The morphology of the major duodenal papilla (MDP) significantly influences the selection and success of endoscopic procedures used for biliary cannulation, according to new research from Taleghani Hospital, Tehran.
Primary needle-knife fistulotomy (pNKF), increasingly adopted due to its lower risk of post-ERCP pancreatitis (PEP), was assessed for its safety and effectiveness across various MDP morphologies. The study reviewed the medical records of 200 patients who underwent the procedure between 2022 and 2024, classifying the papillae as regular, long, and bulging.
Results showed impressive outcomes, with success rates of 94.1% for regular, 98.1% for long, and 98.4% for bulging papillae. Notably, these variances were not statistically significant (p = 0.38). Adverse events, including PEP, bleeding, perforation, and cholangitis, also demonstrated no significant differences among the groups, underpinning the overall safety of pNKF.
Despite the promising rates, the study highlighted specific challenges with the regular papilla, which required more cannulation attempts and longer manipulation times compared to the other types. Specifically, there were increased attempts at cannulation (p = 0.025) and extended time frames for manipulation (p < 0.001), indicating unique procedural nuances tied to papilla morphology.
Prior studies have established links between the shape of the MDP and the difficulty of cannulation. The present study builds on these findings, making clear the imperative for endoscopists to be aware of the anatomical variations to optimize their approach to each procedure. "Endoscopists who perform ERCP remark changes in the macroscopic appearance of the MDP can influence the difficulty of cannulation and the likelihood of adverse outcomes,” noted the study authors.
Overall, this analysis reaffirms the efficacy of pNKF for biliary cannulation across various MDP morphologies. The authors advocate for future multicenter trials to investigate the applicability and outcomes of pNKF particularly for patients with small papillae, who were absent from this study's patient group. The findings are pivotal not only for enhancing clinical practice but also for informing training protocols for endoscopists facing diverse anatomical circumstances.
This research is timely, emphasizing the continuing evolution of techniques aimed at reducing patient risk and improving outcomes during complex biliary procedures.