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.
