The endoscopic morphology of major papillae influences the selected precut technique for biliary access

Impact of major duodenal papilla morphology on the outcomes of primary needle-knife fistulotomy for deep biliary cannulation

The morphology of the major duodenal papilla (MDP) plays a crucial role in the selection of the cannulation technique. Primary needle-knife fistulotomy (pNKF) is an advanced cannulation technique is getting more popular because of the lower risk of post-ERCP pancreatitis (PEP). However, few studies have explored the impact of MDP morphology on pNKF outcomes. This study aimed to assess the safety and efficacy of pNKF for different MDP morphologies. A review of medical records between 2022 and 2024 revealed 200 patients with naïve MDP who underwent pNKF at Taleghani Hospital. Patients were classified into the three groups on the basis MDP morphology: regular: n = 34 (17%), long: n = 104 (52%), and bulging: n = 64 (31%). There were no patients with small papilla who underwent pNKF in the records. We compared successful biliary cannulation, the difficulty of procedure, and post-ERCP adverse events among these three groups. The success rates of pNKF in primary biliary cannulation were 94.1%, 98.1%, and 98.4% in the patients with regular, long, and bulging papilla; respectively (p = 0.38). Moreover, there was no significant difference in the rates of PEP (p = 0.71), bleeding (p = 0.11), perforation (p = 0.48), or cholangitis (p = 1.00). However, the procedure in the regular papilla group was associated with more cannulation attempts (p = 0.025) and longer time for manipulation of the papilla (p < 0.001). In conclusion, pNKF is an effective and safe cannulation technique for regular, long, or bulging papillae, although it may be associated with more cannulation attempts and longer cannulation times for regular papilla. Further multicenter trials with large populations are needed to confirm these findings, and investigate the applicability and the outcomes of pNKF in small papillae.

Impact of duodenal papilla anatomy on needle knife papillotomy safety and efficacy in patients with difficult biliary canulation

BACKGROUND AND AIMS

Needle-knife papillotomy (NKP) is widely performed when biliary cannulation is difficult during endoscopic retrograde cholangiopancreatography (ERCP). However, its safety and efficacy in different types of duodenal papilla are not clear.

PATIENTS AND METHODS

This retrospective study analyzed 217 patients with difficult biliary cannulation who underwent NKP during ERCP procedures from June 2013 to May 2022 in our institution. Patients were classified according to Haraldsson classification type of duodenal papilla: type 1, regular; type 2, small; type 3, protruding or pendulous; and type 4, creased or ridged. Outcome measures were successful biliary cannulation and incidence of adverse events.

RESULTS

Haraldsson classification was type 1 in 115 patients, type 2 in 29, type 3 in 52, and type 4 in 21. Biliary cannulation was successful in 166 patients (76.5%) Success rates according to Haraldsson type were as follows: type 1, 74.8%; type 2, 82.8%; type 3, 80.8%; and type 4, 66.7%. The rates did not significantly differ among the types (p = 0.48). Overall incidence of adverse events was 9.22%. Incidence of adverse events did not significantly differ among the types (p = 0.69).

CONCLUSIONS

NKP was useful to achieve successful cannulation in patients with difficult biliary cannulation. The rate of successful cannulation and incidence of adverse events were similar among the different types of duodenal papilla.

Feasibility and safety of partial ampullary endoscopic mucosal resection: a novel technique for difficult biliary cannulation (with video)

BACKGROUND

Biliary cannulation can be challenging even for expert endoscopists, and rescue techniques are limited. Our objective was to determine the feasibility and safety of partial ampullary endoscopic mucosal resection (PA-EMR), a novel technique for biliary cannulation.

METHODS

Monocentric, retrospective analysis of a prospectively maintained database in a tertiary referral university hospital. Fourteen patients who required endoscopic retrograde cholangiopancreatography (ERCP) and underwent PA-EMR between January 1, 2020 and January 31, 2021 were included. For biliary cannulation of prominent papillae, PA-EMR was performed using a standard polypectomy snare, alone or in combination with needle-knife sphincterotomy. In patients with non-prominent papilla, the papillary mucosa was elevated with the aid of methylene blue injection before resection and combined with needle-knife fistulotomy when needed. The rate of technical success and adverse events was assessed.

