Introduction

The deep selective cannulation of the bile duct or pancreatic duct has been described as the cornerstone of a successful endoscopic retrograde cholangiopancreatography (ERCP), and perhaps the most challenging aspect of the procedure for trainees. A selective cannulation rate of >80–90% of native papilla cases is usually considered as a good surrogate marker of trainee competence. We aimed to assess whether the presence of a native papilla influences differences in ERCP outcomes and adverse events between trainees and attending endoscopists.

Aims & Methods

We conducted a retrospective study of 1384 patients who underwent ERCP in a single large tertiary insititution between January 2019 and July 2023. Clinical data were prospectively collected during routine ERCP procedures. Demographics, native papilla rates, ASGE-grading system of procedure complexity, cholangioscopy, procedure and fluoroscopy time, adverse events, and technical success rates were compared between ERCP with and without trainee involvement. Technical success was defined as successful cannulation and achievement of therapeutic goal. Categorical variables were compared using Pearson’s chi-square test and continuous variables using a standard t-test. Multivariate regressions were performed to adjust for sex, age, clinical setting, and ASGE complexity.

Results

A total number of 903 (65.3%) procedures had a trainee involved and 481 (34.7%) did not have a trainee involved. The mean patient age was 62 years, 53% were male. The proportion of difficult cases (ASGE Grade ≥3) was in 17.3% with trainees involved vs. 15.4% without trainees involved (p = 0.504). The proportion of native papilla was 44.2% with trainee involvement vs. 42% without trainee involvement (p = 0.434). The native papilla was successfully cannulated in 94% with trainees vs. 93.6% without trainees involved (p = 0.839). Cholangioscopy was used in 11.3% of cases with trainees involved vs. 9.2% without trainees involved (p = 0.218). Trainee participation added 4.8 mins to average procedure time (aOR: 1.04, p = 0.001) and 0.6 mins to fluoroscopy time (aOR: 0.93, p = 0.159). No significant difference was noted between trainees and attending endoscopist in the odds of ERCP adverse events (aOR: 1.9, p = 0.27) or native papilla cannulation/technical success (aOR: 3.11, p = 0.062) for native papilla cases, but procedure time remained longer among trainees (aOR 1.03, p = 0.008)

Conclusion

Native papilla cannulation success > 90% was achieved in this study with trainee participation. Native papilla cannulation performed by trainees was associated with increased procedure time but was not associated with a significant difference in ERCP technical success rates or adverse events.

Table. Adjusted odds ratios for ERCP outcomes with and without trainee involvement for native papilla only

References

References
Voiosu, T., Bălănescu, P., Voiosu, A., Benguş, A., Preda, C., Umans, D. S., Bogdan Mateescu, R., & van Hooft, J. E. (2019). Measuring trainee competence in performing endoscopic retrograde cholangiopancreatography: A systematic review of the literature. United European gastroenterology journal, 7(2), 239–249

Mohamed R, Lethebe BC, Gonzalez-Moreno E, Kayal A, Bass S, Cole M, Turbide C, Chau M, Koury HF, Brenner DR, Hilsden RJ, Elmunzer BJ, Keswani RN, Wani S, Heitman SJ, Forbes N. Morphology of the major papilla predicts ERCP procedural outcomes and adverse events. Surg Endosc. 2021 Dec;35(12):6455-6465.

Introduction

The American Society for Gastrointestinal Endoscopy (ASGE) grading system for endoscopic retrograde cholangiopancreatography (ERCP) has been shown to predict success and adverse events rates. We compared ERCP outcomes and adverse events between complex and non-complex procedures using the ASGE-grading system. Our study also sought to assess the impact of the ASGE-grading system on ERCP outcomes with and without trainee involvement.

Aims & Methods

We conducted a retrospective study of 1392 patients who underwent ERCP procedures in a single large tertiary insititution between January 2019 and July 2023. Clinical data were prospectively collected during routine ERCP procedures. Demographics, cholangioscopy, procedure and fluoroscopy time, adverse events, and technical success rates were compared between complex (ASGE Grade ≥3) and non-complex (ASGE Grade <3) ERCP procedures as well as with and without trainee involvement. Categorical variables were compared using Pearson’s chi-square test and continuous variables using a standard t-test. Multivariate regressions were performed to adjust for sex, age, clinical setting, and native papilla.

