Published online Nov 7, 2020. doi: 10.3748/wjg.v26.i41.6391
Peer-review started: July 9, 2020
First decision: September 12, 2020
Revised: September 22, 2020
Accepted: October 13, 2020
Article in press: October 13, 2020
Published online: November 7, 2020
Endoscopic retrograde cholangiopancreatography (ERCP) is a technically challenging and high-risk endoscopic procedure. Cannulation of the duct of interest is the essential primary step in performance of a successful ERCP. At our tertiary care endoscopy unit, we have perceived an increase in the complexity of ERCPs, necessitating increased utilization of advanced biliary cannulation techniques.
Based on this impression of increasing cannulation complexity at ERCP, we designed a retrospective study to systematically evaluate the evolution of ERCP complexity over the past decade at our institution.
Our goal was to characterize changes in ERCP complexity over time so that training and practice patterns may be optimized in accordance with these changes. We intend for these findings to enhance understanding about the factors that underlie escalating complexity of cannulation at ERCP and stimulate future research on the topic.
Demographic/clinical variables and medical records of ERCP patients from the beginning (2008), middle (2013) and end (2018) of the last decade were evaluated and cannulation complexity was assessed (categorized as anatomical barriers, utilization of advanced cannulation techniques and duodenoscope position).
Patients undergoing ERCP in 2018 were significantly older compared to those undergoing ERCP in 2008, and a progressive increase in the proportion of procedures challenged by duodenal/ampullary distortion and peri-ampullary diverticula were noted over the same time period. ERCPs were increasingly performed with a non-standard duodenoscope position, and utilization of more than one advanced cannulation approach during a single ERCP increased significantly over the study period. Primary mass size > 4 cm, pancreatic uncinate tumor, and bilirubin > 10 mg/dL predicted use of advanced cannulation techniques.
ERCP cannulation complexity has sharply increased over the past 5 years, with more elderly patients and patients with malignancy undergoing ERCP, necessitating an increased utilization of advanced cannulation techniques. We found that cannulation complexity at ERCP can be predicted based on patient/ampullary characteristics. Anatomical barriers to duodenoscope advancement prior to cannulation are also increasingly common.
In this new era of escalating complexity of cannulation during ERCP, our data may inform triaging of procedures predicated to be highly complex to more experienced, high-volume endoscopists. These highly complex ERCPs may be less amenable to trainee involvement. Our data highlight the increasing importance of excellent advanced endoscopy training for endoscopists who will perform ERCP.