Introduction

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the most commonly used therapeutic procedure for pancreaticobiliary disorders. Despite the essential role of bile duct cannulation in procedural safety and success, research on this topic is still limited. Certain studies suggest that the anatomy of the papilla affects its efficacy and safety.

Aims & Methods

We aimed to assess the influence of papilla morphology on ERCP outcomes and adverse events.
Patients with a naive papilla scheduled for ERCP were reviewed in a single tertiary care center between September 2022 and January 2023. The papilla was classified into one of four types using the Haralddson classification system. Data on the presence of a periampullary diverticulum (PAD) was also assessed. The indications for ERCP, the rate of post-ERCP adverse events (pancreatitis, bleeding, and perforation), the rate of failed cannulation, and the need and type for rescue cannulations were collected. For the effect size measure, event rates or risk ratios were calculated. For categorical data, the χ² test, and for the test of subgroup (papilla type) differences, a "Cochrane Q" test was used.

Results

A total of 231 patients with naive papillae were included. We found a statistically significant difference in the event rate for cannulation failure between the different papilla types. The highest rate was observed in the case of type II („small”) papilla (14%), followed by type I („regular”) (13%) and type III („protruding or bulging”) (8%). The event rate was lowest in the case of type IV („creased or ridged”) papilla (6%). The presence of PAD was associated with a higher risk of cannulation failure (RR: 2.64; CI: 1.22 – 5.39).
Moreover, a statistically significant difference in the rate of post-ERCP pancreatitis was observed between the papilla types. The event rate was the highest in type III („protruding or bulging”) and IV („creased or ridged”) papilla (13%). The lowest rate rate was observed in type I („regular”) and II („small”) papillae, 6%. There was no significant difference between the post-ERCP bleeding and perforation rate in the different papilla types, likely due to the low event number. The need and the types of the various rescue cannulation techniques also significantly differed between the papilla types.

Conclusion

Certain papilla morphologies are associated with a higher rate of cannulation failure and PEP. The presence of PAD is also associated with an increased rate of cannulation failure. Moreover, we can conclude that the preferred rescue cannulation technique differs between the papilla types.

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.

Introduction

Endoscopic retrograde cholangiopancreatography is the primary therapeutic procedure for pancreaticobiliary disorders, yet bile duct cannulation failure rates
remain 5–20% even among experienced endoscopists. The Haraldsson classification (2017) defines four papilla types, some linked to higher failure and complication rates. Limited research exists on how papilla morphology impacts rescue techniques.

Aims & Methods

This study aims to survey ERCP practitioners to assess the influence of major papilla morphology on their bile duct cannulation strategies. We hypothesize that tailoring cannulation techniques to papilla type may improve success rates and reduce complications.
We are conducting an ongoing international survey targeting physicians who routinely perform ERCP, focusing on how major papilla morphology affects cannulation strategies. The survey was developed using REDCap, a secure web-based platform for data collection, and distributed via professional societies, mailing lists, and social media platforms. It includes questions on respondent demographics, ERCP experience, use of papilla classification systems, and preferred cannulation techniques. Responses are collected anonymously. Initial analysis involves descriptive statistics, with further statistical evaluation planned as data collection progresses. Participation is voluntary, and the survey remains open to ensure broad inclusivity and representation.

