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Criteria for difficult biliary cannulation: start to count.

Shamel Ismail1, Marianne Udd, Outi Lindström

  • 1Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.

European Journal of Gastroenterology & Hepatology
|August 30, 2019
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Summary

The 5-5-2 criteria effectively identify difficult biliary cannulation during ERCP, predicting a higher risk of pancreatitis. Transpancreatic biliary sphincterotomy (TPBS) is a successful advanced technique for these challenging cases.

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Area of Science:

  • Gastroenterology
  • Endoscopic Procedures
  • Clinical Practice Guidelines

Background:

  • Biliary cannulation difficulty in ERCP is defined by the 5-5-2 criteria (papilla contacts, time, unintended pancreatic duct cannulation).
  • Predicting post-ERCP pancreatitis (PEP) risk and evaluating advanced cannulation techniques are crucial for patient safety.

Purpose of the Study:

  • To validate the 5-5-2 criteria in predicting PEP risk in a single-center practice.
  • To assess the efficacy of transpancreatic biliary sphincterotomy (TPBS) as an advanced biliary cannulation method.

Main Methods:

  • Prospective analysis of 821 patients undergoing ERCP with native papilla cannulation.
  • Primary cannulation using sphincterotome and guidewire; advanced methods employed after failed primary attempts.
  • Data collected on cannulation success, time, complications (PEP), and adherence to 5-5-2 criteria.

Main Results:

  • Overall cannulation success rate was 99.1%.
  • PEP risk was 4.0%, with higher rates (13.5%) when advanced methods were required.
  • 37.9% of patients met at least one 5-5-2 criterion; these patients had lower primary cannulation success (20.4%) and higher PEP risk (12.7% if all criteria met).
  • TPBS achieved a 90% success rate.

Conclusions:

  • The 5-5-2 criteria are supported for identifying difficult biliary cannulation.
  • TPBS demonstrates effectiveness as an advanced cannulation technique with an acceptable complication rate.