Success of ERCP at a referral center after a previously unsuccessful attempt

doi:10.1067/mge.2000.108972

Gastrointestinal Endoscopy

Volume 52, Issue 4, October 2000, Pages 478-483

https://doi.org/10.1067/mge.2000.108972 Get rights and content

Abstract

Background: The diagnostic and therapeutic success of endoscopic retrograde cholangiopancreatography (ERCP) depends on a number of factors. When an attempt at ERCP fails, the physician must decide whether to repeat the procedure, rely on another imaging procedure (noninvasive or invasive), or refer to another endoscopist/center. Our aim in this prospective study was to determine the role of a second attempt at ERCP at a referral ERCP center. Methods: Five hundred sixty-two patients were referred for ERCP after having undergone a previous unsuccessful attempt to visualize the clinically relevant duct(s). Results: The overall success in visualizing the desired duct was 96.4% (542 of 562). Advanced techniques for cannulation were used in 41% (229 of 562). Anatomic abnormalities possibly contributing to the previous lack of success were present in 27% of cases. ERCP with or without manometry identified a cause or potential cause for the signs and symptoms in 86% of patients. Sixty complications occurred in 57 patients (10.1%). ERCP was unsuccessful in 20 patients (3.6%). Conclusions: The cannulation success rate and diagnostic yield of further ERCP with an acceptable complication rate warrant consideration of referral to centers with available resources and expertise. (Gastrointest Endosc 2000;52:478-83.)

Section snippets

Patients and methods

Between 1994 and 1998, 562 patients (7.7% of total ERCPs) were referred for an additional ERCP after undergoing a previously unsuccessful attempt to adequately visualize the clinically relevant duct(s). ERCPs were performed by members of the pancreatobiliary unit with one of the following Olympus video duodenoscopes (JF 100, JF 130, TJF 100) and, rarely, with a pediatric colonoscope (PCF 140L) or an enteroscope (SIF 100) (Olympus America Inc., Melville, N.Y.).

Sphincter of Oddi manometry (SOM)

Results

The indications for re-attempting ERCP and the component of the prior procedure that was unsuccessful are shown, respectively, in Tables 1 and 2.

. Indications for a second attempt at ERCP

Indication	Number
Suspected bile duct stones	68 (11.1%)
Pancreatitis, idiopathic, recurrent or chronic	164 (29.2%)
Chronic/recurrent abdominal pain^*	238 (42.3%)
Suspected malignant biliary obstruction	76 (13.5%)
Others	16 (2.8%)
Total	562 (100%)
* All patients had upper abdominal pain with or without liver function test

Discussion

Successful cannulation of the pancreatic and/or bile ducts was achieved in more than 95% of cases in this large series of patients referred for additional ERCP after a prior unsuccessful attempt. These findings are similar to those reported in 1995 from our center⁴; however, in the earlier smaller study of 113 patients referred for ERCP after a prior unsuccessful attempt, a pathologic finding was present in 64% of patients, whereas in the current study a potential cause for the signs and

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Cited by (64)

