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

Area of Science:

• Gastroenterology
• Endoscopy
• Surgical Procedures

Background:

• Bile duct cannulation is crucial for successful endoscopic retrograde cholangiopancreatography (ERCP).
• Needle-knife fistulotomy (NKF) is an alternative when direct cannulation fails.
• Interrupting and repeating ERCP after an unsuccessful NKF is a potential strategy.

Purpose of the Study:

• To evaluate the efficacy and safety of repeating ERCP within 48 hours after an unsuccessful initial NKF.
• To determine the success rate of biliary access in a second ERCP attempt.

Main Methods:

• Retrospective review of 1024 patients undergoing ERCP (2009-2019).
• Analysis of 238 cases with difficult biliary cannulation requiring NKF.
• Evaluation of cannulation success, NKF success rates, and adverse events for first and second ERCP attempts.

Main Results:

• Initial biliary access was achieved in 76.8% of cases.
• A second ERCP attempt after 48 hours in 55 cases resulted in successful biliary access in 83.6% of them.
• The overall success rate of NKF after one or two attempts was 96.2%.

Conclusions:

• Repeating ERCP within 48 hours after an unsuccessful NKF is a safe and effective strategy.
• This approach significantly improves the overall success rate of biliary cannulation.
• Papillary positioning may influence NKF success, warranting further investigation.