Comparison of the process results of the ectopic placement papiles meeting during the ERCP process with the process results of the normal location papilles

Endoscopic retrograde cholangiopancreatography (ERCP), involving the cannulation of the papilla of Vater using a side-viewing endoscope, is used to obtain radiological images of the bile ducts and pancreatic duct after the injection of a contrast medium, and thereby to treat diseases of the bile ducts and pancreas through a therapeutic intervention. The ampulla of Vater is located on the posteromedial wall of the second part of the duodenum, at the point at which the coledoc duct opens up after running along the medial wall of the descending section of the duodenum. Ectopic openings of the coledoc duct into the third or fourth parts of the duodenum, and even more proximally into the stomach, pylorus or bulbus,have also been reported. Ectopic papilla poses a challenge in cannulation due to its localization distant to the duodenoscope in its short position. The present study makes a retrospective review of the data of 60 patients who underwent ERCP in the Department of General Surgery of the Afyon Health Sciences University Faculty of Medicine within a 6-year period between January 2013 and December 2018. The records of a total of 30 patients with ectopic bulbar papillae were compared with 30 randomly selected patients with a papilla of Vater located in the normal position, matched in terms of age, gender, procedure time, biochemical test results following the procedure (ALT, AST, Amilaz, GGT), cannulation success, precut ratio, presence of pancreatitis as a complication after the procedure and the need for analgesics. Of the patients with ectopic bulbar papillae, 14 were female (46.6 %) and 16 were male (53.4 %). Of those with papillae in a normal localization, 18 were female (60 %) and 12 were male (40 %). The age range was 33–90 years in the patients with ectopic bulbar papilla, the mean age being 62.33 years. The age range was 32–93 years in patients with normal papilla, the mean age being 69.83 years. The procedure time ranged between 21 and 76 minutes, with a mean procedure time of 52.57 minutes, in patients with ectopic bulbar papillae. The procedure time ranged between 35 and 67 minutes, with a mean procedure time of 42.67 minutes, in patients with normal papillae. An examination of the biochemical parameters in patients with normal and ectopic bulbar papillae following the procedure revealed normal AST, ALT and GGT values. The amilase values, the number of patients developing pancreatitis and the need for NSAIDs were higher in patients with ectopic bulbar papillae. Cannulation of coledoc duct was successful in 25 patients with ectopic bulbar papillae. However in 5 patients of study group coledoc cannulation could not be achieved. In control group 27 of 30 patients, coledoc cannulation was succesfully done while in 3 patient cannulation has not been achieved. Pre-cut procedure was used in 10 patients with ectopically located papillae. On the other hand same pre-cut procedure was necessary only in 4 patients with normally located papillae.. The present study is somewhat unique in its examination of biochemical parameters following the procedure, and in evaluating the procedure time and the parameters relevant to complications. In conclusion, to date there are many studies showing that recognition of an ectopic papilla that is rarely encountered, but that causes difficulties in cannulation, directly affects the success of the ERCP procedure the risk of complications. It must thereforebe kept in mind that biliary drainage may be an ectopic alternative localization if not found in its usual anatomical position. The intervention at ectopic papilla brings the risk of many complications, including the development of pancreatitis. There is a need for further studies detailing the successful use of endoscopic sphincterotomy and pre-cut procedures.