Comparison of the procedure results of ectopic papillae encountered during ERCP procedure with the procedure results of papillae with normal localization

Emre Ballı; Tamer Akay; Sezgin Yılmaz

doi:10.28982/josam.843063

Authors

Emre Ballı https://orcid.org/0000-0002-3201-9756
Tamer Akay https://orcid.org/0000-0001-8137-3658
Sezgin Yılmaz Afyon Health Sciences University Medical Faculty Hospital https://orcid.org/0000-0003-0213-3758

DOI:

https://doi.org/10.28982/josam.843063

Keywords:

Endoscopy, Endoscopic Retrograde Cholangiopancreatography (ERCP), Ectopic papilla, Pancreatitis

Abstract

Background/Aim: In Endoscopic retrograde cholangiopancreatography (ERCP), Ampulla of Vater is found on the posteromedial wall of the second part of the duodenum. However, ectopic expansion of the common bile duct to the 3rd or 4th part of the duodenum or the proximal stomach, pylorus, or bulb was reported in the literature. This study primarily aims to investigate the risk of complications in patients with ectopic papillae and evaluate the applicability of endoscopic sphincterotomy in these patients. Methods: In this a case-control study, the data of 3,048 patients who underwent ERCP procedure in the ERCP unit of our clinic between January 2013 and December 2018 were retrospectively analyzed, and 30 patients with ectopic bulbar papillae and 30 randomly selected patients with normally localized papillae were compared in terms of age, gender, duration of the procedure, post-procedural biochemical tests, cannulation success, precision rate, postprocedural pancreatitis complications and the need for analgesics. Power analysis was performed with the G*power 3.1.9.7 package program (1-B = 0.95, alpha = 0.05). With a power of 0.954, the sample size to be reached was thirty-three for each group. Results: The rate of pancreatitis complications was higher in patients with ectopic bulbar papillae (50%) compared to those without (16.7%) (P=0.006). Even though the rate of pre-cut was higher in patients with ectopic bulbar papillae (33.3%) compared to patients with normally localized papillae (13.3%), this difference was not statistically significant (P=0.063). Cannulation success in patients with ectopic bulbar papillae (83.3%) was insignificantly lower than in patients with normally localized papillae (90.0%) (P=0.353). The need for both narcotic and non-steroidal anti-inflammatory analgesics was higher in patients with ectopic bulbar papillae (P<0.001, P=0.005, respectively). Conclusions: It should be kept in mind that ectopic biliary drainage may be found in an alternative location when no papillae are observed in the expected anatomical region. The complication risks, including pancreatitis, are increased in the intervention of ectopic papillae. Novel studies showing that endoscopic sphincterotomy and pre-cut are successfully used in patients with ectopic papillae are needed.

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References

Mutlu N, Bolat R, Yorulmaz F, et al. Endoscopic retrograde cholangiopancreatography (ERCP). Current Gastroenterology. 2005;10:120-33.

Adler DG, Baron TH, Davila RE, et al. Standards of Practice Committee of American Society for Gastrointestinal Endoscopy. ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas. Gastrointest Endosc. 2005;62:1-8.

Doty J, Hassal E, Fonkalsrud EW. Anomalous drainage of the common bile duct into the fourth portion of the duodenum. Arch Surg. 1985;120:1077-9.

Qintana EV, Labat R. Ectopic drainage of the common bile ducts. Ann Surg. 1974;180:119-23.

Kubota T, Fujiko T, Honda S, Suetsuna J, Matsunaga K, et al. The papilla of the Vater emptying into the Duodenal bulb. Report of two cases. Jpn J Med. 1988;27:79-82.

Disibeyaz S, Parlak E, Cicek B, Cengiz C, Kuran SO, et al. Anomalous opening of the common bile duct into the duodenal bulb: endoscopic treatment. BMC Gastroenterol. 2007;7:26.

Kanematsu M, Imaeda T, Seki M, Goto H, Doi H, Shimokawa K. Accessory bile duct draining into the stomach: case report and review. Gastrointest Radiol. 1992;17:27-30.

Pereira-Lima J, Pereira-Lima LM, Nestrowski M, Cuervo C. Anomalous location of the papilla of Vater. Am J Surg. 1974;128:7174.

Moosman DA. The surgical significance of six anomalies of the biliary duct system. Surg Gynecol Obstet. 1970;131:655-60.

