Retrospective Study
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World J Gastroenterol. Sep 28, 2014; 20(36): 13153-13158
Published online Sep 28, 2014. doi: 10.3748/wjg.v20.i36.13153
Repeat endoscopic retrograde cholangiopancreaticography after failed initial precut sphincterotomy for biliary cannulation
Michael Pavlides, Ashley Barnabas, Nilesh Fernandopulle, Adam A Bailey, Jane Collier, Jane Phillips-Hughes, Anthony Ellis, Roger Chapman, Barbara Braden
Michael Pavlides, Ashley Barnabas, Nilesh Fernandopulle, Adam A Bailey, Jane Collier, Anthony Ellis, Roger Chapman, Barbara Braden, Translational Gastroenterology Unit, Oxford University Hospitals, Oxford OX3 9DU, United Kingdom
Jane Phillips-Hughes, Department of Radiology, Oxford University Hospitals, Oxford OX3 9DU, United Kingdom
Author contributions: Pavlides M, Barnabas A and Fernandopulle N collected the data; Bailey AA, Collier J, Phillips-Hughes J, Ellis A, Chapman R and Braden B performed the endoscopies and patient management; Braden B designed the study and wrote the manuscript together with Pavlides M; all authors reviewed and approved the final manuscript.
Correspondence to: Barbara Braden, Consultant Gastroenterologist, Professor, Translational Gastroenterology Unit, Oxford University Hospitals, Oxford OX3 9DU, United Kingdom. braden@em.uni-frankfurt.de
Telephone: +44-186-5228760 Fax: +44-186-5228760
Received: March 2, 2014
Revised: May 5, 2014
Accepted: May 26, 2014
Published online: September 28, 2014
Abstract

AIM: To investigate the outcome of repeating endoscopic retrograde cholangiopancreaticography (ERCP) after initially failed precut sphincterotomy to achieve biliary cannulation.

METHODS: In this retrospective study, consecutive ERCPs performed between January 2009 and September 2012 were included. Data from our endoscopy and radiology reporting databases were analysed for use of precut sphincterotomy, biliary access rate, repeat ERCP rate and complications. Patients with initially failed precut sphincterotomy were identified.

RESULTS: From 1839 consecutive ERCPs, 187 (10%) patients underwent a precut sphincterotomy during the initial ERCP in attempts to cannulate a native papilla. The initial precut was successful in 79/187 (42%). ERCP was repeated in 89/108 (82%) of patients with failed initial precut sphincterotomy after a median interval of 4 d, leading to successful biliary cannulation in 69/89 (78%). In 5 patients a third ERCP was attempted (successful in 4 cases). Overall, repeat ERCP after failed precut at the index ERCP was successful in 73/89 patients (82%). Complications after precut-sphincterotomy were observed in 32/187 (17%) patients including pancreatitis (13%), retroperitoneal perforations (1%), biliary sepsis (0.5%) and haemorrhage (3%).

CONCLUSION: The high success rate of biliary cannulation in a second attempt ERCP justifies repeating ERCP within 2-7 d after unsuccessful precut sphincterotomy before more invasive approaches should be considered.

Keywords: Mortality, Post-endoscopic retrograde cholangio-pancreaticography pancreatitis, Precut sphincterotomy, Endoscopic retrograde cholangio-pancreaticography, Choledocholithiasis

Core tip: Selective biliary cannulation during endoscopic retrograde cholangio-pancreaticography (ERCP) fails in 5%-15%, even in expert high volume centres. Precut sphincterotomy facilitates biliary access, but also has a failure rate. Alternative, more invasive options for achieving biliary therapy, such as percutaneous-endoscopic or endoscopic ultrasound guided rendez-vous procedure, percutaneous transhepatic or surgical intervention include a considerable morbidity. This study demonstrates that repeating the ERCP within a few days after initial failed precut is a successful strategy in the majority of patients and should be tried before contemplating more invasive, alternative interventions.