Difficult biliary cannulation in patients with distal malignant biliary obstruction: An underestimated problem?

Area of Science:

• Gastroenterology
• Interventional Endoscopy
• Oncology

Background:

• Failed biliary cannulation is a significant challenge during Endoscopic Retrograde Cholangiopancreatography (ERCP).
• Limited data exists on the rate of Difficult Biliary Cannulation (DBC) specifically in patients with distal malignant biliary obstruction (DMBO).

Purpose of the Study:

• To determine the rate of DBC in patients with DMBO undergoing ERCP.
• To identify secondary outcomes including cannulation failure, adverse events (AEs), and predictive factors for DBC and AEs.

Main Methods:

• Retrospective analysis of 622 patients with DMBO undergoing ERCP across four Italian centers (09/2015-02/2019).
• Primary outcome: rate of DBC. Secondary outcomes: cannulation failure, AEs, and predictive factors.

Main Results:

• A high rate of DBC was observed, affecting 351 (56.4%) of patients.
• ERCP-related AEs occurred in 15.6% of patients, with DBC patients showing a higher risk (p=0.02).
• Factors associated with AEs included lack of pancreatitis prophylaxis, cholangiocarcinoma diagnosis, use of papillotomy, and multiple cannulation techniques.

Conclusions:

• Patients with DMBO experience a high rate of DBC, often requiring alternative biliary drainage methods.
• DBC is associated with an increased risk of adverse events.
• Further prospective multicentric studies are recommended to validate these findings in this patient subgroup.