What is the management of obstructive jaundice with a periampullary mass when Endoscopic Retrograde Cholangiopancreatography (ERCP) cannulation is unsuccessful?

Management of Failed ERCP Cannulation in Obstructive Jaundice with Periampullary Mass

When ERCP cannulation fails in a patient with obstructive jaundice and a periampullary mass, percutaneous transhepatic biliary drainage (PTBD) is the recommended next step for biliary decompression and should be performed promptly to reduce morbidity and mortality. 1

What is this called?

This situation is known as a "failed ERCP" or "unsuccessful biliary cannulation." Despite advances in endoscopic techniques, selective biliary access fails in 5-15% of cases, even in expert high-volume centers 2. When cannulation attempts are unsuccessful due to inability to locate or access the bile duct, this represents a technical failure requiring alternative approaches.

Management Algorithm

1. Initial Assessment

• Confirm the presence of obstructive jaundice (elevated bilirubin, dilated bile ducts)
• Evaluate the severity of symptoms (presence of cholangitis, sepsis)
• Review cross-sectional imaging to understand the anatomy and obstruction

2. First-Line Alternative: Percutaneous Transhepatic Biliary Drainage (PTBD)

• PTBD should be reserved for patients in whom ERCP fails 1
• Success rates utilizing a percutaneous approach have been reported upwards of 95-100% 1
• Procedure involves:
  • Percutaneous access into the biliary ducts
  • Placement of an internal/external biliary catheter
  • Follow-up cholangiogram to confirm adequate drainage

3. Second-Line Options: Rendezvous Techniques

• Percutaneous-endoscopic rendezvous technique:
  • Percutaneous access into biliary ducts
  • Guidewire navigated into small bowel
  • Endoscopist snares guidewire to help navigate and cannulate the papilla 1
  • Success rates reported as high as 92% (11 of 12 patients) 1

4. Third-Line Options: EUS-Guided Biliary Drainage

• For patients with strong preference for internal drainage 1
• Can be accomplished via transgastric or transduodenal approach
• Requires high level of technical expertise
• Available only at tertiary centers with experienced endoscopists

5. Surgical Options

• Reserved for cases where less invasive approaches fail
• Surgical CBD exploration carries higher morbidity (20-40%) and mortality (1.3-4%) 1
• Laparoscopic CBD exploration may be preferable with reported success of up to 95% 1

Special Considerations

Factors that may have contributed to failed cannulation:

• Periampullary mass distorting anatomy
• Periampullary diverticula making cannulation technically difficult 3, 4
• Duodenal infiltration by tumor 5
• Altered surgical anatomy from previous operations

Complications of PTBD to monitor for:

• Biliary peritonitis
• Hemobilia
• Pneumothorax
• Hematoma
• Liver abscesses
• Bile leak
• Overall complication rate approximately 6.8% 1

Comparative Outcomes

When comparing EUS-guided rendezvous techniques with PTBD after failed ERCP:

• PTBD has higher initial technical success (100% vs 76% for EUS-guided) 6
• EUS-guided approaches, when successful, result in:
  • Shorter hospital stays (1 day vs 5 days)
  • Fewer follow-up biliary interventions 6

Pitfalls to Avoid

1. Delay in seeking alternative drainage: Delayed intervention is associated with elevated morbidity, mortality, increased ICU admission, and prolonged hospitalization 1

2. Repeated unsuccessful ERCP attempts: Multiple cannulation attempts increase the risk of post-ERCP pancreatitis 2

3. Failure to consider anatomical barriers: Duodenal obstruction, periampullary diverticula, or altered surgical anatomy may make ERCP technically impossible 7

4. Overlooking cholangitis risk: In patients with biliary obstruction, manipulating an obstructed biliary system carries high risk of inducing suppurative cholangitis 1

Remember that timely biliary decompression is essential for reducing morbidity and mortality in patients with obstructive jaundice, particularly when there is concern for malignancy or cholangitis.