Results

Approximately 83.3% of ERCPs were ASGE Grade <3 and 16.7% were ASGE Grade ≥3. The mean patient age was 62 years, 53% were male. The ampulla was native in 45.3% of ASGE Grade <3 vs. 34.1% of ASGE Grade ≥3 (P=0.002). Cholangioscopy was needed in 1% of ASGE Grade <3 vs. 58.6% of ASGE Grade ≥3 (aOR: 72.2, P <0.001). Procedure and fluroscopy time were longer by 25.4 mins (aOR: 1.04, P < 0.001) and 5 mins (aOR: 1.24, P < 0.001) respectively for ASGE Grade ≥3 . Adverse events (aOR: 0.44, P= 0.274) and technical success (aOR: 1.00, P= 0.983) were similar in both groups. No significant difference was noted between trainees and attending endoscopist in the odds of ERCP adverse events or technical success for ASGE Grade <3 or ASGE Grade ≥3 respectively.

Conclusion

ERCPs with ASGE Grade ≥3 is associated with increased procedure and fluoroscopy time, and displayed increased odds of requiring cholangioscopy. ERCP technical success and adverse events did not significantly differ with trainee participation regardless of procedural complexity.

Table. ERCP outcomes for complex (ASGE Grade ≥ 3) vs. non-complex procedures (ASGE Grade <3). N=1392.

References

References
1. Sahar, N., La Selva, D., Gluck, M., Gan, S. I., Irani, S., Larsen, M., Ross, A. S., & Kozarek, R. A. (2019). The ASGE grading system for ERCP can predict success and complication rates in a tertiary referral hospital. Surgical endoscopy, 33(2), 448–453
2. Zhou, F., Zhan, X., Song, C., Li, G., Hong, J., Chen, Y., & Zhou, X. (2022). The assessment of the ASGE-grading system of ERCP: a large-sample retrospective study. Surgical endoscopy, 36(9), 6480–6487

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

A common finding in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) is periampullary diverticulum (PAD). It is more prevalent in females and elderly patients but is also linked to cholangitis and common bile duct stones. The anatomy may be distorted by PAD, possibly making papilla cannulation challenging. Whether PAD increases the difficulty of cannulation and whether it is linked to a higher incidence of adverse events has been debated. To provide further insights into this scenario, we conducted a nationwide registry-based study.

Aims & Methods

Our objective was to determine the impact of PAD on the cannulation rate, adverse events, and ERCP duration. We collected data on ERCP procedures performed between 2006 and 2021 from the Swedish Registry for Gallstone Surgery and ERCP (GallRiks). The 125,558 ERCPs that were registered in the registry during the study period were reduced to 73,937 after we excluded rendezvous procedures, previous sphincterotomies, previous stenting, and procedures with missing follow-up data.

Results

PAD was discovered in 12,782 (10.2%) ERCPs, with data recorded in the registry, and was present in 8,589 (11.6%) ERCPs in the study population. For 2,796 (3.8%) of the patients in the study group had the papilla inside the PAD (Boix Type 1), while 5,793 (7.8%) of the patients had a papilla on the edge of the PAD (Boix Type 2) or immediately next to it (Boix Type 3). The probability of successful cannulation was greater in non-PAD patients (89.7% vs. 88.6%; P=.002), whereas successful cannulation was reduced to only 81.1% if the papilla was located within the PAD (Type 1) (P<.001). The procedure time did not differ between the PAD (37.4 min) and non-PAD (37.5 min) groups (P=.73). There were no differences in intraprocedural complications (3.1%) or adverse events (16.4% vs. 15.5%; P=.05), whether PAD was present or not. In the PAD group, the risk of bleeding increased (1.8% vs. 1.3; P=.001). The perforation risk did not differ across the groups (PAD 0.8% vs. 0.7% non-PAD; P=.22), however PAD had a reduced incidence of cholangitis (1.8% vs. 2.3%; P=.01) and pancreatitis (4.5% vs. 5.2%; P=.008).