RESULTS

The bile duct cannulation success was 99% in the first attempt and 100% overall with the PA-EMR technique. Only one patient experienced mild bleeding, which spontaneously stopped.

CONCLUSION

PA-EMR is an effective technique that may be considered as a rescue technique for difficult biliary cannulation in expert hands. Future studies including larger cohorts and comparisons with other techniques are warranted to further confirm the feasibility and safety of this novel technique.

Success and Safety of Needle Knife Papillotomy and Fistulotomy Based on Papillary Anatomy: A Prospective Controlled Trial

BACKGROUND

Needle knife papillotomy (NKP) and fistulotomy (NKF) are the two most commonly used rescue techniques for patients with difficult biliary cannulation (DBC). Anatomy of the major duodenal papillae (MDP) influences the optimal precut technique for biliary access. However, comparative studies of the success and safety of NKP and NKF based on the anatomy of MDP have been scarce.

METHODS

Patients with intact MDPs for therapeutic endoscopic retrograde cholangio-pancreatography (ERCP) in our center were enrolled. Early needle knife precuts were uniformly applied to patients with DBC. Difficult MDPs were classified into one of five types based on their endoscopic anatomy. Each type of MDP was allocated to NKP or NKF treatment. Patients with types 1 and 2 papillae always received NKF, 3 and 4 received NKP, and 5 could receive either. The safety and efficacy were analyzed between NKP and NKF, and among different types of MDPs.

RESULTS

A total of 188 out of 1674 patients undergoing ERCP satisfied the criteria for early precutting: 75 patients were assigned to the NKP group and 113 to the NKF group. The total initial success rate of biliary cannulation (ISRBC) of the precut techniques (both NKP and NKF) for patients with DBC was 91.5%. The ISRBC of patients of the NKP group was similar to that of the NKF group (90.7% vs 92.0%, P > 0.05). The ISRBC of the patients in the swollen MDP subgroup (96.1%) was higher than that of patients in the distorted MDP subgroup (81.8%, P = 0.030). The total and specific complications of the patients of the NKP group were similar to those of the NKF group (P > 0.05).

CONCLUSIONS

NKP and NKF, as selected on the basis of MDP anatomy, are equally safe and highly efficient for patients with DBC to allow biliary cannulation. Patients with swollen MDPs had a higher ISRBC than patients with distorted MDPs. Selecting a precut method based on MDP anatomy is an effective and safe strategy for patients with DBC.

Needle knife fistulotomy in flat and diverticular papillae: Is it time for redemption?

BACKGROUND

European Society of Gastrointestinal Endoscopy (ESGE) recommends needle-knife fistulotomy (NKF) as the preferred precut technique in cases when standard cannulation techniques fail. Despite scarce scientific evidence, flat and diverticular papillae are thought not to be ideal for NKF, as they are associated with poor outcomes. The present study aimed to determine the outcomes of the use of NKF in relation to flat and intradiverticular papillae.

METHODS

This prospective multicenter study enrolled consecutive patients, evidencing naïve flat (group A, n = 49) or diverticular papilla (group B, n = 28), who underwent NKF after failure of standard cannulation techniques. Diverticular morphology was subdivided into intradiverticular (group B1, n = 14) and diverticular border papillae (group B2, n = 14), using a previously validated endoscopic classification of the major papilla. The success of biliary cannulation at initial endoscopic retrograde cholangiopancreatography (ERCP), overall biliary cannulation, overall cannulation time, and the rate of adverse events were assessed in the study.

RESULTS

The initial cannulation rates were 93.9%, 64.3% and 71.4% for group A, B1, and B2, respectively (P = 0.005); overall cannulation rates after a second ERCP were 98.0%, 92.9% and 85.7%, respectively (P = 0.134). Adverse events occurred in 11.7% of patients, with post-ERCP pancreatitis (PEP) being the most common adverse event (10.4%). Although there was a trend towards a higher incidence of PEP in flat papillae, univariate and multivariate analyses did not show any significant relationship between pancreatitis and trainee involvement, papillary morphology, nor overall cannulation time.