Results

Among the 141 respondents, 27% reported using a classification system for papilla morphology. Of these, 57.9% were from certified training centers and 60.5% were affiliated with university-based hospitals. Additionally, 55.3% of classification system users had more than five years of experience, compared to 67% among non-users. Rescue cannulation strategies varied significantly based on papilla type and guidewire placement. For type I papilla, when the guidewire did not enter the pancreatic duct, 35.5% opted for needle-knife precut (NKP), 30.5% for needle-knife fistulotomy (NKF), and 28.4% continued with the standard technique. In contrast, if the guidewire was inadvertently inserted into the pancreatic duct, the double guidewire technique (DGT) was the most common first-line approach (54.6%), followed by prophylactic pancreatic stent (PPS) placement combined with NKF (21.4%) and transpancreatic precut papillotomy (TPPP) (9.2%). For type II papilla, NKP was the most frequently chosen technique (41.1%) when there was no guidewire entry into the pancreatic duct, whereas DGT was preferred (58.9%) when the guidewire was in place. A similar pattern was observed with type III papilla, where DGT was favored (48.9%) in cases of pancreatic duct guidewire placement, and NKP was the leading choice (40.4%) when no guidewire was used. For type IV papilla, DGT was selected by 51.8% of respondents when the guidewire entered the pancreatic duct, while 41.8% preferred to continue with the standard cannulation technique in the absence of guidewire entry.

Conclusion

Differences were observed between classification system users and non-users. DGT was preferred when the guidewire entered the pancreatic duct, while NKP was commonly used when it did not. These findings suggest that adapting techniques based on papilla morphology may improve cannulation success.

Introduction

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the most commonly used therapeutic procedure for pancreaticobiliary disorders. However, how to best achieve safe and effective bile duct cannulation is still debated. Endoscopists doing ERCP routinely recognize the differences in the macroscopic appearance of the major papilla. This has led to a conception that certain appearances of the papilla are more difficult to cannulate and, therefore, more prone to adverse events.

Aims & Methods

We aimed to quantify the influence of papilla morphology on ERCP outcomes.
PROSPERO registration number: CRD42022360894. We systematically searched three medical databases from inception in September 2022. Studies detailing the cannulation or the rate of adverse events in the context of papilla morphology were included. For the primary classification of the major papilla, the Haraldsson system was used, differentiating four morphological types. Data on studies using other classification systems were also collected. A pooled event rate with a 95% confidence interval (CI) was used for the effect size measure. For the test of subgroup differences, a "Cochrane Q" test was used. The risk of bias assessment was performed using the Joanna Briggs Institute Critical Appraisal tool for studies reporting prevalence.

Results

A total of 17 studies were eligible, and 14 were included in the quantitative synthesis. In studies using the Haraldsson classification, the rate of difficult cannulation was the lowest in type I („regular”) papilla (26%; CI: 18–37), followed by type III („protruding or bulging”) (35%; CI: 25–48) and type II („small”) papilla (39%; CI: 28–52). The highest rate was observed in the case of type IV („creased or ridged”) papilla (41%; CI: 28–55). For post-ERCP pancreatitis, the event rate was the highest in type II („small”) papilla (11%; CI: 8–15) and the lowest in type I („regular”) (6%; CI: 5–8) and III („protruding or bulging”) papilla (6%; CI: 4–8). There was no statistically significant difference in the cannulation failure and post-ERCP bleeding event rates between the different papilla types. Similar trends were observed in the analyses including other classification systems comparable to the Haraldsson's. Most studies carried a low risk of bias.

Conclusion

In conclusion, other types are associated with a higher rate of difficult cannulation compared to the regular papilla type. The small papilla is associated with a higher rate of post-ERCP pancreatitis.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is widely used for biliary diseases, yet safety data in transplant recipients remain scarce.

Aims & Methods

This study aimed to evaluate short-term survival and ERCP-related complications in transplant patients. We conducted a retrospective cohort study using the TriNetX database (December 2020–December 2024). Patients diagnosed with acute cholangitis who underwent ERCP were included. Transplant recipients were matched 1:1 with non-transplant controls without active cancer using propensity score matching. Outcomes assessed included survival (Kaplan-Meier analysis) and ERCP-related complications such as post-ERCP pancreatitis (PEP), sepsis, perforation, retroperitoneal abscess, liver abscess, blood transfusion, and emergency department visits.

