Managing failed cannulation during ERCP – more than one way to skin a cat!

Aims Deep cannulation of the target duct is the cornerstone of ERCP procedures, however deep cannulation of the duct of interest can fail in up to 5-10% of the cases, even in expert hands. We aimed to analyze the rate and reason for failed cannulation during ERCP procedures in native papilla cases and to evaluate the type of reintervention performed as well as procedure-related complications in these cases.

Methods We conducted a retrospective analysis of a prospectively maintained endoscopy database in a tertiary referral unit for therapeutic endoscopy. All consecutive ERCP procedures conducted between July and October 2023 in the Gastroenterology Department of Colentina Clinical Hospital were analyzed. Clinical and procedure-related data were collected from the endoscopy database and patient charts and analyzed using dedicated software (SPSS).

Results A total of 234 procedures were included in the final analysis. 130 patients were male (55,6%) and mean age was 67,5±13 years. The most frequent indications for ERCP were choledocolithiasis in 98 cases (41.8%) and malignant strictures of the bile duct (cholangiocarcinoma – 52 cases (22,2%) and pancreatic cancer 32 (13.6%)). Failure to access the duct of interest was noted in 24 cases (10.2%). Cannulation attempts failed in 11 cases (4.7%) and the papilla was inaccessible due to malignant or benign strictures of the duodenum in 8 cases (3.4%). An additional 4 procedures were prematurely stopped due to anesthesia-related complications (1.7%) and there was also 1 case of duodenal perforation. A second intervention was performed in 22 out of 24 cases; re-do ERCP was performed in 15 cases, a percutaneous rendez-vous in 3 cases. EUS-guided biliary drainage was performed in 2 cases and there was 1 case of EUS-facilitated ERCP via EUS guided gastro-duodenostomy to bypass a malignant stricture of the duodenum. Finally, there was 1 case referred for surgical treatment. 18 / 22 reintervention procedures were technically successful (81.8%) but a third procedure was required in the case of 4 failed re-do ERCPs, with an additional 2 ERCPs and 2 external drainage procedures performed as salvage reinterventions.

Conclusions Failure to access the desired duct during ERCP remains an important issue for endoscopists and a significant proportion of patients will require additional therapeutic interventions beyond their index ERCP to complete the treatment plan, including ERCP, EUS and interventional radiology procedures. Further studies are needed to clarify the best way to manage an initial failed cannulation during index ERCP.

Conflicts of interest

Authors do not have any conflict of interest to disclose.

Publication History

Article published online:
15 April 2024