Clinical significance of different periampullary diverticulum classifications for endoscopic retrograde cholangiopancreatography cannulation

doi:10.3748/wjg.v26.i19.2403

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World Journal of Gastroenterology

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Retrospective Study

World J Gastroenterol. May 21, 2020; 26(19): 2403-2415
Published online May 21, 2020. doi: 10.3748/wjg.v26.i19.2403

Table 1 Baseline clinical characteristics of the periampullary diverticulum and non- periampullary diverticulum groups

	Non-PAD group (n = 2597)	PAD group (n = 967)	P value
Age, mean ± SD	58 ± 16	65 ± 13	< 0.001
Sex, n (%)			0.004
Male	1248 (48.1)	517 (53.5)
Female	1349 (51.9)	450 (46.5)
History of cholecystectomy	909 (35.0)	356 (36.8)	0.32
Gallbladder stones	1001 (38.5)	369 (38.2)	0.83
Indications, n (%)
Common bile duct stones	1846 (71.1)	823 (85.1)	< 0.001
Acute cholangitis	291 (11.2)	171 (17.7)	< 0.001
Malignant biliary stricture	359 (13.8)	50 (5.2)	< 0.001
Benign biliary stricture	101 (3.9)	33 (3.4)	0.51
Acute pancreatitis	248 (9.6)	54 (5.6)	< 0.001
Pancreatic duct stones	18 (0.7)	4 (0.4)	0.35
Comorbidity, n (%)
Hypertension	536 (20.6)	239 (24.7)	0.009
Diabetes	212 (8.2)	100 (10.3)	0.04
Coronary disease	67 (2.6)	29 (3.0)	0.49
Virus hepatitis	140 (5.4)	31 (3.2)	0.007

PAD: Periampullary diverticulum.

Table 2 Baseline clinical characteristics of different types of periampullary diverticulum patients in the three classification systems

	Lobo classification, 1998		Boix classification, 2006			Li-Tanaka classification, 2012
	IDP	JPD	I	II	III	I	II	III	IV
Total	65	902	306	556	105	65	655	105	142
Age, mean ± SD	65 ± 11	65 ± 14	64 ± 13	65 ± 13	65 ± 15	65 ± 11	64 ± 14	65 ± 15	66 ± 12
Sex, n (%)
Male	32 (49.2)	485 (53.8)	167 (54.6)	293 (52.7)	57 (54.3)	32 (49.2)	358 (54.7)	57 (54.3)	70 (49.3)
Female	33 (50.8)	417 (46.2)	139 (45.4)	263 (47.3)	48 (45.7)	33 (50.8)	297 (45.3)	48 (45.7)	72 (50.7)
History of cholecystectomy	15 (23.1)	341 (37.8)^a	111 (36.3)	221 (39.8)	24 (22.9)^a	15 (23.1)	263 (40.2)	24 (22.9)	54 (38.0)^a
Gallbladder stones	28 (43.1)	341 (37.8)	117 (38.2)	215 (38.7)	37 (35.2)	28 (43.1)	249 (38.0)	37 (35.2)	55 (38.7)
Indications, n (%)
Common bile duct stones	53 (81.5)	770 (85.4)	265 (86.6)	471 (84.7)	87 (82.9)	53 (81.5)	561 (85.7)	87 (82.9)	122 (85.9)
Acute cholangitis	11 (16.9)	160 (17.7)	61 (19.9)	96 (17.3)	14 (13.3)	11 (16.9)	119 (18.2)	14 (13.3)	27 (19.0)
Malignant biliary stricture	2 (3.1)	48 (5.3)	13 (4.3)	28 (5.0)	9 (8.6)	2 (3.1)	30 (4.6)	9 (8.6)	9 (6.3)
Benign biliary stricture	1 (1.5)	32 (3.6)	8 (2.6)	22 (4.0)	3 (2.9)	1 (1.5)	26 (4.0)	3 (2.9)	3 (2.1)
Acute pancreatitis	5 (7.7)	49 (5.4)	25 (8.2)	26 (4.7)	3 (2.9)^a	5 (7.7)	42 (6.4)	3 (2.9)	4 (2.8)
Pancreatic duct stones	0	4 (0.4)	2 (0.7)	2 (0.4)	0	0	4 (0.6)	0	0
Comorbidity, n (%)
Hypertension	19 (29.2)	220 (24.4)	77 (25.2)	134 (24.1)	28 (26.7)	19 (29.2)	159 (24.3)	28 (26.7)	33 (23.2)
Diabetes	11 (16.9)	89 (9.9)	34 (11.1)	54 (9.7)	12 (11.4)	11 (16.9)	66 (10.1)	12 (11.4)	11 (7.8)
Coronary disease	5 (7.7)	24 (2.7)^a	10 (3.3)	18 (3.2)	1 (1.0)	5 (7.7)	16 (2.4)	1 (1.0)	7 (4.9)^a
Virus hepatitis	2 (3.1)	29 (3.2)	9 (2.9)	17 (3.1)	5 (4.8)	2 (3.1)	17 (2.6)	5 (4.8)	7 (4.9)

^aP < 0.05. IDP: Intradiverticular papilla; JPD: Juxtapapillary diverticula.

