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Morphology of the major duodenal papilla for the selection of advanced cannulation techniques in difficult biliary cannulation

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Abstract

Background

Morphology of the major duodenal papilla (MDP) influences the outcome of standard biliary cannulation. However, those data on advanced cannulation techniques are scarce. We aimed to study the impact of MDP morphology on the outcome of both standard and advanced cannulation methods.

Methods

Images of naïve papilla were retrospectively reviewed and independently classified into 4 types (1: classic appearance, 2: small, 3: bulging, and 4: ridged papillae). All cannulation was started with guidewire cannulation. After failure, advanced cannulation including double guidewire (DG) and/or precut sphincterotomy (PS) was performed. Outcomes including success rate and complications were analyzed.

Results

A total 805 naïve papilla were included. The overall advanced cannulation rate was 23.2%. The MPD type 2 (OR 1.8, 95% CI 1.8–2.9) and type 4 (OR 2.1, 95% CI 1.1–3.8) required advanced cannulation technique at a higher rate than type 1. Type 3 significantly needed a higher proportion of PS when compared with type 1 (59.09% vs 27.03%, OR 3.90, 95% CI 1.51–10.06). Overall post-ERCP pancreatitis (PEP) was 8% and was not different among MDP types. PEP was significantly increased in difficult cannulation group (15.38% vs 5.71%, p-value < 0.001). Multivariate analysis demonstrated that DG independently increased risk of PEP (OR 3.6, 95% CI 2.0–6.6).

Conclusions

MDP type 2 and type 4 were related to difficult cannulation. Although DG and PS can be used as advanced cannulation in all types, DG carries risk of PEP and PS may be preferred over DG in MDP type 3.

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Acknowledgements

This project was funded by National Research Council of Thailand (NRCT): N42A640330 and support by Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology.

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Authors and Affiliations

  1. Department of Anatomy, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand

    Phonthep Angsuwatcharakon & Chompoonuch Thongsuwan

  2. Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand

    Phonthep Angsuwatcharakon, Wiriyaporn Ridtitid, Panida Piyachaturawat, Santi Kulpatcharapong, Pradermchai Kongkam & Rungsun Rerknimitr

  3. Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

    Rungsun Rerknimitr

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  1. Phonthep Angsuwatcharakon
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Contributions

PA and CT were involved in study design, data analysis, and drafting of manuscript. PA, CT, WR, PP, SK, PK were involved in data collection. PA, CT, WR, PP, SK, PK, and RR were involved in editing and final approval of the manuscript.

Corresponding author

Correspondence to Rungsun Rerknimitr.

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Disclosures

Drs. Phonthep Angsuwatcharakon, Chompoonuch Thongsuwan, Wiriyaporn Ridtitid, Panida Piyachaturawat, Santi Kulpatcharapong, Pradermchai Kongkam, and Rungsun Rerknimitr have no conflicts of interest or financial ties to disclose. This work was presented in part at the Digestive Disease Week, May 21, 2021.

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Angsuwatcharakon, P., Thongsuwan, C., Ridtitid, W. et al. Morphology of the major duodenal papilla for the selection of advanced cannulation techniques in difficult biliary cannulation. Surg Endosc 37, 5807–5815 (2023). https://doi.org/10.1007/s00464-023-10058-1

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  • DOI: https://doi.org/10.1007/s00464-023-10058-1

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