CONCLUSIONS

Although flat papillae are associated with high success rates of biliary cannulation using NKF, the rate of PEP is not negligible. NKF is feasible in diverticular papillae, but it is associated with a modest success rate in the initial ERCP.

Outcomes of single-endoscopist-performed needle-knife fistulotomy for selective biliary access in 842 consecutive patients: learning curve and changes over a 14-year period in a retrospective study

BACKGROUND AND AIMS

Needle-knife fistulotomy (NKF) has emerged as the preferred precut technique. From a late strategy, NKF has shifted to an early rescue technique and has been used recently as a primary method for biliary access. It is unknown how these changes have affected NKF outcomes. We analyzed the outcomes of NKF over time in a large cohort of patients.

METHODS

Multicenter retrospective cohort study of 842 patients who underwent NKF for biliary access between 2006 and 2019. Patients were divided into four study periods according to a late or early cannulation strategy and to the use of post-ERCP pancreatitis prophylaxis (Period 1-Period 4). We assessed outcomes of NKF, learning curves and shifts over time.

RESULTS

Bile duct access was obtained in 88.0% of the patients. The initial cannulation rate increased significantly from 77.5% in P1 to 92.0% in P4 (p < .001). An endoscopist can obtain 80% success rate after performing 100 NKF procedures (95% CI: 0.79-0.86) and a 95% success rate after 830 procedures (95% CI: 0.92-0.98). Adverse events and pancreatitis were observed in 6.5% and 4.9% of patients respectively. The rate of pancreatitis was not significantly different during the 4 periods (p = .190). A decline in the pancreatitis rate was observed from 2006 until 2016 (no trainees) and then an increase until 2019 (trainees involved). The presence of trainees increased the rate of pancreatitis in the last period by 9.9%.

CONCLUSIONS

The success of NKF has increased significantly over the years, initially in a rapid manner and then more slowly. It is associated with a low rate of complications, which tend to decrease with experience. The involvement of trainees is associated with an increased rate of pancreatitis.

Influence of a novel classification of the papilla of Vater on the outcome of needle-knife fistulotomy for biliary cannulation

Background

Existing proposed classification systems for the Papilla of Vater (PV) suboptimally account for all relevant, encountered PV appearances, are too complex or have not been assessed for intra- or interobserver variability. We proposed a novel endoscopic classification system for PV, determined its inter- and intraobserver rates and used the classification system to assess whether the success and complications of needle-knife fistulotomy (NKF) are influenced by the morphology of the PV.

Methods

The classification system was developed by expert endoscopists. To evaluate the inter- and intraobserver agreement, an online questionnaire was sent to 20 endoscopists from several countries (10 experts and 10 nonexperts) that included 50 images of papillae of Vater divided among various categories. Four weeks later, a second survey, with the images from the first questionnaire randomly reordered, was sent to the same endoscopists. The inter- and intraobserver agreements among the experts and nonexperts was calculated. Using the proposed classification system, all 361 consecutive patients who underwent NKF for biliary access to a naïve papilla were prospectively enrolled in the study.

Results

The novel classification system comprises 7 categories: type I, flat type, lacking an oral protrusion; type IIA, prominent tubular nonpleated type, with an oral protrusion and < 1 transverse fold over the oral protrusion; type IIB, prominent tubular pleated type, with an oral protrusion and > 2 transverse folds over the oral protrusion; type IIC: prominent bulging type, with an enlarged and bulging oral protrusion; type IIIA, diverticular-intradiverticular type, with a papillary orifice inside the diverticulum; type IIIB: diverticular-diverticular border type, with a papillary orifice less than 2 cm from the diverticular border; type IV: unclassified papilla, with no morphology classified in the other categories. The interobserver agreement between experts was substantial (K = 0.611, 95% CI 0.498–0.709) and was higher than that between nonexperts (K = 0.516; 95% CI 0.410–0.636). The intraobserver agreement was substantial among both experts (K = 0,651; 95% CI 0.586–0.715) and nonexperts (K = 0.646, 95% CI 0.615–0.677). In a multivariate model, type IIIA and IIIB were the only independent risk factors for difficult rescue NKF biliary cannulation (P = 0.003 and P = 0.019, respectively), and type I and type IIB were the only independent risk factors for a prolonged cannulation time using NKF (P < 0.001 and P = 0.005, respectively).

