Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP

Erik Haraldsson, Leena Kylänpää, Juha Grönroos, Arto Saarela, E. Tóth, Gunnar Qvigstad, Mari Hult, Outi Lindström, Simo Laine, Heikki Karjula, Truls Hauge, Riadh Sadik, Urban Arnelo

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Abstract

Background and Aims: Certain appearances of the major duodenal papilla have been claimed to make cannulation more difficult during ERCP. This study uses a validated classification of the endoscopic appearance of the major duodenal papilla to determine if certain types of papilla predispose to difficult cannulation. Methods: Patients with a naïve papilla scheduled for ERCP were included. The papilla was classified into 1 of 4 papilla types before cannulation started. Time to successful bile duct cannulation, attempts, and number of pancreatic duct passages were recorded. Difficult cannulation was defined as after 5 minutes, 5 attempts, or 2 pancreatic guidewire passages. Results: A total of 1401 patients were included from 9 different centers in the Nordic countries. The overall frequency of difficult cannulation was 42% (95% confidence interval [CI], 39%-44%). Type 2 small papilla (52%; 95% CI, 45%-59%) and type 3 protruding or pendulous papilla (48%; 95% CI, 42%-53%) were more frequently difficult to cannulate compared with type 1 regular papilla (36%; 95% CI, 33%-40%; both P <.001). If an inexperienced endoscopist started cannulation, the frequency of failed cannulation increased from 1.9% to 6.3% (P <.0001), even though they were replaced by a senior endoscopist after 5 minutes. Conclusions: The endoscopic appearance of the major duodenal papilla influences bile duct cannulation. Small type 2 and protruding or pendulous type 3 papillae are more frequently difficult to cannulate. In addition, cannulation might even fail more frequently if a beginner starts cannulation. These findings should be taken into consideration when performing studies regarding bile duct cannulation and in training future generations of endoscopists.

Original languageEnglish
JournalGastrointestinal Endoscopy
DOIs
Publication statusAccepted/In press - Jan 1 2019

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ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Gastroenterology

Cite this

Haraldsson, E., Kylänpää, L., Grönroos, J., Saarela, A., Tóth, E., Qvigstad, G., Hult, M., Lindström, O., Laine, S., Karjula, H., Hauge, T., Sadik, R., & Arnelo, U. (Accepted/In press). Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP. Gastrointestinal Endoscopy. https://doi.org/10.1016/j.gie.2019.07.014