Introduction:

Difficult biliary cannulation (CBD) occurs in approximately 20% of endoscopic retrograde cholangiopancreatography (ERCP), and is associated with the development of complications, specifically post-ERCP pancreatitis. The morphology of the papilla of Vater could be associated to CBD; however, few endoscopic classifications are available, and none has been correlated with clinical outcomes.

Objective:

To validate an endoscopic classification of the papilla of Vater and to analyze the association of papilla type with the risk of CBD and complications.

Material and methods:

Retrospective, prolective, analytical and transversal study. Consecutive patients older than 18 years who underwent ERCP with a native papilla were included. To validate the endoscopic scale proposed by Harraldson et al., endoscopic images were distributed among 6 endoscopists to calculate interobserver variability using Cohen’s kappa coefficient. The gold standard was considered the consensus of two expert endoscopists; in case of disagreement, a third endoscopist gave guideline to the final result. The type of papilla was correlated with the rate of CBD and complications (post-ERCP pancreatitis, post-sphincterotomy bleeding, and perforation) using a logistic regression model.

Results:

100 patients were included (mean age 47 ± 19.1 years, 75% women). The main indication was high risk of choledocholithiasis. A kappa index of 0.634 (95% CI: 0.512-0.757) was obtained for expert endoscopists, 0.565 (95% CI: 0.439-0.692) for non-experts and 0.208 (95% CI: 0.048-0.367) for endoscopy fellows. The patients were divided according to the type of papilla in types 1 to 4. The percentage of CBD was lower for the papilla type 1, so it was chosen as a risk comparator. The papilla type 2 (OR 4.4 (95% CI 1.48-13.31, p = 0.008) and the papilla type 4 (OR 4.2 IC 95% 1.30 - 14.03, p = 0.016) were associated with an increased risk of CBD. Papilla type 2 (OR 3.18 IC 95% 1.08 - 9.34, p = 0.035) was associated with an increased risk of complications.

Conclusion:

The type 2 and 4 papila of Harraldson et al classification were associated with an increased risk of CBD, while the papilla type 2 was associated with an increased risk of complications; the use of this classification showed a moderate concordance between expert endoscopists. This classification can be useful to predict adverse outcomes in patients undergoing ERCP.

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