Precut Fistulotomy for Difficult Biliary Cannulation: Is It a Risky Preference in Relation to the Experience of an Endoscopist?

Abstract

After therapeutic ERCP training involving at least 100 ERCPs, including at least half that were therapeutic cases and more than ten that were precut papillotomies, a precut fistulotomy can be performed safely and effectively in low-risk patients.

Sequential algorithm analysis to facilitate selective biliary access for difficult biliary cannulation in ERCP: a prospective clinical study

“…A study of precuts in DBC reported that endoscopist experience with the precut procedure was important, particularly in experienced hands, no increasing the number of complications [6,7,16-18]. We used stricter DBC criteria to prevent frequent papillary contacts causing PEP (5-min cannulation time and 5 attempts at papillary contact) compared with a study which defined DBC as failure to achieve biliary access despite 10 min of attempted cannulation or more than 5 attempted unintentional pancreatic duct cannulations [6,19]. Of the DBC criteria, unintentional pancreatic duct cannulation more than 3 times indicated DGC, and subsequent PPS was attempted without delay when DGC failed, according to the algorithm (Figure 1).…”

“…Consequently, we applied the step-wise techniques early following the stricter DBC criteria, resulting in a higher technical success rate and reduced successful cannulation time compared with a previous our report (9.2 ± 7.3 minutes in our study vs . 16.9 ± 9.1 minutes, P  < 0.05) [6]. …”

“…Difficult biliary cannulation was defined as failure to achieve selective biliary access by wire-guided cannulation despite 5 min of attempted cannulation (cannulation time > 5 min), papillary contacts > 5 times, attempted unintentional pancreatic duct cannulation ≥ 3 times, or hook-nose-shaped papilla (difficult type of cannulation) [6]. Meaningful papillary contact was defined as sustained contact for cannulation between the guidewire-preloaded papillotome and the ampulla of Vater for at least 3–5 seconds of manipulation [6,8,9].…”

“…Meaningful papillary contact was defined as sustained contact for cannulation between the guidewire-preloaded papillotome and the ampulla of Vater for at least 3–5 seconds of manipulation [6,8,9]. The configuration of a hook-nose-shaped papilla, which is a difficult type to cannulate conventionally, was based on a previous report; papilla shapes were classified into one of four categories: the non-prominent type, wherein the major papilla lacked a marked oral protrusion; the prominent type, with marked oral protrusion of the major papilla; the bulging or hook-nose type, with marked swelling of the oral protrusion; and the distorted type, with an unclassified unusual shape and position [6]. The frequency of papillary contact or unintentional pancreatic duct cannulation was measured by skilled assistant nurses.…”

Needle Knife Precut Papillotomy and Fistulotomy for Difficult Biliary Cannulation during Endoscopic Retrograde Cholangiopancreatography

“…Even so, the success rate of NKF is still low [8,9]. For another technique, NKPP, only pinkish or dark red bile duct has been mentioned in most literature without more details about the procedure [10].…”