Conclusions

The novel endoscopic classification system for PV is highly reproducible among experienced ERCPists according to the substantial level of agreement between experts. However, nonexperts require further training in its use. Using the novel classification system, we identified different types of papillae significantly associated with a lower efficacy of NKF and a prolonged time to obtain successful biliary cannulation using NKF.

Should we use papilla morphology to estimate the size of the terminal common bile duct during endoscopic retrograde cholangiopancreatography?

OBJECTIVE

A small common bile duct (CBD) diameter has been associated with complications and with a difficult biliary cannulation. Previous studies suggested that this diameter can be predicted during the endoscopic retrograde cholangiopancreatography (ERCP) simply by observing the papillary morphology. Despite this published suggestion there is no study addressing this topic. This study evaluated a possible association between the morphology of the major papilla and the diameter of the terminal CBD (t-CBD).

METHODS

Observational cross-sectional study including consecutive patients with naïve papillae was referred for ERCP in two affiliated university hospitals. The transverse (p-transv) and longitudinal measures (p-long) of the papilla were obtained using a visual method. Papillae were classified into nonprominent, prominent, bulging or other. The t-CBD was measured 1 cm from the papilla using fluoroscopic images in prone/supine. Measurements were performed by two senior endoscopists and outcomes were evaluated using correlation and linear regression model.

RESULTS

We included 245 patients with a median age of 76 years. The median p-transv for each type of papillae was as follows: nonprominent = 6 mm, prominent = 9 mm, bulging = 15 mm and other = 6 mm; P < 0.001. The median t-CBD for nonprominent = 7.62 mm, prominent = 8.34 mm, bulging = 8.60 mm and other = 8.52 mm; P = 0.40. The correlation between the transverse and longitudinal measures of papilla and the t-CBD were 0.0092 and 0.0614, respectively. In the regression model, the t-CBD diameter was not explained by papilla's size or morphology (R = 1.70%; P = 0.80).

CONCLUSION

The morphology of the papilla must not be used as a predictor of the diameter of the CBD as there is no correlation between these two items.

Needle-knife fistulotomy vs. standard biliary sphincterotomy for choledocholithiasis: common bile duct stone recurrence and complication rate

Background and study aims  With common bile duct (CBD) stones, access to the CBD can be achieved through the papilla orifice followed by standard biliary sphincterotomy (SBS), or through precut fistulotomy (PF) in case of difficult cannulation. The two methods alter papilla anatomy differently, potentially leading to a different rate of stone recurrence. No data have been published on stone recurrence after PF in patients with CBD stones. The aim of this study was to evaluate CBD stone recurrence, reintervention rate after PF versus SBS, and complications. Patients and methods  This was a retrospective single-center cohort study including patients undergoing for the first time endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones with PF in case of failed repeated cannulation attempts, matched for sex/age to patients with SBS randomly extracted from our database. T -test and Fisher's tests were used for continuous and categorical variable comparison. Recurrence probability was calculated with Kaplan-Meier curve. Factors associated with ERCP repetition were evaluated with logistic regression through a Cox's proportional hazards model. Results  Eighty-five patients with PF were included, with 85 matched controls (mean age 68.7 years, 45.9 % males). Overall, patients with PF had the same reintervention rate as those with SBS (14.1 % vs. 12.9 %) with a hazard ratio (HR) of 1.11 (95 % CI 0.49 - 2.50; P  = 0.81), but mean time to reintervention was significantly lower (74.9 ± 74.6 vs. 765.6 ± 961.3 days; P  < 0.0001), with 100 % of stones recurring within the first year in the PF group vs. 54.5 % in the SBS group ( P  = 0.01). The only factor associated with ERCP repetition risk was incomplete CBD clearing. Complications, including pancreatitis, did not differ significantly. Conclusions  The reintervention rate was significantly higher in the short term after PF. Therefore, closer follow-up in the first 6 to 12 months after ERCP might be appropriate for patients underoing PF.