Procedural Characteristics and Cannulation Difficulty During ERCP for Choledocholithiasis: Experience from a Tertiary Care Center

Aun Ali Mehdi S; Zeeshan Jafar; Fariduddin Md; Afzal Anees; Meraj Ahmed

doi:10.37022/wjcmpr.v8i3.458

Authors

S Aun Ali Mehdi Resident Doctor, Department of Surgery, Era’s Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India.
Zeeshan Jafar Resident Doctor, Department of Surgery, Era’s Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India.
Md Fariduddin Resident Doctor, Department of Surgery, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
Afzal Anees Professor, Department of Surgery, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
Meraj Ahmed Assistant Professor, Department of Surgery, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Abstract

Background: Difficult biliary cannulation is a major determinant of procedural complexity and adverse events during endoscopic retrograde cholangiopancreatography (ERCP); however, Indian tertiary-center data on its frequency and associated features are limited. We describe the procedural characteristics and cannulation difficulty in patients undergoing ERCP for choledocholithiasis.

Methods: We analyzed the ERCP arm of a prospective comparative study at the Department of Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University (May 2024–May 2026). Cannulation difficulty (endoscopist-recorded), number of attempts, papilla morphology, sphincterotomy, stenting, procedure duration, post-ERCP pancreatitis (PEP), and hospital stay were also recorded. Patients with and without difficult cannulation were compared using exploratory analyses.

Results: Twenty-nine patients (21 women; mean age 41.5 ± 15.8 years) were included. Difficult cannulation occurred in 14 (48.3%) and multiple attempts in 12 (41.4%). The papilla was normal in 22 (75.9%), bulging in five, and flat in two. Sphincterotomy was performed in 24 (82.8%); the mean procedure time was 57.7 ± 11.7 min. PEP occurred in two patients (6.9%), both with difficult cannulation. Multiple stones (71.4% vs 20.0%, p = 0.009) and higher alkaline phosphatase (466 vs 293 IU/L, p = 0.012) were more frequent with difficult cannulation, and the bile duct tended to be narrower (9.8 vs 11.5 mm, p = 0.053). No perforation, bleeding, cholangitis, or death occurred.

Conclusions: Nearly half of the ERCPs for choledocholithiasis involved difficult cannulation, clustering with multiple stones, and a less dilated duct. Standardized definitions, anticipation of difficulty, early rescue techniques, and PEP prophylaxis merit prospective evaluation.

Keywords:

ERCP, choledocholithiasis, difficult biliary cannulation, post-ERCP pancreatitis, and papilla morphology

DOI

https://doi.org/10.37022/wjcmpr.v8i3.458

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