Table 3 Diagnosis, procedures, and post-procedure complications for different types of periampullary diverticulum in three classification systems

	Lobo classification, 1998			Boix classification, 2006				Li-Tanaka classification, 2012
	IDP	JPD	P value	I	II	III	P value	I	II	III	IV	P value
Total	65 (6.7)	902 (93.3)		306 (31.6)	556 (57.5)	105 (10.9)		65 (6.7)	655 (67.7)	105 (10.9)	142 (14.7)
Diameter of CBD (mm)	14 ± 4	14 ± 5	0.33	14 ± 5	15 ± 5	14 ± 6	0.37	14 ± 4	14 ± 5	14 ± 6	15 ± 5	0.56
Max. size of PAD (mm)	19 ± 8	13 ± 7	< 0.001	15 ± 8	13 ± 7	11 ± 7	< 0.001	19 ± 8	13 ± 7	11 ± 7	14 ± 9	< 0.001
≤ 10	11 (16.9)	531 (58.9)		146 (47.7)	325 (58.5)	71 (67.6)		11 (16.9)	384 (58.6)	71 (67.6)	76 (53.5)
10-20	38 (58.5)	287 (31.8)		118 (38.6)	182 (32.7)	25 (23.8)		38 (58.5)	217 (33.1)	25 (23.8)	45 (31.7)
> 20	16 (24.6)	84 (9.3)		42 (13.7)	49 (8.8)	9 (8.6)		16 (24.6)	54 (8.2)	9 (8.6)	21 (14.8)
CBD stones	51 (86.4)	765 (85.6)	0.85	262 (87.9)	470 (85.0)	84 (82.4)	0.31	51 (86.4)	559 (85.9)	84 (82.4)	122 (86.5)	0.79
Max diameter (mm)	13 ± 5	12 ± 7	0.23	12 ± 6	13 ± 7	12 ± 6	0.26	13 ± 5	12 ± 6	12 ± 6	13 ± 8	0.58
Multiple stone	19 (37.3)	353 (46.1)	0.22	115 (43.9)	224 (47.7)	33 (39.3)	0.29	19 (37.3)	258 (46.2)	33 (39.3)	62 (50.8)	0.24
Difficult stone removal	16 (31.4)	273 (35.7)	0.53	96 (36.6)	159 (33.8)	34 (40.5)	0.44	16 (31.4)	195 (34.9)	34 (40.5)	44 (36.1)	0.71
Mechanical lithotripsy	4 (6.2)	35 (3.9)	0.33	21 (6.9)	16 (2.9)	2 (1.9)	0.008	4 (6.2)	31 (4.7)	2 (1.9)	2 (1.4)	0.13
Retained stones	3 (5.9)	59 (7.7)	0.79	20 (7.6)	34 (7.2)	8 (9.5)	0.77	3 (5.9)	38 (6.8)	8 (9.5)	13 (10.7)	0.42
Guide wire in PD	6 (9.2)	86 (9.5)	0.94	30 (9.8)	48 (8.6)	14 (13.3)	0.32	6 (9.2)	66 (10.1)	14 (13.3)	6 (4.2)	0.08
ERPD	1 (1.5)	45 (5.0)	0.36	11 (3.6)	31 (5.6)	4 (3.8)	0.38	1 (1.5)	36 (5.5)	4 (3.8)	5 (3.5)	0.50
Operative time (min)	44 ± 21	41 ± 18	0.35	41 ± 18	41 ± 17	43 ± 21	0.81	44 ± 21	41 ± 17	43 ± 21	39 ± 17	0.48
Difficult cannulation	15 (23.1)	93 (10.3)	0.002	38 (12.4)	57 (10.3)	13 (12.4)	0.57	15 (23.1)	68 (10.4)	13 (12.4)	12 (8.5)	0.01
Successful cannulation	59 (90.8)	894 (99.1)	< 0.001	298 (97.4)	553 (99.5)^a	102 (97.1)	0.02	59 (90.8)	651 (99.4)^b	102 (97.1)	141 (99.3)^b	< 0.001
Adverse events	8 (12.3)	79 (8.8)	0.33	26 (8.5)	48 (8.6)	13 (12.4)	0.44	8 (12.3)	57 (8.7)	13 (12.4)	9 (6.3)	0.30
Post-ERCP pancreatitis	5 (7.7)	53 (5.9)	0.58	19 (6.2)	29 (5.2)	10 (9.5)	0.23	5 (7.7)	38 (5.8)	10 (9.5)	5 (3.5)	0.24
Acute cholangitis	2 (3.1)	25 (2.8)	0.70	6 (2.0)	18 (3.2)	3 (2.9)	0.55	2 (3.1)	18 (2.8)	3 (2.9)	4 (2.8)	0.98
Perforation	1 (1.5)	1 (0.1)	0.13	1 (0.3)	1 (0.2)	0 (0.0)	1.00	1 (1.5)	1 (0.2)	0 (0.0)	0 (0.0)	0.20

