title: Optimal timing for a second ERCP after failure of initial biliary cannulation following precut sphincterotomy: an analysis of experience at two tertiary centers.
abstract: Precut sphincterotomy increases the success of deep biliary cannulation, but the method fails at the initial ERCP in 5-12% of cases. Although other invasive strategies are often used to access the bile duct, a second ERCP may be effective and safe. We evaluated the efficacy, safety, and factors related to a second ERCP after failed cannulation using a precut sphincterotomy.
  
  
  
  We reviewed all patients that underwent an ERCP with native papilla from 2006 to 2014 at two tertiary institutions. Efficacy was based on the cannulation rate of the second ERCP, and safety was assessed in terms of adverse events.
  
  
  
  We identified 112 patients with failed cannulation after precut, and a second ERCP was performed in 72 (64.3%). Median time between procedures was 7 days (IQR 5-11). Deep cannulation was achieved in 54 cases (75%). The only factor associated with cannulation failure was an ERCP within 4 days after the initial precut (cannulation success 44.4 vs. 79.4% after 4 days, p = 0.026). Adverse events were recorded after the first ERCP in 13 of 112 patients (11.8%): delayed bleeding in four, pancreatitis in five, and perforation in four. After the second ERCP, three of 72 patients (4.2%) presented adverse events: two delayed bleeding and one pancreatitis.
  
  
  
  A second ERCP after failure of initial biliary cannulation following precut appears to be safe and effective. A second ERCP should be delayed at least 4 days if feasible.
authors.affiliation: Servei de Patologia Digestiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, C/San Quintí, 89, 08041, Barcelona, Spain.
authors.forename: Juan
authors.initials: J
authors.lastname: Colan-Hernandez
authors.affiliation: Hospital Clinic, Universitat de Barcelona, Barcelona, Spain.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Aldana
authors.affiliation: Servei de Patologia Digestiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, C/San Quintí, 89, 08041, Barcelona, Spain.
authors.forename: Mar
authors.initials: M
authors.lastname: Concepción
authors.affiliation: Hospital Clinic, Universitat de Barcelona, Barcelona, Spain.
authors.forename: Karina
authors.initials: K
authors.lastname: Chavez
authors.affiliation: Servei de Patologia Digestiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, C/San Quintí, 89, 08041, Barcelona, Spain.
authors.forename: Cristina
authors.initials: C
authors.lastname: Gómez
authors.affiliation: Hospital Clinic, Universitat de Barcelona, Barcelona, Spain.
authors.forename: Angela
authors.initials: A
authors.lastname: Mendez-Bocanegra
authors.affiliation: Servei de Patologia Digestiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, C/San Quintí, 89, 08041, Barcelona, Spain.
authors.forename: Miguel
authors.initials: M
authors.lastname: Martínez-Guillen
authors.affiliation: Hospital Clinic, Universitat de Barcelona, Barcelona, Spain.
authors.forename: Oriol
authors.initials: O
authors.lastname: Sendino
authors.affiliation: Servei de Patologia Digestiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, C/San Quintí, 89, 08041, Barcelona, Spain.|CIBERehd, Barcelona, Spain.
authors.forename: Càndid
authors.initials: C
authors.lastname: Villanueva
authors.affiliation: Hospital Clinic, Universitat de Barcelona, Barcelona, Spain.
authors.forename: Josep
authors.initials: J
authors.lastname: Llach
authors.affiliation: Servei de Patologia Digestiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, C/San Quintí, 89, 08041, Barcelona, Spain. cguarnera@santpau.cat.
authors.forename: Carlos
authors.initials: C
authors.lastname: Guarner-Argente
authors.affiliation: Hospital Clinic, Universitat de Barcelona, Barcelona, Spain.
authors.forename: Andrés
authors.initials: A
authors.lastname: Cárdenas
authors.affiliation: Servei de Patologia Digestiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, C/San Quintí, 89, 08041, Barcelona, Spain.|CIBERehd, Barcelona, Spain.
authors.forename: Carlos
authors.initials: C
authors.lastname: Guarner
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002404:Catheterization / Q000379:methods*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D012086:Reoperation / Q000379:methods*; D012189:Retrospective Studies; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome
keywords: Difficult biliary cannulation; ERCP; Endoscopic retrograde cholangiopancreatography; Needle–knife; Precut; Sphincterotomy