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

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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 ( IF 7.7 ) Pub Date : 2019-07-18 , DOI: 10.1016/j.gie.2019.07.014
Erik Haraldsson ₁ , Leena Kylänpää ₂ , Juha Grönroos ₃ , Arto Saarela ₄ , Ervin Toth ₅ , Gunnar Qvigstad ₆ , Mari Hult ₇ , Outi Lindström ₂ , Simo Laine ₃ , Heikki Karjula ₄ , Truls Hauge ₈ , Riadh Sadik ₉ , Urban Arnelo ₁₀

Affiliation

Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Skaraborg Hospital, Skövde, Sweden.
Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
Department of Surgery, University of Turku, and Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.
Department of Surgery, Oulu University Hospital, Oulu, Finland.
Department of Gastroenterology, Skåne University Hospital, Lund University, Malmö, Sweden.
Department of Gastroenterology and Hepatology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
Department of Medicine, Solna, Unit of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.
Department of Gastroenterology, Oslo University Hospital and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
Department of Gastroenterology, Sahlgrenska Academy, Gothenburg, Sweden.
Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.

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.

中文翻译：

主要十二指肠乳头的宏观外观影响胆管插管：斯堪的纳维亚消化内镜协会ERCP研究组的一项前瞻性多中心研究。

背景和目标

据称，十二指肠主要乳头的某些外观使得在ERCP期间插管更加困难。这项研究使用了经验证的十二指肠主要乳头的内窥镜外观分类，以确定某些类型的乳头是否易于插管困难。

方法

包括计划用于ERCP的幼稚乳头的患者。在开始插管之前，将乳头分为4种乳头中的1种。记录成功完成胆管插管的时间，尝试次数和胰管通过次数。困难插管定义为5分钟，5次尝试或2次胰腺导丝通过后。

结果

来自北欧国家9个不同中心的1401名患者被纳入研究。困难插管的总频率为42％（95％置信区间[CI]，39％-44％）。与1型普通型相比，2型小乳头（52％; 95％CI，45％-59％）和3型突出或下垂型乳头（48％; 95％CI，42％-53％）更难插管。乳头（36％; 95％CI，33％-40％;均P <.001）。如果没有经验的内窥镜医师开始进行插管，则即使在5分钟后由资深内窥镜医师代替，失败的插管频率也会从1.9％增加到6.3％（P <.0001）。