For Boix classification, P = 0.017 with Bonferroni adjustment. For Li-Tanaka classification, P = 0.008 with Bonferroni adjustment. Successful cannulation: Boix: Type II vs type I,

^aP < 0.05; Li-Tanaka classification: Type II vs type I,

^bP < 0.01, type IV vs type I, ^bP < 0.01. CBD: Common bile duct; PAD: Periampullary diverticulum; ERCP: Endoscopic retrograde cho-langiopancreatography; ERPD: Endoscopic retrograde pancreatic drainage; PD: Pancreatic duct.

Table 4 Difficult cannulation for different types of periampullary diverticulum in the three classification groups compared with the non- periampullary diverticulum group

Variable	n/N (%)	Difficult cannulation
Variable	n/N (%)	OR (95%CI)	P value
Total
Non-PAD	317/2597 (12.2)	Ref
PAD	108/967 (11.2)	0.86 (0.68-1.09)	0.21
Lobo classification
Non-PAD	317/2597 (12.2)	Ref
IDP	15/65 (23.1)	2.04 (1.13-3.68)	0.006
JPD	93/902 (10.3)	0.79 (0.61-1.01)	0.001
Boix classification
Non-PAD	317/2597 (12.2)	Ref
I	38/306 (12.4)	0.98 (0.68-1.40)	0.73
II	57/556 (10.3)	0.78 (0.58-1.05)	0.21
III	13/105 (12.4)	0.97 (0.53-1.75)	0.85
Li-Tanaka classification
Non-PAD	317/2597 (12.2)	Ref
I	15/65 (23.1)	2.04 (1.13-3.68)	0.004
II	68/655 (10.4)	0.80 (0.60-1.06)	0.13
III	13/105 (12.4)	0.97 (0.53-1.75)	0.91
IV	12/142 (8.5)	0.62 (0.34-1.13)	0.06

Adjusted for age and sex. PAD: Periampullary diverticulum; IDP: Intradiverticular papilla; JPD: Juxtapapillary diverticula; OR: Odds ratio; CI: Confidence interval.

Table 5 Successful cannulation for different types of periampullary diverticulum in the three classification groups compared with the non- periampullary diverticulum group

Variable	n/N (%)	Successful cannulation
Variable	n/N (%)	OR (95%CI)	P value
Total
Non-PAD	2531/2597 (97.5)	Ref
PAD	953/967 (98.6)	1.87 (1.04-3.37)	0.037
Lobo classification
Non-PAD	2531/2597 (97.5)	Ref
IDP	59/65 (90.8)	0.27 (0.11-0.66)	< 0.001
JPD	894/902 (99.1)	3.07 (1.46-6.46)	< 0.001
Boix classification
Non-PAD	2531/2597 (97.5)	Ref
I	298/306 (97.4)	1.02 (0.48-2.15)	0.27
II	553/556 (99.5)	5.09 (1.59-16.30)	0.009
III	102/105 (97.1)	0.94 (0.29-3.04)	0.33
Li-Tanaka classification
Non-PAD	2531/2597 (97.5)	Ref
I	59/65 (90.8)	0.27 (0.11-0.66)	< 0.001
II	651/655 (99.4)	4.44 (1.61-12.29)	0.01
III	102/105 (97.1)	0.94 (0.29-3.04)	0.49
IV	141/142 (99.3)	3.97 (0.55-28.95)	0.19

Adjusted for age and sex. PAD: Periampullary diverticulum; IDP: Intradiverticular papilla; JPD: Juxtapapillary diverticula; OR: Odds ratio; CI: Confidence interval.

Citation: Yue P, Zhu KX, Wang HP, Meng WB, Liu JK, Zhang L, Zhu XL, Zhang H, Miao L, Wang ZF, Zhou WC, Suzuki A, Tanaka K, Li X. Clinical significance of different periampullary diverticulum classifications for endoscopic retrograde cholangiopancreatography cannulation. World J Gastroenterol 2020; 26(19): 2403-2415
URL: https://www.wjgnet.com/1007-9327/full/v26/i19/2403.htm
DOI: https://dx.doi.org/10.3748/wjg.v26.i19.2403