to expose lesions, thereby improving the efficacy and safety of EP.

Initial experience of visualized biliary cannulation during ERCP

BACKGROUND : Selective biliary cannulation is the most challenging step in endoscopic retrograde cholangiopancreatography (ERCP) because only indirect radiographic images can be obtained. Therefore, we developed a novel endoscopic retrograde direct cholangioscopy (ERDC) technology to facilitate visible biliary cannulation. METHODS : In this case series, we used ERDC to treat 21 patients with common bile duct stones who were enrolled consecutively between July 2022 and December 2022. The procedure details and complications were recorded, and all patients were followed up for 3 months after the procedure. The learning curve effect was analyzed by comparing the early and later cases. RESULTS : Biliary cannulation was successful in all patients, and the stones were removed completely. The median (interquartile range [IQR]) time for cholangioscopy-guided biliary cannulation was 240.0 (10.0-430.0) seconds, and the median (IQR) number of cannulation procedures was 2 (1-5). Despite there being one episode of post-ERCP pancreatitis, one of cholangitis, and three patients developing asymptomatic hyperamylasemia, all of the patients recovered after symptomatic treatment, being discharged and with no serious adverse events occurring during the 3-month follow-up period. Compared with the early cases, the number of intubations and the use of guidewire guidance decreased in later cases. CONCLUSION : Our research confirms that ERDC is a feasible technology for biliary cannulation under direct vision.

A new classification of periampullary diverticulum: cannulation of papilla on the inner margins of the diverticulum (Type IIa) is more challenging

BACKGROUND

Periampullary diverticulum (PAD) may make the performance of endoscopic retrograde cholangiopancreatography (ERCP) in patients with choledocholithiasis more difficult and may increase complication rates. The present study evaluated the effects of PAD on first-time ERCP in patients with choledocholithiasis.

METHODS

Outcomes were compared in patients with and without PAD and in those with four types of PAD: papilla located completely inside the diverticulum (type I), papilla located in the inner (type II a) and outer (type II b) margins of the diverticulum; and papilla located outside the diverticulum (type III). Parameters compared included cannulation time and rates of difficult cannulation, post-ERCP pancreatitis (PEP) and perforation.

RESULTS

The median cannulation times in patients with types I, II a, II b, III PAD and in those without PAD were 2.0 min, 5.0 min, 0.67 min, 3.5 min, and 3.5 min, respectively, with difficult cannulation rates in these groups of 7.4%, 31.4%, 8.3%, 18.9%, and 23.2%, respectively. The rates of PEP in patients with and without PAD were 5.3% and 5.1%, respectively. Four patients with and one without PAD experienced perforation.

CONCLUSIONS

The division of PAD into four types may be more appropriate than the traditional division into three types. Cannulation of type I and II b PAD was easier than cannulation of patients without PAD, whereas cannulation of type II a PAD was more challenging. PAD may not increase the rates of PEP.

Predictive factors of needle-knife pre-cut papillotomy failure in patients with difficult biliary cannulation

Predictors of needle-knife pre-cut papillotomy (NKP) failure for patients with difficult biliary cannulation has not been reported. Between 2004 and 2016, 390 patients with difficult biliary cannulation undergoing NKP were included in this single-center study. Following NKP, deep biliary cannulation failed in 95 patients (24.4%, NKP-failure group) and succeeded in 295 patients (75.6%, NKP-success group). Patient and technique factors were used to identify the predictors of initial NKP failure. Compared with the NKP-success group, periampullary diverticulum (28.4% vs. 18%, p = 0.028), surgically altered anatomy (13.7% vs. 7.1%, p = 0.049), number of cases performed by less experienced endoscopists, and bleeding during NKP (38.9% vs. 3.4%, p < 0.001), were significantly more frequent in the NKP-failure group. On multivariate analysis, surgically altered anatomy (OR 2.374, p = 0.045), endoscopists' experience (OR 3.593, p = 0.001), and bleeding during NKP (OR 21.18, p < 0.001) were significantly associated with initial failure of NKP. In conclusion, NKP is a highly technique-sensitive procedure, as endoscopists' experience, bleeding during NKP, and surgically altered anatomy were predictors of initial NKP failure.

Propensity score-matched analysis for comparing transpancreatic sphincterotomy and needle-knife precut in difficult biliary cannulation

Transpancreatic sphincterotomy (TPS) can be an alternative approach of difficult biliary access in endoscopic retrograde cholangiopancreatography (ERCP). We aimed to evaluate the efficacy and safety of TPS compared to needle-knife precut (NKP), considering the early and late outcomes of both techniques. The prospectively collected clinical data, ERCP procedure findings, and outcomes of patients who underwent ERCP with difficult biliary access in our hospital from July 2016 to January 2018 were retrospectively analyzed. The patients were divided into two groups according to the applied secondary cannulation techniques. The propensity score matching (PSM) was applied to reduce the potential selection bias and unify the preventive measures of post-ERCP pancreatitis (PEP) in both groups. A total of 125 patients were enrolled in this study, with 54.4% male and a mean age of 63.29 ± 16.33 years. NKP group included 82 patients, and 43 patients received TPS. Prophylactic pancreatic stents were placed in all patients with TPS and 58.5% of patients with NKP. After applying PSM, the cohort was comprised to 86 patients with 43 patients in each TPS and NKP groups. Successful selective cannulation was achieved by 95.3% using TPS and by 93% using NKP. The mean procedure time was shorter in the TPS group without significant difference. Compared to NKP, using TPS did not affect the rate of PEP. Moreover, TPS was associated with less frequent post-ERCP bleeding and perforation, but without significant differences (all p > 0.05). Patients who received TPS or NKP had no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period. In conclusion, using TPS in difficult cannulation cases was useful to achieve success cannulation with an acceptable PEP rate and less frequent post-ERCP bleeding and perforation compared to NKP. There were no symptoms related to papillary stenosis or chronic pancreatitis during the follow-up period.