Cholangiography and Pancreatography
2019, Clinical Gastrointestinal Endoscopy
Endoscopic retrograde cholangiopancreatography (ERCP) is no longer the first choice for diagnostic imaging for many conditions of the biliary tree and pancreas, due to relative risk for complications compared to current noninvasive modalities. However, ERCP remains a firmly established therapeutic modality that offers a wide range of interventions for pancreaticobiliary disease. Skillful execution of diagnostic ERCP remains crucial for the safe and effective deployment of endoscopic therapies. The pancreaticobiliary endoscopist must also master the interpretation of normal and pathologic radiographic findings encountered during ERCP to ensure the highest quality of care for patients. We present an evidence-based review of techniques for safe and efficient diagnostic ERCP. We also review radiographic features of a normal cholangiogram and pancreatogram, as well as findings associated with frequently encountered pathologies of the pancreas and biliary tree.
Cannulation of the Major Papilla
2018, ERCP, Third Edition
Cannulation of the major papilla is the first and often most difficult aspect of endoscopic retrograde cholangiopancreatography (ERCP). Variations in papillary morphology and biliary and duodenal anatomy are usually responsible for most difficult cannulations. Tailoring procedural technique to specific situations helps overcome challenging cannulations in many cases. However, repeated and prolonged attempts at selective biliary cannulation (SBC) are associated with an increased risk of post-ERCP pancreatitis (PEP), and the optimal method is one that is swift, successful, and atraumatic. Wire-guided cannulation (WGC), as opposed to contrast cannulation, has been shown to achieve greater cannulation success with reduced incidence of PEP and is the preferred first-line approach to SBC. Nonetheless, endoscopists require a strategy for difficult cannulations as WGC is unsuccessful in a minority of cases and timely adoption of adjunctive cannulation techniques, including double wire, pancreatic stent placement, and use of the needle knife (access) sphincterotomy, may be required. This chapter discusses technical aspects of major papilla cannulation, with a particular focus on methods that improve procedural success and minimize adverse events, according to an evidence based approach.
Training pathways and competency assessment in endoscopic retrograde cholangiopancreatography
2017, Techniques in Gastrointestinal Endoscopy
Citation Excerpt :
A lack of further incremental improvement in performance occurred after 350 cases. Expert endoscopists have been shown to successfully cannulate the common bile duct (CBD) at a rate of >95% [21-24]. However, wide ranges of CBD cannulation success rates from 76%-95% are reported among practitioners [25].
Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most technically demanding and high-risk procedures performed by gastrointestinal endoscopists. It requires significant focused training and experience to maximize success and to minimize poor outcomes. Ensuring competence in ERCP has recently emerged as an area of intense scrutiny as training programs and hospital credentialing committees attempt to approve, respectively, adequately trained endoscopists. Despite this, universally accepted standards for competence in ERCP have not been established. It is not a question of overall numbers, although we know that more is better. With the appreciation that different trainees develop endoscopic skills at different rates, there has been a shift toward competency-based training and certification. An assessment of individual performance is probably more robust than the use of minimum numbers for defining competence. It is still not clear what the exact measures should be and how to measure them, and no one has defined how trainee involvement in a procedure count as a “case” for the trainee. In this review, we sought to define ERCP competence, performance measures, quality indicators for training, maintenance of competency, and credentialing to help ensure that future ERCPists receive adequate quality and quantity of training to achieve procedural competency.
Role of Endoscopic Ultrasonography and Endoscopic Retrograde Cholangiopancreatography in the Clinical Assessment of Pancreatic Neoplasms
2016, Surgical Oncology Clinics of North America
Difficult Biliary Access at ERCP
2013, Gastrointestinal Endoscopy Clinics of North America
Needle knife sphincterotomy does not increase the risk of pancreatitis in patients with difficult biliary cannulation
2013, Clinical Gastroenterology and Hepatology
Citation Excerpt :
At this point the risk of PEP is steadily escalating with each attempt. This decision should be made on the basis of the procedure indication and risk profile of the patient, the skill and expertise of the endoscopist and their team, the availability of medical resources in the event of complications, as well as alternative methods of biliary access including tertiary referral27,28 or interventional radiology.29 The current data confirm that NKS is a safe and effective strategy when used by experienced biliary endoscopists and does not increase the risk of PEP.
Biliary cannulation is unsuccessful during 5%–10% of endoscopic retrograde cholangiopancreatography (ERCP) procedures. Needle knife sphincterotomy (NKS) can improve success of cannulation but is often used as a last resort and is associated with post-ERCP pancreatitis (PEP). We evaluated the safety and efficacy of performing NKS during early stages of difficult cannulation and the relationship between difficult cannulation and the risk of PEP.
We performed a prospective trial of consecutive patients with an intact papilla who were undergoing ERCP at tertiary referral center; 73 patients were defined as having difficult biliary cannulation according to predefined cannulation parameters. These patients were randomly assigned to groups that received either NKS or continued standard cannulation. Main outcome measures were PEP and successful biliary cannulation.
Of 464 patients with an intact papilla undergoing ERCP, 73 met the criteria for difficult cannulation. Cannulation success in difficult cannulation cases was 86%, with a PEP rate of 19%. There was no difference in eventual cannulation success between the groups. However, 65% of the patients assigned to the standard cannulation group required crossover to NKS. There was no significant difference in development of PEP among patients in the early NKS group (20.5%) vs standard cannulation (17.6%). Pancreatic duct stents were inserted in 23 of the patients in the early NKS arm and in 15 in the standard cannulation arm. The number of cannulation attempts (more than 7) increased the risk of PEP (P < .01). On the basis of multivariate analysis, independent risk factors for PEP were failure of early cannulation and failure of biliary cannulation.
Early application of NKS during difficult cannulation does not increase the risk of PEP. The risk of PEP increases greatly after 7–8 attempts at or failure of cannulation. Further studies are required to assess whether early implementation of NKS during difficult cannulation reduces the development of PEP. Australia and New Zealand Clinical Trials registry: ANZTRN 12,612,000,060,842.

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^☆: Reprint requests: Stuart Sherman, MD, Division of Gastroenterology/Hepatology, Indiana University Medical Center, 550 North University Blvd., Suite 2300, Indianapolis, IN 46202-5000; fax 317-278-0164.

^☆☆: Gastrointest Endosc 2000;52:478-83.

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Original ArticlesSuccess of ERCP at a referral center after a previously unsuccessful attempt☆,☆☆

Abstract

Section snippets

Patients and methods

Results

Discussion

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Original Articles
Success of ERCP at a referral center after a previously unsuccessful attempt☆,☆☆