Morphology of the papilla can predict procedural safety and efficacy of ERCP – a retrospective cohort study

Aims Endoscopic Retrograde Cholangiopancreatography (ERCP) is a key therapeutic procedure for managing pancreaticobiliary disorders such as biliary obstruction and cholangitis. While bile duct cannulation is crucial for success, limited data exist on factors affecting its outcomes. Papilla morphology, classified by the Haraldsson system, may significantly influence technical success and complication risks, including post-ERCP pancreatitis (PEP), perforation, and bleeding [1]. Periampullary diverticula (PAD) can further challenge the cannulation process [2]. This study evaluated the impact of papilla anatomy on ERCP outcomes, including cannulation success, rescue techniques, and complications.

Methods A retrospective cohort study was conducted at a single tertiary care center on patients with a nave papilla scheduled for ERCP between September 2022 and August 2024. The morphology of the papilla was classified into one of four types according to the Haraldsson classification system, based on endoscopic appearance [3]. Data on the presence of PAD and its association with papilla types were also assessed. Key procedural outcomes, including the indications for ERCP, the rate of post-ERCP adverse events, the rate of failed primary cannulation, and the need for rescue cannulation techniques, were collected and analyzed. Descriptive statistics were employed to summarize the findings.

Results A total of 409 patients with native papilla were included in the study. Cannulation failure rate varied among papilla types, being highest in type II papilla (15.6%), followed by type I (9.1%), type IV (8.1%), and type III (4.4%). PAD was most common in type IV papillae (13.5%) and least common in type III (4.4%). Biliary etiology was the leading indication for ERCP across all papilla types, with rates of 60.6% for type I, 59.4% for type II, 66.7% for type III, and 56.8% for type IV. PEP occurred most frequently in type IV papillae (10.8%), followed by type III (6.7%), type I (6.5%), and type II (4.2%). Other complications, including cholangitis, perforation, and bleeding, were rare, with rates of 1.73% for type I and 2.08% for type II papillae, while none occurred in type III or IV papillae. Rescue cannulation techniques were most often required in type III papillae (46.7%) and similarly in type I (40.7%) and type IV (40.5%), but less often in type II papillae (29.2%).

Conclusions Papilla morphology influences ERCP outcomes, including cannulation success and complication rates. Type II papilla had the highest cannulation failure rate, while type IV was linked to the highest rates of PEP and PAD. Recognizing and understanding papilla anatomy is crucial for optimizing procedural strategies, enhancing success rates, and ensuring patient safety.

Publication History

Article published online:
27 March 2025

• References

• 1 Yue P, Zhu KX, Wang HP, Meng WB, Liu JK, Zhang L, Zhu XL, Zhang H, Miao L, Wang ZF, Zhou WC, Suzuki A, Tanaka K, Li X.. Clinical significance of different periampullary diverticulum classifications for endoscopic retrograde cholangiopancreatography cannulation. World J Gastroenterol 2020; 26 (19): 2403-15
• 2 Tari E, Gagyi EB, Rancz A, Veres DS, Váncsa S, Hegyi PJ, Hagymási K, Hegyi P, Erőss B.. Morphology of the papilla can predict procedural safety and efficacy of ERCP—a systematic review and meta-analysis. Sci Rep 2024; 14 (01): 12345
• 3 Haraldsson S, Käppi M, Toth E, Lindström O, Ljungberg C, Thorlacius H.. Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study. United European. Gastroenterol J 2017; 5 (04): 504-10