Erik Haraldsson1, Leena Kylänpää2, Juha Grönroos3, Arto Saarela4, Ervin Toth5, Gunnar Qvigstad6, Mari Hult7, Outi Lindström2, Simo Laine3, Heikki Karjula4, Truls Hauge8, Riadh Sadik9, Urban Arnelo10. 1. Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Skaraborg Hospital, Skövde, Sweden. 2. Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland. 3. Department of Surgery, University of Turku, and Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland. 4. Department of Surgery, Oulu University Hospital, Oulu, Finland. 5. Department of Gastroenterology, Skåne University Hospital, Lund University, Malmö, Sweden. 6. Department of Gastroenterology and Hepatology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway. 7. Department of Medicine, Solna, Unit of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden. 8. Department of Gastroenterology, Oslo University Hospital and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway. 9. Department of Gastroenterology, Sahlgrenska Academy, Gothenburg, Sweden. 10. Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.
Abstract
BACKGROUND AND AIMS: Certain appearances of the major duodenal papilla have been claimed to make cannulation more difficult during ERCP. This study uses a validated classification of the endoscopic appearance of the major duodenal papilla to determine if certain types of papilla predispose to difficult cannulation. METHODS: Patients with a naïve papilla scheduled for ERCP were included. The papilla was classified into 1 of 4 papilla types before cannulation started. Time to successful bile duct cannulation, attempts, and number of pancreatic duct passages were recorded. Difficult cannulation was defined as after 5 minutes, 5 attempts, or 2 pancreatic guidewire passages. RESULTS: A total of 1401 patients were included from 9 different centers in the Nordic countries. The overall frequency of difficult cannulation was 42% (95% confidence interval [CI], 39%-44%). Type 2 small papilla (52%; 95% CI, 45%-59%) and type 3 protruding or pendulous papilla (48%; 95% CI, 42%-53%) were more frequently difficult to cannulate compared with type 1 regular papilla (36%; 95% CI, 33%-40%; both P < .001). If an inexperienced endoscopist started cannulation, the frequency of failed cannulation increased from 1.9% to 6.3% (P < .0001), even though they were replaced by a senior endoscopist after 5 minutes. CONCLUSIONS: The endoscopic appearance of the major duodenal papilla influences bile duct cannulation. Small type 2 and protruding or pendulous type 3 papillae are more frequently difficult to cannulate. In addition, cannulation might even fail more frequently if a beginner starts cannulation. These findings should be taken into consideration when performing studies regarding bile duct cannulation and in training future generations of endoscopists.
BACKGROUND AND AIMS: Certain appearances of the major duodenal papilla have been claimed to make cannulation more difficult during ERCP. This study uses a validated classification of the endoscopic appearance of the major duodenal papilla to determine if certain types of papilla predispose to difficult cannulation. METHODS:Patients with a naïve papilla scheduled for ERCP were included. The papilla was classified into 1 of 4 papilla types before cannulation started. Time to successful bile duct cannulation, attempts, and number of pancreatic duct passages were recorded. Difficult cannulation was defined as after 5 minutes, 5 attempts, or 2 pancreatic guidewire passages. RESULTS: A total of 1401 patients were included from 9 different centers in the Nordic countries. The overall frequency of difficult cannulation was 42% (95% confidence interval [CI], 39%-44%). Type 2 small papilla (52%; 95% CI, 45%-59%) and type 3 protruding or pendulous papilla (48%; 95% CI, 42%-53%) were more frequently difficult to cannulate compared with type 1 regular papilla (36%; 95% CI, 33%-40%; both P < .001). If an inexperienced endoscopist started cannulation, the frequency of failed cannulation increased from 1.9% to 6.3% (P < .0001), even though they were replaced by a senior endoscopist after 5 minutes. CONCLUSIONS: The endoscopic appearance of the major duodenal papilla influences bile duct cannulation. Small type 2 and protruding or pendulous type 3 papillae are more frequently difficult to cannulate. In addition, cannulation might even fail more frequently if a beginner starts cannulation. These findings should be taken into consideration when performing studies regarding bile duct cannulation and in training future generations of endoscopists.
Authors: Rachid Mohamed; B Cord Lethebe; Emmanuel Gonzalez-Moreno; Ahmed Kayal; Sydney Bass; Martin Cole; Christian Turbide; Millie Chau; Hannah F Koury; Darren R Brenner; Robert J Hilsden; B Joseph Elmunzer; Rajesh N Keswani; Sachin Wani; Steven J Heitman; Nauzer Forbes Journal: Surg Endosc Date: 2020-11-04 Impact factor: 4.584