Conclusion

The cannulation rate is slightly reduced in the presence of PAD, and this effect is more pronounced and particularly apparent in patients with Type 1 PAD. The safety of ERCP is unaffected by the presence of PAD.

References

[1] Boix J, Lorenzo-Zúñiga V, Añaños F, et al. Impact of periampullary duodenal diverticula at endoscopic retrograde cholangiopancreatography: a proposed classification of periampullary duodenal diverticula. Surg Laparosc Endosc Percutan Tech 2006; 16: 208–211.
[2] Tham TCK, Kelly M. Association of periampullary duodenal diverticula with bile duct stones and with technical success of endoscopic retrograde cholangiopancreatography. Endoscopy 2004; 36: 1050–1053.
[3] Loffeld RJLF, Dekkers PEP. The Impact of Duodenal Diverticuli and the Execution of Endoscopic Retrograde Cholangiopancreaticography. Int Sch Res Not 2016; 2016: 5026289.
[4] Sun Z, Bo W, Jiang P, et al. Different Types of Periampullary Duodenal Diverticula Are Associated with Occurrence and Recurrence of Bile Duct Stones: A Case-Control Study from a Chinese Center. Gastroenterol Res Pract 2016; 2016: 9381759.
[5] Corral JE, Mousa OY, Kröner PT, et al. Impact of Periampullary Diverticulum on ERCP Performance: A Matched Case-Control Study. Clin Endosc 2019; 52: 65–71.
[6] Tabak F, Ji G-Z, Miao L. Impact of periampullary diverticulum on biliary cannulation and ERCP outcomes: a single-center experience. Surg Endosc 2021; 35: 5953–5961.

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.

Introduction

The benign papillary stenosis (BPS) leads to obstruction of the outflow of bile. The importance as an incidental finding has been insufficiently characterised. In particular, it is unclear whether endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic papillotomy (EPT) and the resulting risk of adverse events should be performed in asymptomatic BPS.

Aims & Methods

Hence, the primary objectives were to evaluate the risk of adverse events (i.e. overall, bleeding, perforation, cholangitis, post-ERCP-pancreatitis, and death) after endoscopic retrograde cholangiopankreaticography (ERCP) with endoscopic papillotomy (EPT) in patients with benign papillary stenosis (BPS) and the course after EPT in comparison to patients with EPT for other reasons than BPS. Secondary objectives included the characterisation of clinical features of BPS and the evaluation of particular risk factors for adverse events in this group.
In a retrospective case-control study 92 BPS patients (age: 77.0 (68.3; 83.8) years, women: 64 (69.6 %)) who had undergone ERCP with EPT from 2010 to 2019 were assigned to a control group matched for gender, age and year of procedure that had undergone ERCP with EPT for other reasons than BPS. Statistics were realised using analysis of variance (ANOVA), Pearson’s chi-squared test, Fisher’s exact test, paired t-test and Mann-Whitney-U-test. Within the BPS group risk factor analysis was accomplished via binary logistic regression.

Results

Jaundice before ERCP with EPT occurred less frequently in patients with BPS (14,4% vs. 33,0%, p = 0,003). The laboratory tests before the intervention showed that both the cholestasis parameters (AP [U/l]: 118.0 (80.0; 213.0) vs. 244.0 (119.0; 395.0), p < .001; gamma-GT [U/l]: 249.0 (68.8; 626.8) vs. 508.0 (290.0; 820.0), p < .001; total bilirubin [mg/dl]: 1.3 (0.7; 3,5) vs. 2.8 (1.3; 6.5), p < .001) and the transaminases (ALT [U/l]: 58.0 (24.0; 150.0) vs. 158.5 (76.5; 275.3), p < 0.001; AST [U/l]: 55.0 (22.5; 202.5) vs. 129.0 (61.5; 275.8), p = .002) were significantly lower in patients with BPS. The bile duct as measured by ultrasound before the EPT was nominally wider in patients with BPS (11.0 (9.0; 14.0) mm vs. 9.5 (7.0; 13.0) mm, p = 0.055). The ERCP revealed that BPS was moderate in 29.8 % and high in 70.2 %; the median length was 4.0 mm (IQR 3.0; 5.0). The EPT successfully drained the bile drainage in the majority of cases in both groups (100 % and 97.8 %, p = .497). After the intervention the size of the bile duct decreased tendentially more in the BPS group (-6.5 (-9.7; -3.2) mm vs. -3.5 (-6.7; 0.0) mm, p = .381 and -50.0 (-59.5; -24.7) % vs. -38.7 (-53.4; 0.0) %), p = .198). The overall rate of adverse events tended to be higher in patients with BPS (20.7 % vs. 10.9 %, p = .069). The applied for both bleeding (12.0 % vs. 5.4 %, p = .116) and post-ERCP-pancreatitis (10.1 % vs. 4.4 %, p = .144). Significantly more patients with BPS died after ERCP with EPT (9.8% vs. 2.2%, p = .030); the deceased presented a reduced state of health (ASA 3: 22.2 % or ASA 4: 77.8 %). Two out of nine BPS patients died from direct complications of ERCP with EPT. Within the BPS group no risk factors for adverse events or death could be detected.

