DIFFICULT BILIARY CANNULATION: SHOULD WE ALWAYS TRY A SECOND ERCP AFTER A FAILED NEEDLE-KNIFE FISTULOTOMY?

BACKGROUND: A successful bile duct cannulation is a prerequisite for the realization of endoscopic retrograde cholangiopancreatography (ERCP). When biliary cannulation is not possible, needle-knife fistulotomy (NKF) can be performed. However, when biliary access is not successfully achieved even after performing NKF, it is possible to interrupt the procedure, and repeat the ERCP after a short interval. OBJECTIVE: The aim of this study is to analyze if repeating an ERCP after a short interval of 48 hours is effective in achieving biliary access after an initial NKF was unsuccessfully performed. METHODS: A total of 1024 patients with a naive papilla, that underwent ERCP between the years of 2009-2019, were retrospectively reviewed. Difficult biliary cannulation was identified in 238 of these cases and NKF was performed. Success of biliary cannulation, NKF success at the first and second ERCPs, the associations between the type of the papilla, biliary dilatation, and overall success of NKF and adverse events rates were evaluated. RESULTS: Biliary access was initially achieved in 183 (76.8%) cases. Of the 55 (23.1%) remaining cases a second attempt was performed after 48 hours, and biliary access was successfully achieved in 46 (83.6%) of them. The overall success of NKF after the first and second ERCP, the success rate was 96.2%. Papilla located out of its normal position was related to a minor chance of success at NKF (P<0.05). CONCLUSION: We conclude that when biliary access is not achieved after the performance of a NKF, a second attempt is safe and effective and should be attempted.

Canulação biliar difícil: devemos tentar uma segunda CPRE após uma fistulotomia papilar mal-sucedida? / Difficult biliary cannulation: should we always try a second ercp after a failed needle-knife fistulotomy?

ABSTRACT BACKGROUND: A successful bile duct cannulation is a prerequisite for the realization of endoscopic retrograde cholangiopancreatography (ERCP). When biliary cannulation is not possible, needle-knife fistulotomy (NKF) can be performed. However, when biliary access is not successfully achieved even after performing NKF, it is possible to interrupt the procedure, and repeat the ERCP after a short interval. OBJECTIVE: The aim of this study is to analyze if repeating an ERCP after a short interval of 48 hours is effective in achieving biliary access after an initial NKF was unsuccessfully performed. METHODS: A total of 1024 patients with a naive papilla, that underwent ERCP between the years of 2009-2019, were retrospectively reviewed. Difficult biliary cannulation was identified in 238 of these cases and NKF was performed. Success of biliary cannulation, NKF success at the first and second ERCPs, the associations between the type of the papilla, biliary dilatation, and overall success of NKF and adverse events rates were evaluated. RESULTS: Biliary access was initially achieved in 183 (76.8%) cases. Of the 55 (23.1%) remaining cases a second attempt was performed after 48 hours, and biliary access was successfully achieved in 46 (83.6%) of them. The overall success of NKF after the first and second ERCP, the success rate was 96.2%. Papilla located out of its normal position was related to a minor chance of success at NKF (P<0.05). CONCLUSION: We conclude that when biliary access is not achieved after the performance of a NKF, a second attempt is safe and effective and should be attempted.

RESUMO CONTEXTO: A canulação biliar de sucesso é pré-requisito para a realização da colangiopancreatografia retrógrada endoscópica (CPRE). Quando a canulação biliar não é possível, a fistulotomia com auxílio do cateter Needle-Knife (NKF) pode ser realizada. Entretanto, quando o acesso biliar não é atingido mesmo após a realização de um NKF, é possível optar-se pela interrupção do procedimento, e pela repetição da CPRE após curto intervalo de 48 horas. OBJETIVO: O objetivo desse estudo é analisar se a repetição da CPRE após um curto intervalo de 48 horas é efetivo em atingir o acesso biliar, quando um NKF foi realizado inicialmente sem sucesso. MÉTODOS: Um total de 1024 pacientes com papila virgem de tratamento, submetidos à CPRE entre os anos de 2009-2019, foram retrospectivamente analisados. Canulação biliar difícil foi identificada em 238 deles, e NKF foi então realizado. Foram avaliadas as taxas de sucesso durante a canulação biliar, assim como durante a realização de NKF na primeira e segunda CPREs. A associação entre o tipo de papila, dilatação biliar e o sucesso final na realização do NFK também foi avaliada, assim como a presença de eventos adversos associados à realização do NKF. RESULTADOS: Dentre todos os NKF realizados, acesso biliar foi inicialmente atingido em 183 (76,8%) casos. Os 55 (23,1%) casos restantes, foram submetidos a uma segunda CPRE após 48 horas e o acesso biliar foi atingido em 46 (83,6%) deles, resultando em uma taxa final de sucesso, após a primeira e segunda CPREs, de 96,2%. Papila localizada fora da sua posição habitual foi relacionada a menor chance de sucesso durante a realização de NKF (P<0,05). CONCLUSÃO: Concluiu-se que quando o acesso biliar não pode ser atingido após a realização de um NKF, uma segunda CPRE é segura, efetiva e deve ser realizada.