Results

Before matching, 2,209 transplant recipients and 41,202 non-transplant controls met the inclusion criteria. After propensity score matching, 1,710 matched pairs were analyzed. Survival rates were comparable between transplant and non-transplant groups. Transplant recipients had significantly lower rates of PEP (HR: 0.591, 95% CI: 0.371–0.943, p=0.0254) and emergency department visits (HR: 0.667, 95% CI: 0.498–0.893, p=0.0061). Rates of other complications were not significantly different: sepsis (HR: 1.183, 95% CI: 0.799–1.754, p=0.4005), retroperitoneal abscess (HR: 1.514, 95% CI: 0.587–3.906, p=0.3468), liver abscess (HR: 1.377, 95% CI: 0.826–2.293, p=0.2176), perforation (HR: 2.088, 95% CI: 0.793–5.493, p=0.1272), and blood transfusions (HR: 1.642, 95% CI: 1.255–2.147, p=0.0003). Subgroup analysis of liver transplant patients showed lower PEP rates (HR: 0.592, 95% CI: 0.347–1.009, p=0.0510), but higher risks of retroperitoneal abscess (HR: 3.499, 95% CI: 0.976–12.544, p=0.0402), liver abscess (HR: 2.682, 95% CI: 1.303–5.521, p=0.0053), and blood transfusions (HR: 1.797, 95% CI: 1.282–2.518, p=0.0005).

Conclusion

ERCP appears safe in transplant recipients, demonstrating comparable short-term survival and overall complication rates to non-transplant patients. However, careful monitoring for post-ERCP bleeding and infections is particularly warranted in liver transplant recipients.

References

1. O'Connor HJ, Vickers CR, Buckels JA, McMaster P, Neuberger JM, West RJ, Elias E. Role of endoscopic retrograde cholangiopancreatography after orthotopic liver transplantation. Gut. 1991 Apr;32(4):419-23. doi: 10.1136/gut.32.4.419. PMID: 2026341; PMCID: PMC1379083.
2. Predictors of Early Repeat Endoscopic Retrograde Cholangiopancreatography After Liver Transplantation by Organ Donor TypeSinha, Jasmine et al. Techniques and Innovations in Gastrointestinal Endoscopy, Volume 24, Issue 2, 159 - 166

Introduction

Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy represents a real challenge for endoscopists. The most widely used options for ERCP in these cases are enteroscopy-assisted ERCP (EA-ERCP), laparoscopy-assisted ERCP (LA-ERCP), and endoscopic ultrasound-directed ERCP (EDGE).

Aims & Methods

Our aim is to compare EA-ERCP, LA-ERCP, and EDGE in terms of safety and efficacy by performing a systematic review and meta-analysis. The protocol was registered beforehand with PROSPERO (ID: CRD42022368788). We systematically searched three medical databases, namely MEDLINE (via PubMed), Embase, and Cochrane CENTRAL, to look for studies investigating EA-ERCP, LA-ERCP, or EDGE. We performed indirect comparison to compare the interventions based on comparative and single-arm studies. Proportions were calculated by pooling together event rates with 95% confidence intervals (CI). Differences between interventions were considered significant if p<0.05. Random-effect model was used to pool effect sizes.

Results

In total, 67 studies were included (2,714 patients). The technical success rate was 78% (CI: 0.71-0.83) for EA-ERCP, 93% (CI: 0.9-0.95) for LA-ERCP, and 96% (CI: 0.92-0.98) for EDGE with total heterogeneity (I²) 0%. Subgroup differences were significant between EA-ERCP and EDGE or LA-ERCP groups, p < 0.05. The clinical success rate was 65% (CI: 0.58-0.73) for EA-ERCP, 92% (CI: 0.89-0.94) for LA-ERCP, and 93% (CI: 0.88-0.97) for EDGE, I²: 18%, p< 0.05. Overall adverse event rates were 12% (CI: 0.7-0.21), 19% (CI: 0.14-0.24), and 20% (CI: 0.12-0.31), respectively with I²: 60%, p= 0.343.

Conclusion

EA-ERCP performed poorly compared to LA-ERCP and EDGE regarding technical and clinical success rates, with no significant difference in adverse event rates. Our results question he role of EA-ERCP in the RYGB population.

