Gut Liver.  2021 May;15(3):459-465. 10.5009/gnl19304.

Difficult Biliary Cannulation from the Perspective of PostEndoscopic Retrograde Cholangiopancreatography Pancreatitis: Identifying the Optimal Timing for the Rescue Cannulation Technique

  • 1Department of Internal Medicine, Inje University College of Medicine, Goyang, Korea.
  • 2Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
  • 3Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea.
  • 4Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea.
  • 5Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea.
  • 6Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea.


Recently, the European Society of Gastrointestinal Endoscopy (ESGE) proposed criteria for “difficult biliary cannulation” during endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to investigate the clinical relevance of the ESGE criteria from the perspective of post-ERCP pancreatitis (PEP).
An ERCP database was prospectively maintained between November 2014 and December 2015 across six teaching hospitals in South Korea. The ESGE criteria (biliary cannulation time, the number of cannulation attempts, and inadvertent pancreatic duct [PD] manipulation) were recorded in this database as well as other technical factors. Logistic regression analysis was used to identify risk factors for PEP. Then, the PEP prediction model was investigated using decision tree analysis.
We analyzed 1,067 consecutive patients with naïve papilla. The overall rate of PEP was 6.6%. Multivariate analysis revealed that female sex (odds ratio [OR], 1.860; 95% confidence interval [CI], 1.124 to 3.078), a selective biliary cannulation duration >5 minutes (OR, 3.282; 95% CI, 1.641 to 6.566), and inadvertent PD manipulation (OR, 2.614; 95% CI, 1.480 to 4.617) were significant factors affecting PEP. Decision tree analysis revealed that biliary cannulation time (χ2 =49.857, p<0.001) and inadvertent PD manipulation (χ2 =8.556, p=0.010) were decisive factors. PEP occurred in 3.9%, 11.8%, and 16.2% of patients with biliary cannulation duration lasting 3 to 5 minutes, >5 minutes, and >5 minutes with inadvertent PD manipulation, respectively.
Biliary cannulation time and inadvertent PD manipulation could be relevant indicators of PEP, and 5 minutes might be used as a cutoff value for the implementation of the rescue cannulation technique.


Pancreatitis; Cholangiopancreatography; endoscopic retrograde; Risk factors; Decision trees; Practice guideline
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