Introduction
Endoscopic Retrograde Cholangiopancreatography (ERCP) is the most commonly used therapeutic procedure for pancreaticobiliary disorders. Despite the central role of bile duct cannulation in procedural success and safety, data on influencing factors remain limited. Cannulation outcomes can be affected by periampullary diverticula (PAD), anatomical variations, and the experience of the endoscopist. Our previous meta-analysis and systematic review identified papilla morphology as a significant contributing factor. Further research suggests that different papilla types may influence technical success and complication rates, including post-ERCP pancreatitis (PEP). Moreover, papilla morphology appears to impact both the need for and choice of rescue cannulation techniques, making its evaluation particularly relevant in clinical practice.
Aims & Methods
This study aims to evaluate how papilla morphology affects ERCP outcomes, including cannulation success, rescue techniques, and complications like post-ERCP pancreatitis (PEP). We conducted a retrospective cohort study at a tertiary care center, reviewing patients with native papilla scheduled for ERCP between September 2022 and August 2024. Papillae were classified according to the Haraldsson system into four types. Demographic, clinical, and procedural outcome data were collected, including complications such as PEP. Rescue techniques included transpancreatic sphincterotomy (TPS), needle-knife papillotomy (NKP), needle-knife fistulotomy (NKF), and double guidewire technique (DGT). Descriptive statistics were used to analyze the data.
Results
A total of 409 patients with native papilla were included in the study. Cannulation failure rates varied across papilla types, being highest in type II papilla (15.6%), followed by type I (9.1%), type IV (8.1%), and type III (4.4%). The rate of PAD was highest in type IV papillae (13.5%) and lowest in type III (4.4%). Biliary etiology was the leading indication for ERCP across all papilla types, with rates of 60.6% for type I, 59.4% for type II, 66.7% for type III, and 56.8% for type IV. PEP occurred most frequently in type IV papillae (10.8%), followed by type III (6.7%), type I (6.5%), and type II (4.2%). Other complications, including cholangitis, perforation, and bleeding, were rare, with rates of 1.73% for type I and 2.08% for type II papillae, while none occurred in type III or IV papillae. Rescue cannulation techniques were most frequently required in type III papillae (46.7%), where the most common methods included transpancreatic sphincterotomy and needle-knife papillotomy, both of which were used in 20% of cases. The double guidewire technique was employed in 15.6% of type III cases, while needle-knife fistulotomy was used in 6.7%. Type I and type IV papillae also had significant rates of rescue cannulation (40.7% and 40.5%, respectively), with needle-knife papillotomy being the most commonly used method in both types (19.9% for type I and 24.3% for type IV). For type I papillae, TPS was used in 16% of cases, while the DGT was the preferred method for type IV papillae in 13.5% of cases. Rescue techniques were less frequently needed for type II papillae (29.2%), with DGT being the most commonly applied (10.4%), followed by TPS (9.4%) and NKP (8.3%).
Conclusion
Papilla morphology affects ERCP outcomes and the choice of rescue cannulation techniques. Types III and IV were associated with higher use of advanced techniques and complication rates. Identifying papilla type may support individualized procedural planning and improve success and safety.