Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation, especially with regard to postoperative anatomic factors

Background: Biliary cannulation is the first step in therapeutic endoscopic retrograde cholangiopancreatography. This study aimed to evaluate unsuccessful cases of biliary cannulation in which the standard procedure was changed to a needle-knife precut papillotomy (NKPP), with particular attention given to postoperative anatomic factors. Methods: Between October 2002 and February 2006, a total of 501 consecutive patients with an intact duodenal papilla were retrospectively investigated. After biliary cannulation using standard maneuvers was unsuccessful within 20 min, NKPP was performed in 80 cases (16%). The clinical backgrounds for difficult biliary cannulation were compared between patients who had standard maneuvers (n = 421, 84%) and those who underwent NKPP. Results: For 76 difficult cannulation cases (95%), successful cannulation after NKPP was accomplished, and the total success rate reached 99% (497/501). Multivariate analysis indicated that female gender (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.34-3.79), left lobe hypertrophy after hepatectomy (OR, 6.25; 95% CI, 2.52-15.54), history of Billroth I reconstruction after gastrectomy (OR, 7.49; 95% CI, 2.55-22.02), and malignant biliary stricture (OR, 2.31; 95% CI, 1.21- 4.41) were significant risk factors associated with unsuccessful standard procedures used for biliary cannulation. Complications after NKPP were observed in nine cases (11%), all of which were pancreatitis. Conclusions: Difficult biliary cannulation was strongly associated with postoperative anatomic factors. In these situations, early introduction of NKPP should be recommended if the conventional biliary cannulation promises to be difficult.