KEYWORDS:
Cannulation
-
common bile duct
-
sphincterotomy
INTRODUCTION
Selective common bile duct (CBD) cannulation is one of the most crucial steps of a
successful endoscopic retrograde cholangiopancreatography (ERCP) procedure. Although
developments in various endoscopic accessories have improved the CBD cannulation rate,
still failure rate in CBD cannulation remains at 5%–15%.[1] Failure in cannulating CBD results from altered anatomy, ampullary tumors, inflammatory
changes of the intestine due to pancreatitis, and juxtapapillary diverticula. Alternative
techniques for cannulating CBD include precut spincterotomy, needle-knife papillotomy,
fistulotomy, percutaneous endoscopic or endoscopic ultrasound-guided rendezvous procedure,
percutaneous transhepatic biliary therapy, or surgical intervention.[2]
Although precut sphincterotomy ensures over 90% success of biliary cannulation,[3] sometimes it becomes difficult to cannulate due to papillary edema and vision loss
due to bleeding. Therefore, it appears worthwhile to repeat the ERCP after a short
interval following the initial precut sphincterotomy when the papillary edema has
resolved.
The aim of the present study was to determine the success rate of biliary cannulation
in cases where ERCP is repeated after failed precut sphincterotomy.
MATERIALS AND METHODS
We retrospectively studied 1872 ERCPs done at our center during 4 years period from
August 2013 to June 2017. These ERCPs were analyzed for indication, use of precut
sphincterotomy, biliary access rate, repeat ERCP rate, and complications.
Selective biliary cannulation of the naïve papilla was done using Ultratome™ (5.5Fr)
from Boston Scientific and a straight 0.035-inch guidewire.
For precut sphincterotomy, MicroKnife™ triple-lumen needle knife from Boston Scientific
was used, and the incision was made from below upward starting from the edge of the
papilla and moving upward in the 11 O'clock direction. Length of the cut was determined
by the intraduodenal part of the CBD.
Precut was performed if the standard attempt failed to achieve biliary cannulation
within 10 min or after 5 unsuccessful CBD cannulation attempts or after 3 repeated
cannulation of the pancreatic duct.
In cases of failed precut, repeat ERCP was performed after a median of 3 days (range:
3–4 days). There were two reasons for this criterion. First, previous studies done
in this regard have used a range of 3–6 days for repeating ERCP, and second, endoscopic
intervention days in our department are repeated after a gap of 3 days.
Simple statistics were used to analyze the available data.
RESULTS
Indications for ERCP in these 1872 patients included CBD stones (55%), malignant obstructive
jaundice (37%) and biliary leak (8%).
Out of 1872 cases, selective biliary cannulation of the naïve papilla was achieved
in 1590, i.e., 84.9%; with the remaining 15.1% of cases required precut sphincterotomy
to facilitate biliary access. In 282 cases requiring precut, 175 (62.05%) patients
were females with a mean age of 46 years while 107 (37.94%) patients were male with
a mean age of 58 years. The reason for precut sphincterotomy were juxtapapillary diverticula
(28.36%), impacted stone (21.98%), pancreatitis (8.51%), ampullary tumor (15.95%),
and idiopathic (25.17%). Selective biliary cannulation was successful in 245 out of
282, i.e., 86.87%.
Out of the 37 unsuccessful cases, 20 patients had juxtapapillary diverticula, 3 patients
had pancreatitis, and 14 patients had ampullary tumor.
In this failed precut group, 5 patients developed mild acute pancreatitis, 2 patients
developed iatrogenic bleed, and 2 patients died due to septicemia. Apart from the
2 patients who died, the rest were managed conservatively and later subjected to surgery
for biliary drainage. In the remaining 28 cases, ERCP was repeated after a median
interval of 3 days (range: 3–4 days), and biliary cannulation was achieved in 22 cases,
i.e., 78.5%. Out of 6 cases in which repeat cannulation attempt failed, 4 patients
had ampullary tumor while 2 patients had juxtapillary diverticula. They were later
subjected to percutaneous transhepatic biliary drainage (4 patients) and surgery (2
patients).
DISCUSSION
Although there have been considerable advances in biliary cannulation techniques,
the success rate of standard biliary cannulation during ERCP is successful in around
90% cases. Remaining 10%–15% cases require precut sphincterotomy.[4] Difficulty in cannulation is because of anatomic abnormalities, papillary spasms,
or impacted stones.[5]
However, precut sphincterotomy is not successful in 100% of cases. In such cases,
alternative techniques are used such as percutaneous-endoscopic or endoscopic ultrasound-guided
rendezvous procedure, percutaneous transhepatic biliary drainage, and finally, surgical
intervention.
Apart from precut sphincterotomy, other techniques are more invasive and have considerable
morbidity and mortality. Even though techniques involving endoscopic ultrasound are
safe, but the technical skill and resources required for such procedures are not available
widely.
Therefore, we planned a study to determine the success of biliary cannulation if ERCP
is repeated after few days of failed precut sphincterotomy.
A review of literature shows that study done in the United kingdom by Pavlides et
al.[6] had a success rate of 78% in 89 patients undergoing repeat ERCP after failed initial
precut sphincterotomy. Similarly, Kevans et al.[7] reported a success rate of 68% in 19 Irish patients undergoing repeat ERCP following
failed initial needle-knife fistulotomy. Another recent study by Kim et al.[8] from South Korea showed a success rate of 76.8% in 69 patients undergoing repeat
ERCP after failed initial precut sphincterotomy.
In our study, 282 patients (15.1%) underwent precut sphincterotomy and selective biliary
cannulation was successful in 245 out of 282, i.e., 86.87%.
37 cases could not be cannulated even after precut sphincterotomy. Majority of these
patients had juxtapapillary diverticula (20 patients) and ampullary tumor (14 patients).
A total of 28 cases underwent repeat ERCP after failed precut sphincterotomy. Out
of this, 22 patients, i.e., 78.5% cases had successful biliary cannulation and drainage.
This is similar to the above-discussed studies.
A possible reason for this finding can be that edema caused by initial cannulation
attempts and cautery usually resolves in 3 to 4 days after the initial precut, and
thus, the anatomy of the papilla becomes better delineated.
As far as failed cannulation after precut sphincterotomy is concerned, it was mostly
seen in malignant biliary obstruction patients and could be due to infiltration of
the biliary tract by tumor cells.
CONCLUSION
The present study concludes that repeating ERCP after 3 days in cases of failed initial
precut sphincterotomy should be practiced and recommended as this allows definitive
biliary therapy in majority of such patients and prevents morbidity and mortality
from other invasive alternative therapies.
Financial support and sponsorship
Nil.
