Success of ERCP at an academic center after referral for a failed cannulation or failure to complete therapeutic goal

The diagnostic and therapeutic yield of ERCP depends on a number of factors, including endoscopic skill and experience as well as adequate radiological support. When an attempt at ERCP fails, several options exist depending on the indications for ERCP. If ERCP is clearly indicated, these alternatives include a second attempt at ERCP or referral to an experienced center. Methods: We retrospectively reviewed the data from 104 consecutive patients referred to our institution for a failed cannulation or failure to achieve the therapeutic objective. This review specifically focused on (1) indications and success rate of a repeat attempt at our institution; (2) techniques used to achieve cannulation or to complete therapeutic intervention; (3)conditions associated with a failed, previous attempt at ERCP and (4) complication rate of these patients at our institution. Results: The primary indications for ERCP were recurrent/chronic pancreatitis (26%); chronic/recurrent abdominal pain (25%); pancreatic mass/jaundice (19%) and abnormal liver enzymes/abdominal pain (30%). Repeat ERCP was done for failure to cannulate the preferred duct in 61.5%; remove stones in 26%; place biliary/pancreatic stents in 10.5%; perform minor papilla sphincterotomy and remove a biliary stent in 1 patient (1%) each. The success rate for CBD cannulation was 55/58 (95%): pancreatic duct 17/18 (94%); both ducts 27/28 (96.4%) with an overall success rate of 95% (99/104). The most common associated factors for a previously failed procedure were biliary strictures (23 patients); papillary stenosis (12) and pancreas divisum (11); other conditions included duodenal diverticulum (8); pancreatic strictures (5) and miscellaneous (5). A standard cannula was used in 33 patients (44%); Cremer catheter in 12 (11.5%); NKS in 16 (15%); sphincterotome and glidewire in 42 (40.5%) and esophageal dilatation in 1 patient (1%). The diagnostic findings were biliary stones in 25%; malignant CBD obstruction 15.5%; SOD 11.6%; pancreas divisum 10.6%; chronic pancreatitis or pseudocyst 9.7%; biliary/pane, strictures 9.7% and biliary leak 1%. Complications included mild pancreatitis in 5.8% of the patients, cardiopulmonary complications hi 4.8%; pane, duct leak and mild perforation in 1 patient each (1%), both treated conservatively. Conclusions: The improved diagnostic and therapeutic yield of second attempt at ERCP warrants referral to centers with available resources and expertise where this procedure can be performed with a high success rate and an acceptably low complication rate.