Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Nov 7, 2020; 26(41): 6391-6401
Published online Nov 7, 2020. doi: 10.3748/wjg.v26.i41.6391
Escalating complexity of endoscopic retrograde cholangiopancreatography over the last decade with increasing reliance on advanced cannulation techniques
Monique T Barakat, Mohit Girotra, Nirav Thosani, Shivangi Kothari, Subhas Banerjee
Monique T Barakat, Divisions of Adult and Pediatric Gastroenterology and Hepatology, Stanford University Medical Center, Cupertino, CA 95014, United States
Mohit Girotra, Division of Gastroenterology and Hepatology, University of Miami Miller School of Medicine, Miami, FL 33136, United States
Nirav Thosani, Department of Internal Medicine, Division of Gastroenterology, Hepatology & Nutrition, University of Texas Health Science Center Houston, Houston, TX 77030, United States
Shivangi Kothari, Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14627, United States
Subhas Banerjee, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA 94304, United States
Author contributions: Barakat MT and Banerjee S were involved in conception and design of the study as well as collection and analysis of the data and initial draft of the manuscript; Barakat MT, Girotra M, Thosani N, Kothari S, and Banerjee S were involved in refined analysis and interpretation of the data, and critical revision of the article for important intellectual content; Banerjee S granted final approval of the article.
Institutional review board statement: The study was reviewed and approved by the Stanford University Medical Center Institutional Review Board (Approval #36658).
Conflict-of-interest statement: None of the authors of this manuscript have relevant conflicts of interest to disclose. 
Data sharing statement: No additional data are available. 
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Subhas Banerjee, MD, Full Professor, Division of Gastroenterology and Hepatology, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94304, United States.
Received: July 9, 2020
Peer-review started: July 9, 2020
First decision: September 12, 2020
Revised: September 22, 2020
Accepted: October 13, 2020
Article in press: October 13, 2020
Published online: November 7, 2020
Research background

Endoscopic retrograde cholangiopancreatography (ERCP) is a technically challenging and high-risk endoscopic procedure. Cannulation of the duct of interest is the essential primary step in performance of a successful ERCP. At our tertiary care endoscopy unit, we have perceived an increase in the complexity of ERCPs, necessitating increased utilization of advanced biliary cannulation techniques.

Research motivation

Based on this impression of increasing cannulation complexity at ERCP, we designed a retrospective study to systematically evaluate the evolution of ERCP complexity over the past decade at our institution.

Research objectives

Our goal was to characterize changes in ERCP complexity over time so that training and practice patterns may be optimized in accordance with these changes. We intend for these findings to enhance understanding about the factors that underlie escalating complexity of cannulation at ERCP and stimulate future research on the topic.

Research methods

Demographic/clinical variables and medical records of ERCP patients from the beginning (2008), middle (2013) and end (2018) of the last decade were evaluated and cannulation complexity was assessed (categorized as anatomical barriers, utilization of advanced cannulation techniques and duodenoscope position).

Research results

Patients undergoing ERCP in 2018 were significantly older compared to those undergoing ERCP in 2008, and a progressive increase in the proportion of procedures challenged by duodenal/ampullary distortion and peri-ampullary diverticula were noted over the same time period. ERCPs were increasingly performed with a non-standard duodenoscope position, and utilization of more than one advanced cannulation approach during a single ERCP increased significantly over the study period. Primary mass size > 4 cm, pancreatic uncinate tumor, and bilirubin > 10 mg/dL predicted use of advanced cannulation techniques.

Research conclusions

ERCP cannulation complexity has sharply increased over the past 5 years, with more elderly patients and patients with malignancy undergoing ERCP, necessitating an increased utilization of advanced cannulation techniques. We found that cannulation complexity at ERCP can be predicted based on patient/ampullary characteristics. Anatomical barriers to duodenoscope advancement prior to cannulation are also increasingly common.

Research perspectives

In this new era of escalating complexity of cannulation during ERCP, our data may inform triaging of procedures predicated to be highly complex to more experienced, high-volume endoscopists. These highly complex ERCPs may be less amenable to trainee involvement. Our data highlight the increasing importance of excellent advanced endoscopy training for endoscopists who will perform ERCP.