Difficult cannulation as defined by a prospective study of the Scandinavian Association for Digestive Endoscopy (SADE) in 907 ERCPs

Abstract

Background. The definition of a “difficult” cannulation varies considerably in reports of endoscopic retrograde cholangiopancreatography (ERCP). Aims. To define a difficult cannulation, which translates into higher risk of post-ERCP pancreatitis. Patients and methods. Prospective consecutive recording of 907 cannulations in Scandinavian centers done by experienced endoscopists. Inclusion: indication for biliary access in patients with intact papilla. Exclusion: acute non-biliary and chronic pancreatitis at time of procedure. Results. The primary cannulation succeeded in 74.9%, with median values for time 0.88 min (53 s), with two attempts and with zero pancreatic passages or injections. The overall cannulation success was 97.4% and post-ERCP pancreatitis (PEP) rate was 5.3%. The median time for all successful cannulations was 1.55 min (range 0.02–94.2). If the primary cannulation succeeded, the pancreatitis rate was 2.8%; after secondary methods, it rose to 11.5%. Procedures lasting less than 5 min had a PEP rate of 2.6% versus 11.8% in those lasting longer. With one attempt, the PEP rate was 0.6%, with two 3.1%, with three to four 6.1%, and with five and more 11.9%. With one accidental pancreatic guide-wire passage, the risk of the PEP was 3.7%, and with two passages, it was 13.1%. Conclusions. If the increasing rate of PEP is taken as defining factor, the wire-guided cannulation of a native papilla can be considered difficult after 5 min, five attempts, and two pancreatic guide-wire passages when any of those limits is exceeded.

Key Words::

• cannulation
• ERCP
• needle knife
• sphincterotomy

Acknowledgements

ANDRE, the Allied Network for Development and Research in Endoscopy, which is the research group of the Scandinavian Association for Digestive Endoscopy (SADE), is funded by unrestricted educational grants from Cook, Boston Scientific, and Olympus.

Declaration of interest: Dr. Søren Meisner is an ad hoc consultant for Coloplast Denmark, Boston Scientific, Olympus Europe and Olympus Denmark. Drs. Jorma Halttunen, Lars Aabakken, Urban Arnelo, Juha Grönroos, Truls Hauge, Per M. Kleveland, Palle Nordblad Schmidt, Arto Saarela, Fredrik Swahn, Ervin Toth, J.-Matthias Löhr, and Mr. Harri Mustonen have nothing to disclose.