Risk: Benefit ratio of unintentional ductal opacification at ERCP

Unintentional cannulation of either pancreatic or biliary ducts is not uncommon in clinical practice. The risks of the unintentional opacification may be higher than those without, pancreatitis in particular for the case of unintentional PD opacification. The potential benefit may include the discovery of unsuspected pathology that may change the approach and management of the patient. Aim: To determine the risk:benefit ratio of unintentional ductal opacification at ERCP. Setting: Endoscopy Unit VA Medical Center. Statistical Analysis: Chi-square. Materials and Methods: All consecutive ERCPs performed at a single institution were retrospectively reviewed. All ERCPs were performed by GI Fellows in training under the direct supervision of a single therapeutic endoscopist. All ERCPs had a defined duct(s) of interest before the beginning of each procedure. Unintentional ductal opacification was defined as the opacification of the duct of no primary interest as defined a priori. Unsuspected ERCP diagnosis and complications were recorded. The complication rate in the group with unintentional opacification (Group A) was compared with that in whom the duct(s) of interest was opacified only (Group B). Results: A total of 802 ERCPs were performed over a 5 year period. Of these, 271 (33.8%) had an unintended duct opacified. In 50 ERCPs (18.4%) unintentional opacification of the duct showed abnormalities; of these 32 (64%) were never diagnosed before and required endoscopic therapy in only 3 (9.4%). Abnormal findings included: Pancreatic duct dilation: 20; CBD stricture with dilation: 11; PD stricture with dilation: 7; CBD dilation: 4; CBD stricture: 4; PD stricture: 2; CBD stones: 2. The overall ERCP-related complication rate for the entire study group was 6.0% for Group A was 7.4% and not different from Group B (4.8%). The risk of post-ERCP pancreatitis in the unintended duct opacification group was 3.7% and not different from the intended group (2.9%). Conclusions: 1) One-third of all ERCPs had an unintentional opacified duct. 2) Unintentional ductal opacification was not associated with an increased overall risk of ERCP-related complications, nor post-ERCP pancreatitis in particular. 3) Although unintentional opacification leads to new diagnosis in 12% patients, only 10% of them required endoscopic therapy.