Application And Safety Of Precut Sphincterotomy For Difficult ERCP Cannulation

Objective: To evaluate the application of the precut techniques fordifficult ERCP cannulation, and evaluate the safety to compare thecomplication rates between precutting techniques and standard endoscopicsphincterotomy (EST).Methods: A retrospective evaluation of collected non-randomized dataof438first underwent ERCP cases from December2004to December2011inthe Department of Gastroenterology of the Second Hospital of Hebei MedicalUniversity. All difficult cannulation cases (including guidewire and biopsyforceps cannulation techniques) underwent precut, total73cases. Theprecutting techniques include precut papillotomy, transpancreatic precutsphincterotomy, needle-knife precut sphincterotomy and needle-knifefistulotomy. The standard endoscopic sphincterotomy would be performedafter precut procedure if needed. Statistics cannulation success rates,postoperative diagnosis, and postoperative complications of conventionalcannulation group and the precut group, and compare postoperativecomplications between the precut group and the EST group.Results: A total of438therapeutic biliary ERCP procedures were performedbetween December2004and December2011, mean age63±14.3years old,range from17～94years old. All first used conventional cannulation,364cases succeed, the success rate was83.1%.74cases of patients withconventional difficult cannulation,1case transferred surgery, the remaining73cases were performed precut technique immediately after bile ductcannulation failed,57patients succeed.7cases who bile duct cannulationfailed underwent ERCP again a few days later,6cases succeed. The totalERCP success rate of bile duct cannulation was97.7%(table1). Of these,244cases had common bile duct stones,7cases had gallstone,21cases had common bile duct occupying lesions,2cases had duodenal papilla lesions,40cases had common bile duct cancer,27cases had pancreatic cancer,7caseshad periampullary cancer,9cases had duodenal papilla adenocarcinoma,3cases had bile duct metastatic carcinoma,14cases had biliary tract infection,31cases had duodenal papilla inflammation,3cases had sclerosing papillitis,8cases had acute gallstone pancreatitis,6patients had chronic pancreatitis,2cases had cholangiopancreatography shunt abnormalities,3cases hadobstructive jaundice,2cases had acute cholecystitis,1cases had ascariasis,2cases had biliary fistula complicated with liver abscess,1cases hadpost-traumatic jaundice,2cases had primary sclerosing cholangitis,1case hadbiliary-enteric anastomosis,2cases was normal. In the73patients of precut,25cases had common bile duct stones,2cases had gallstone,1case hadcommon bile duct occupying lesion,2cases had duodenal papilla lesions,9cases had common bile duct cancer,9cases had pancreatic cancer,2cases hadperiampullary cancer,2cases had duodenal papilla adenocarcinoma,1casehad bile duct metastatic carcinoma,2cases had biliary tract infection,7caseshad duodenal papilla inflammation,3cases had sclerosing papillitis,1caseshad acute gallstone pancreatitis,2patients had chronic pancreatitis,2caseshad obstructive jaundice,1cases had biliary fistula complicated with liverabscess,1cases had post-traumatic jaundice,1cases had primary sclerosingcholangitis (table2). Postoperative hyperamylasemia rate was39.7%(174/438), EST group40%(114/285), precut group45.2%(33/73), P=0.42,and there was no significant difference. Postoperative mild pancreatitis ratewas14.4%(63/438), EST group15.1%(43/285), precut group13.7%(10/73),P=0.77, and there was no significant difference. Postoperative infection ratewas3.4%(15/438), EST group3.5%(10/285), precut group2.8%(2/73), P=0.75, and there was no significant difference. In total complication rate, ESTgroup43.9%(125/285), precut group47.9%(35/73), P=0.53, and there wasno significant difference.3cases appeared serious complications afterconventional cannulating:1case had severe acute pancreatitis and sepsis,1case had bile duct bleeding,1case had duodenal papilla bleeding. No serious complications in precut group. All patients with postoperative complicationscould be restored to normal after conservative treatment.Conclusion: precut is an effective and safe technique in difficult biliarycannulation. A second ERCP after precut may have a higher bile ductcannulation success rate. It can be used in experienced hands when clinicallyindicated on therapeutic ERCP.