Endoscopic assessment of minor papilla morphology: Predictors of successful cannulation and procedural pancreatitis risk in minor papilla endotherapy

Background We evaluated for predictors of successful cannulation and post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in minor papilla endotherapy (MPE), emphasizing endoscopic minor papilla morphology. Methods We retrospectively analyzed 232 MPEs in 65 patients, assessing minor papilla morphology based on three features: bulge as “prominent” or “subtle,” mucosal appearance as “papilla‐like” resembling the main papilla or “SMT‐like” akin to a gastrointestinal submucosal tumor, and orifice visibility as “clear” or “unclear.” Cannulation success was evaluated in 65 enrolled patients, with PEP risk assessed in all 232 MPEs. Results Minor papilla morphology was categorized as prominent/subtle bulge in 42/23 patients, papilla‐like/SMT‐like mucosal appearance in 42/23, and clear/unclear orifice visibility in 24/41. Cannulation succeeded in 54/65 patients (83%). A papilla‐like appearance and clear orifice visibility was significantly associated with cannulation success. PEP incidence was 5.2% and predominantly mild. A papilla‐like appearance significantly decreased PEP incidence, while precutting technique and orifice dilation significantly increased PEP risk. Conclusion Evaluating minor papilla morphology may help predict cannulation success and PEP risk in MPE. A papilla‐like mucosal appearance prognosticates cannulation success and reduced PEP risk, with clear orifice visibility serving as a success predictor. These findings provide practical guidance for preprocedural planning by emphasizing the importance of minor papilla morphology evaluation. Kuraishi and colleagues demonstrated the usefulness of endoscopic assessment of minor papilla morphology in predicting cannulation success and the likelihood of complications following minor papilla endotherapy, providing critical guidance for planning. In particular, a papilla‐like mucosal appearance and clear orifice visibility significantly predicted successful cannulation, reducing the risk of post‐ERCP pancreatitis.