title: Difficult cannulation as defined by a prospective study of the Scandinavian Association for Digestive Endoscopy (SADE) in 907 ERCPs.
abstract: BACKGROUND
  The definition of a "difficult" cannulation varies considerably in reports of endoscopic retrograde cholangiopancreatography (ERCP).
  
  
  OBJECTIVE
  To define a difficult cannulation, which translates into higher risk of post-ERCP pancreatitis.
  
  
  METHODS
  Prospective consecutive recording of 907 cannulations in Scandinavian centers done by experienced endoscopists. Inclusion: indication for biliary access in patients with intact papilla. Exclusion: acute non-biliary and chronic pancreatitis at time of procedure.
  
  
  RESULTS
  The primary cannulation succeeded in 74.9%, with median values for time 0.88 min (53 s), with two attempts and with zero pancreatic passages or injections. The overall cannulation success was 97.4% and post-ERCP pancreatitis (PEP) rate was 5.3%. The median time for all successful cannulations was 1.55 min (range 0.02-94.2). If the primary cannulation succeeded, the pancreatitis rate was 2.8%; after secondary methods, it rose to 11.5%. Procedures lasting less than 5 min had a PEP rate of 2.6% versus 11.8% in those lasting longer. With one attempt, the PEP rate was 0.6%, with two 3.1%, with three to four 6.1%, and with five and more 11.9%. With one accidental pancreatic guide-wire passage, the risk of the PEP was 3.7%, and with two passages, it was 13.1%.
  
  
  CONCLUSIONS
  If the increasing rate of PEP is taken as defining factor, the wire-guided cannulation of a native papilla can be considered difficult after 5 min, five attempts, and two pancreatic guide-wire passages when any of those limits is exceeded.
authors.affiliation: Department of Gastrointestinal and General Surgery, Helsinki University Central Hospital , Helsinki , Finland.
authors.forename: Jorma
authors.initials: J
authors.lastname: Halttunen
authors.forename: Søren
authors.initials: S
authors.lastname: Meisner
authors.forename: Lars
authors.initials: L
authors.lastname: Aabakken
authors.forename: Urban
authors.initials: U
authors.lastname: Arnelo
authors.forename: Juha
authors.initials: J
authors.lastname: Grönroos
authors.forename: Truls
authors.initials: T
authors.lastname: Hauge
authors.forename: Per M
authors.initials: PM
authors.lastname: Kleveland
authors.forename: Palle
authors.initials: P
authors.lastname: Nordblad Schmidt
authors.forename: Arto
authors.initials: A
authors.lastname: Saarela
authors.forename: Fredrik
authors.initials: F
authors.lastname: Swahn
authors.forename: Ervin
authors.initials: E
authors.lastname: Toth
authors.forename: Harri
authors.initials: H
authors.lastname: Mustonen
authors.forename: J-Matthias
authors.initials: JM
authors.lastname: Löhr
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater; D002404:Catheterization / Q000009:adverse effects* / Q000592:standards*; D002648:Child; D002675:Child, Preschool; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010195:Pancreatitis / Q000209:etiology*; D011446:Prospective Studies; D012537:Scandinavian and Nordic Countries; D016717:Sphincterotomy, Endoscopic; D013997:Time Factors; D055815:Young Adult
keywords: ERCP; cannulation; needle knife; sphincterotomy