Lee SS, Kim MH, Lee SK, et al. Ectopic opening of the common bile duct in the duodenal bulb: clinical implications. Gastrointest Endosc. 2003;57:679-82.

Rosario MT, Neves CP, Ferreira AF, Luis AS. Ectopic papilla of Vater. Gastrointest Endosc. 1990;36:606-7.

Keddie NC, Taylor AW, Sykes PA. The termination of the common bile duct. Br J Surg. 1974;61:623-5.

Krstic M, Stimec B, Krstic R, Ugljesic M, Knezevic S, Jovanovic I. EUS diagnosis of ectopic opening of the common bile duct in the duodenal bulb: a case report. World J Gastroenterol. 2005;11:50685071.

Lindner HH, Pena VA, Ruggeri RA. A clinical and anatomical study of anomalous terminations of the common bile duct into the duodenum. Ann Surg. 1976;184:626-32.

Lurje A. The topography of the extrahepatic biliary passages. Ann Surg. 1937; 05:161.

Dowdy JR GS, Waldron GW, Brown WG. Surgical anatomy of the pancreatobiliary ductal system. Arch Surg. 1962;84:229.

Tan CE, Morosco GJ. The developing human biliary system at the porta hepatis level betwen 29 days and 8 weeks of gestation: a way to understanding biliary atresia. Part I. Pathol Int. 1994;44:587-99.

Boyden EA. Congenital variations of the extrahepatic biliary tract: a review. Minn Med. 1944;27:932-3.

Saritas U, Senol A, Ustundag Y. The clinical presentations of ectopic biliary drainage into duodenal bulbus and stomach with a thorough review of the current literatüre. BMC Gastroenterology. 2010;2-10.

Guerra I, Rábago LR, Bermejo F, Quintanilla E, García-Garzón S. Ectopic papilla of Vater in the pylorus. World J Gastroenterol. 2009;15(41):5221-3.

Sung HY, Kim JI, Park YB, Cheung DY, Cho SH, et al. The Papilla of Vater just below the Pylorus Presenting as Recurrent Duodenal Ulcer Bleeding. Internal Medicine. 2007;1853-6.

Ersoz G, Ozutemiz O, Akay S, Tekesin O. Patients with Ectopic Papilla of Vater, Bulbar Stenosis and Choledocholithiasis: A New Syndrome? Gastroıntestınal Endoscopy. 2005;61:5. T1252.

Nasseri-Moghaddam S, Nokhbeh-Zaeem H, Soroush Z, Bani-Solaiman Sheybani S, Mazloum M. Ectopic Location of the Ampulla of Vater Within the Pyloric Channel. Middle East Journal of Digestive Diseases. 2011;3(1):56-8.

Sezgin O, Altintas E, Ucbilek E. Ectopic opening of the common bile duct into various sites of the upper digestive tract: a case series. Gastroıntestınal Endoscopy. 2010;72(1):198-203.

Haraldsson E, Kylänpää L, Grönroos J, Saarela A, Toth E, et al. Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP. Gastrointest Endosc. 2019;90(6):957-63.

Krutsri C, Kida M, Yamauchi H, Iwai T, Imaizumi H, et al. Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy. World J Gastroenterol. 2019;25(26):3313-33.

Niu F, Liu YD, Chen RX, Niu YJ. Safety and efficacy of enhanced recovery after surgery in elderly patients after therapeutic endoscopic retrograde cholangiopancreatography. Wideochir Inne Tech Maloinwazyjne. 2019;14(3):394-400.

Ismail S, Udd M, Lindström O, Rainio M, Halttunen J, et al. Criteria for difficult biliary cannulation: start to count. Eur J Gastroenterol Hepatol. 2019;31(10):1200-5.

Katsinelos P, Papaziogas B, Paraskevas G, Chatzimavroudis G, Koutelidakis J, et al. Ectopic papilla of vater in the stomach, blind antrum with aberrant pyloric opening, and congenital gastric diverticula: an unreported association. Surg Laparosc Endosc Percutan Tech. 2007;17:434-7.

Kanematsu M, Imaeda T, Seki M, Goto H, Doi H, Shimokawa K. Accessory bile duct draining into the stomach: case report and review. Gastrointest Radiol. 1992;17:27-30.

Dacha S, Wang XJ, Qayed E. A Case of an Ectopic Ampulla of Vater in the Pyloric Channel. ACG Case Rep J. 2014;1(3):161-3.