The Effectiveness of Forceps-Assisted Cannulation for Difficult Cannulation During ERCP: Results of the SOCCER Randomized Controlled Trial

Forceps-assisted cannulation has been reported to facilitate difficult papillary cannulation during endoscopic retrograde cholangiopancreatography (ERCP), especially in the context of abnormal papillary anatomy or associated papillary diverticula. We performed a randomized, controlled trial to evaluate if forceps-assisted cannulation improves cannulation success rates, reduces the incidence of difficult cannulations, and decreases the risk of post-ERCP pancreatitis. One hundred fifty-two patients with difficult papillary cannulation during ERCP were randomized to cannulation with or without forceps. Difficult cannulation was defined as follows: papilla in/on the rim of a diverticulum, difficult cannulation (defined as 5 or more attempts, 5 or more minutes, or 2 or more unintended pancreatic duct wire passages), redundant tissue overlaying the papilla, or a type 2, 3, or 4 papilla. The primary clinical outcome was rate of successful cannulation. In total, 70 patients underwent forceps-assisted cannulation and 81 did not use forceps. Forceps patients were younger (62 vs 68 years P = 0.009), but otherwise baseline demographics, ERCP indication, trainee involvement, and papilla classification were similar with failed initial cannulation the most common reason for enrollment. One hundred percent of patients in the forceps-assisted group vs 83.9% in the no forceps group ( P < 0.001) underwent successful cannulation. All patients in the no forceps group who crossed over to the forceps group had successful cannulation. Although not statistically significant, the difficult cannulation rate (57.1 vs 69.1, P = 0.132) was higher in the no forceps group and the post-ERCP pancreatitis rate was low in both groups (5.7 vs 3.7, P = 0.705). Using forceps-assisted technique to overcome difficult cannulation improves ERCP cannulation success rates.