Difficult biliary cannulation in ERCP procedures with or without trainee involvement: a comparative study

Abstract

Background The 5–5–1 criteria (> 5 minutes – 5 cannulation attempts – 1 unintended pancreas duct cannulation) were proposed by the European Society of Gastrointestinal Endoscopy to define difficult biliary cannulation. However, the criteria may be inappropriate for trainee-involved procedures. We developed criteria for difficult cannulation in trainee-involved procedures.

Methods Patients undergoing biliary cannulation with or without trainee involvement were eligible. Procedures that might be too easy (e. g. fistula) or too difficult (e. g. altered anatomy) were excluded. The primary outcome was difficult cannulation, defined as cannulation time, attempts, or inadvertent pancreatic duct (PD) cannulation exceeding the 75 % percentile of each variable. Propensity score matching (PSM) analysis was used.

Results After PSM, there were 1596 patients in each group. Trainee-involved procedures had longer median (interquartile range [IQR]) cannulation time (7.5 [2.2–15.3] vs. 2.0 [0.6–5.2] minutes), and more attempts (5 [2–10] vs. 2 [1–4]) and inadvertent PD cannulation (0 [0–2] vs. 0 [0–1]) vs. procedures without trainee involvement (all P < 0.001). The 15–10–2 criteria for difficult cannulation were proposed for trainee-involved cannulation and the 5–5-1 criteria were nearly confirmed for cannulation without trainee involvement. The proportions of difficult cannulation using these respective criteria were 35.5 % (95 % confidence interval [CI] 33.2 %–37.9 %) and 31.8 % (95 %CI 29.5 %–34.2 %), respectively (odds ratio 1.18 [95 %CI 1.02–1.37]). Incidences of post-ERCP pancreatitis following difficult cannulation were comparable (7.8 % [95 %CI 5.7 %–10.3 %] vs. 9.8 % [95 %CI 7.4 %–12.8 %], respectively).

Conclusion By using the 75 % percentiles as cutoffs, the proposed 15–10–2 criteria for difficult cannulation could be appropriate in trainee-involved procedures.

^* These authors contributed equally to the work.

Publication History

Received: 18 November 2020

Accepted after revision: 04 June 2021

Accepted Manuscript online:
04 June 2021

Article published online:
03 August 2021

• References

• 1 Liao WC, Angsuwatcharakon P, Isayama H. et al. International consensus recommendations for difficult biliary access. Gastrointest Endosc 2016; 85: 295-304
• 2 Debenedet AT, Elmunzer BJ, Mccarthy ST. et al. Intraprocedural quality in endoscopic retrograde cholangiopancreatography: a meta-analysis. Am J Gastroenterol 2013; 108: 1696-1704
• 3 Ismail S, Udd M, Lindström O. et al. Criteria for difficult biliary cannulation: start to count. Eur J Gastroenterol Hepatol 2019; 31: 1200-1205
• 4 Dumonceau JM, Kapral C, Aabakken L. et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 127-149
• 5 Halttunen J, Meisner S, Aabakken L. et al. Difficult cannulation as defined by a prospective study of the Scandinavian Association for Digestive Endoscopy (SADE) in 907 ERCPs. Scand J Gastroenterol 2014; 49: 752-758
• 6 Chen Q, Jin P, Ji X. et al. Management of difficult or failed biliary access in initial ERCP: a review of current literature. Clin Res Hepatol Gastroenterol 2019; 43: 365-372
• 7 Testoni PA, Mariani A, Aabakken L. et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2016; 48: 657-683
• 8 Sundaralingam P, Masson P, Bourke M. Early precut sphincterotomy does not increase risk during endoscopic retrograde cholangiopancreatography in patients with difficult biliary access: a meta-analysis of randomized controlled trials. Clin Gastroenterol Hepatol 2015; 13: 1722-1729
• 9 Pan YL, Zhao L, Leung J. et al. Appropriate time for selective biliary cannulation by trainees during ERCP – a randomized trial. Endoscopy 2015; 47: 688-695
• 10 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 11 Voiosu T, Boskoski I, Voiosu AM. et al. Impact of trainee involvement on the outcome of ERCP procedures: results of a prospective multicenter observational trial. Endoscopy 2020; 52: 115-122
• 12 Elmunzer B, Scheiman J, Lehman G. et al. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med 2012; 366: 1414-1422
• 13 Luo H, Zhao LN, Leung J. et al. Routine pre-procedural rectal indometacin versus selective post-procedural rectal indometacin to prevent pancreatitis in patients undergoing endoscopic retrograde cholangiopancreatography: a multicentre, single-blinded, randomised controlled trial. Lancet 2016; 387: 2293-2301
• 14 Wang X, Luo H, Luo B. et al. Combination prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients undergoing double-guidewire assisted biliary cannulation: A case-control study with propensity score matching. J Gastroenterol Hepatol 2021;
• 15 Wani S, Hall M, Wang AY. et al. Variation in learning curves and competence for ERCP among advanced endoscopy trainees by using cumulative sum analysis. Gastrointest Endosc 2016; 83: 711-719
• 16 Zheng L, Wang L, Ren G. et al. Patient-related factors associated with successful cannulation by trainees during hands-on endoscopic retrograde cholangiopancreatography training. Dig Endosc 2019; 31: 558-565
• 17 Siau K, Dunckley P, Feeney M. et al. ERCP assessment tool: evidence of validity and competency development during training. Endoscopy 2019; 51: 1017-1026
• 18 Duloy A, Keswani R, Hall M. et al. Time given to trainees to attempt cannulation during endoscopic retrograde cholangiopancreatography varies by training program and is not associated with competence. Clin Gastroenterol Hepatol 2020; 18: 3040-3042
• 19 Tian C, Gamboa A, Chaudhury B. et al. Cannulation time is a more accurate measure of cannulation difficulty in endoscopic retrograde cholangiopancreatography than the number of attempts. Gastroenterol Rep 2013; 1: 193-197