Steps to be considered in the unsuccessful endoscopic retrograde cholangiopancreatography pre-criteria: Early pre-cut intervention. A retrospective cohort study

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used procedure for the treatment of several hepatobiliary and pancreatic diseases and also for diagnostic purposes of rare conditions. Despite advances in endoscopic accessories, selective biliary cannulation fails in 5–15% of cases, even in expert high-volume centers. However, there is still no consensus regarding the clinical outcomes of failed ERCP patients who underwent precut sphincterotomy. In the current work, we present the therapeutic approach and the outcomes of our patients with failed ERCP due to several reasons.
METHODS: There were 1986 patients who were referred from another center due to primary ERCP requirement (n=1862) or unsuccessful attempts to study at the primary center (n=124). If the papilla has prerequisite criteria for failed ERCP, then the procedure was begun directly with precut incision.
RESULTS: The ERCP procedure was successfully performed in all 1794 patients using a classic cannulation procedure. Pre-cut sphincterotomy method was successfully performed in 160 patients. There were 123 patients diagnosed by ERCP in our center and 103 of them were cannulated successfully with pre-cut sphincterotomy method. Pancreatitis developed in 12 of the 1794 patients (0.66%) whose primary cannulation was successful. However, only two of the 160 patients (1.25%) who underwent precut sphincterotomy developed pancreatitis postoperatively. One of these two patients had undergone unsuccessful precut trials.
DISCUSSION AND CONCLUSION: The cannulation rate depends on the experience, the referral center where the procedure is carried out, the anatomical structure of the papilla, the indication necessitating the ERCP, and also the use of precut incision. In cannulation failure, patients should be directed to experienced, high-volume, and tertiary centers. In patients with failed ERCP pre-criteria, intervention should be initiated with the liberal use of the precut method. In unsuccessful cannulation, a 3-day waiting period reduces complications.