Introduction

Cannulation of the papilla of Vater is a pivotal step in endoscopic retrograde cholangiopancreatography (ERCP), directly impacting technical success and complication risk. (1) While factors such as endoscopist experience and anatomical variants are known to influence outcomes, (2) the role of papillary morphology remains understudied, particularly in Latin America. Morphology-based risk stratification may aid in anticipating the need for advanced cannulation techniques or expert-level intervention.

Aims & Methods

We prospectively enrolled adults with an intact, naïve major duodenal papilla undergoing ERCP at a high-complexity institution in Bogotá, Colombia. Patients with surgically altered anatomy or periampullary tumors were excluded. Papilla morphology was classified macroscopically according to Haraldsson et al. (3) Difficult cannulation was defined by ESGE criteria: >5 papilla contacts, >5 minutes to cannulate after visualizing the papilla, or ≥2 unintentional pancreatic duct guidewire passes. We recorded clinical and procedural variables, including use of advanced cannulation techniques and complications. Associations were assessed through bivariate comparisons using Fisher’s exact test and odds ratios with 95% confidence intervals (p < 0.05).

Results

58 patients were included (mean age 59.9 years; 63.8% female). The most frequent indication for ERCP was choledocholithiasis (81.0%). Papilla types were: type 1 (63.8%), type 3 (27.6%), type 2 (6.9%), and type 4 (1.7%). Difficult cannulation occurred in 8 cases (13.8%), with overlapping criteria: >5 contacts (n=5), >5 minutes (n=3), and ≥2 pancreatic guidewire passes (n=3). Difficult cannulation was more frequent in type 1 (13.5%) and type 3 (12.5%) papillae and occurred in the single type 4 case; none in type 2. The mean number of contacts with the papilla was 2.4 (range 0–16). Use of advanced cannulation techniques was required in 20 cases (34.5%). Cannulation time was significantly longer when advanced techniques were required, with a median of 21.2 minutes and a mean of 27.6 minutes, compared to 0.5 and 0.9 minutes, respectively, in cases managed conventionally. Post-ERCP prophylaxis measures were used in 35 patients (60.3%), including diclofenac (37.9%), aggressive hydration (32.8%), and pancreatic stenting (27.6%). Three patients (5.2%) received all three preventive measures. Complications included pancreatitis (n = 4, 6.9%) and cholangitis (n = 2, 3.4%). Complication rates did not significantly differ according to papilla type (p = 0.68). No significant difference in pancreatitis incidence was observed between patients who did and did not receive prophylactic measures (p = 1.0; OR 0.64, 95% CI 0.04–9.48). The incidence of post-ERCP pancreatitis was 8.3% in type 1 and 25.0% in type 2 papillae, with no cases observed in type 3 or type 4 papillae. However, the association between papilla morphology and pancreatitis occurrence was not statistically significant (p = 0.268).

Conclusion

Type 1 and type 3 papillae were associated with greater cannulation difficulty, though complications did not differ significantly by morphology. These findings support a growing body of evidence linking papillary type to ERCP complexity. While limited by sample size and the absence of endoscopist stratification, the prospective design, standardized use of ESGE criteria, and regional focus contribute valuable insight into procedural risk. This study provides a foundation for considering papilla morphology in preprocedural planning and for guiding training priorities in high-complexity endoscopy units.

References

1. Liao WC, Angsuwatcharakon P, Isayama H, Dhir V, Devereaux B, Khor CJL, et al. International consensus recommendations for difficult biliary access. Gastrointest Endosc. 2017 Feb;85(2):295–304.
2. Testoni P, Mariani A, Aabakken L, Arvanitakis M, Bories E, Costamagna G, et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016 Jun 14;48(07):657–83.
3. Haraldsson E, Kylänpää L, Grönroos J, Saarela A, Toth E, Qvigstad G, et al. 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. Gastrointest Endosc. 2019 Dec;90(6):957–63.