Conclusion

The EPT in BPS is associated to an increased risk of adverse events, in particular increased deaths, although the majority of patients did not die from procedural adverse events. Further studies on the natural course of BPS and the effect of elective EPT in this patient group are mandatory.

Introduction

Improving the biliary cannulation technique in endoscopic retrograde cholangiopancreatography (ERCP), especially for native papilla, is challenging for trainees. Several previous studies have shown that improving it required a large caseload, usually 350–400 cases, or a special education program. Therefore, we created an e-learning educational video series system to allow trainees to learn biliary cannulation anywhere with ease and conducted a multicenter prospective study to evaluate it.

Aims & Methods

We created 27 educational videos containing biliary cannulation for native papilla with explanations. Twelve endoscopists with less than 6 years of ERCP experience at two general hospitals in Shizuoka, Japan, participated in this educational program using an e-learning system. First, each participant performed 10 biliary cannulations of native papillae with a preceptor, followed by e-learning and additional 10 biliary cannulations of native papillae. Data from 120 biliary cannulations each for pre-e-learning (PR) and pro-e-learning (PO) were compared according to comprehension score (CS), difficult cannulation (DC), failed biliary cannulation (FB), and adverse events (AE). CS was given by the preceptor-to-trainee oral test before biliary cannulation (maximum of six points). DC was defined as biliary cannulation time >300 sec, >5 biliary cannulation attempts, and ≥2 unintended pancreatic duct cannulation. The correlation between CS and DC was analyzed using the Cochran-Armitage test for trends, and receiver-operating characteristic (ROC) curves were used to determine CS's cut-off value.

Results

There were no significant differences in age, gender, and benign/malignant status of patients undergoing biliary cannulation between PR and PO groups. The outcomes are shown in the table. CS was higher in the PR group than in the PR group; however, no significant differences in DC, FB, and AE rates were observed between the two groups. There was a negative correlation between CS and DC (P<0.01), and the cut-off value and area under the ROC curve for CS for DC were scored 4 and 0.72 (95% confidence interval: 0.66–0.78), respectively. On per-participant comparison, CS≥4 became higher after e-learning (P=0.04); however, there were no significant differences in DC, FB, and AE rates.

Conclusion

Our e-learning system could help deepen comprehension of papilla but did not significantly reduce DC, UBC, and AEs. E-learning and technical acquisition may be needed to improve biliary cannulation.

References

1. Sachin Wani, Matthew Hall, Andrew Y Wang et al. Variation in Learning Curves and Competence for ERCP Among Advanced Endoscopy Trainees by Using Cumulative Sum Analysis. Gastrointest Endosc. 2016 Apr;83(4):711-9.e11.
2. Brian S Lim, Joseph W Leung, John Lee et al. Effect of ERCP Mechanical Simulator (EMS) Practice on Trainees' ERCP Performance in the Early Learning Period: US Multicenter Randomized Controlled Trial. Am J Gastroenterol. 2011 Feb;106(2):300-6.
3. James G Bittner 4th 1, John D Mellinger, Toufic Imam et al. Face and Construct Validity of a Computer-Based Virtual Reality Simulator for ERCP. Gastrointest Endosc. 2010 Feb;71(2):357-64. doi: 10.1016/j.gie.2009.08.033.