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Transpapillary Biliary Cannulation is Difficult in Cases with Large Oral Protrusion of the Duodenal Papilla

  • Masafumi Watanabe
  • Kosuke OkuwakiEmail author
  • Mitsuhiro Kida
  • Hiroshi Imaizumi
  • Hiroshi Yamauchi
  • Toru Kaneko
  • Tomohisa Iwai
  • Rikiya Hasegawa
  • Eiji Miyata
  • Hironori Masutani
  • Masayoshi Tadehara
  • Kai Adachi
  • Wasaburo Koizumi
Original Article

Abstract

Background

Biliary cannulation failure is a major problem during endoscopic retrograde cholangiopancreatography. It remains unclear how duodenal papilla morphology affects biliary cannulation. Therefore, we proposed a new classification system for the duodenal papilla based on oral protrusion pattern (ratio of the length of the oral protrusion to the transverse diameter of the papilla) and papilla pattern.

Aims

To retrospectively compare biliary cannulation results with regard to classification and operator experience.

Methods

We analyzed 589 naïve major duodenal papillae. Our classification system comprised oral protrusion pattern, classified as small (Protrusion-S), regular (Protrusion-R), or large (Protrusion-L), and the papilla pattern, classified as annular (Papilla-A), unstructured (Papilla-U), longitudinal (Papilla-LO), isolated (Papilla-I), or gyrus (Papilla-G). Intra-evaluator concordance and the results of biliary cannulation were analyzed.

Results

The following oral protrusion pattern classifications were observed: Protrusion-S, 11.7%; Protrusion-R, 77.9%; and Protrusion-L, 10.4%. The following papilla patterns were observed: Papilla-A, 67.1%; Papilla-U, 7.0%; Papilla-LO, 7.5%; Papilla-I, 1.2%; Papilla-G, 15.6%; and unclassified, 1.7%. Intra-evaluator concordance value (Fleiss kappa) was 0.788 for oral protrusion pattern and 0.750 for papilla pattern. A logistic regression analysis of cannulations performed by an experienced endoscopist identified Protrusion-L as a significant risk factor for difficult cannulation (odds ratio 2.956; 95% confidence interval 1.115–7.84; p = 0.029). Multivariate analysis confirmed Protrusion-L as an independent risk factor for difficult biliary cannulation (odds ratio 3.772; 95% confidence interval 1.359–10.464; p = 0.011).

Conclusions

We propose a new general classification system for the duodenal papilla. Protrusion-L is a significant risk factor for difficult biliary duct cannulation.

Keywords

Cholangiopancreatography Endoscopic retrograde Ampulla of vater Risk factors 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Masafumi Watanabe
    • 1
  • Kosuke Okuwaki
    • 1
    Email author
  • Mitsuhiro Kida
    • 1
  • Hiroshi Imaizumi
    • 1
  • Hiroshi Yamauchi
    • 1
  • Toru Kaneko
    • 1
  • Tomohisa Iwai
    • 1
  • Rikiya Hasegawa
    • 1
  • Eiji Miyata
    • 1
  • Hironori Masutani
    • 1
  • Masayoshi Tadehara
    • 1
  • Kai Adachi
    • 1
  • Wasaburo Koizumi
    • 1
  1. 1.Department of GastroenterologyKitasato University School of MedicineSagamiharaJapan

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