Safety and efficacy of precut needle-knife fistulotomy

Abstract

OBJECTIVE. Although precut is considered an useful alternative when standard methods of biliary access have failed, there is some controversy about it's safety. The study aim was to evaluate the effectiveness of needle-knife fistulotomy (NKF) after a difficult biliary cannulation and whether common bile duct (CBD) diameter influenced complications. MATERIAL AND METHODS. Between November 2006 and December 2010, a total of 1087 consecutive patients with naive papilla were submitted to endoscopic retrograde cholangiopancreatography (ERCP) for biliary access, in an affiliated university hospital. If the biliary cannulation was unsuccessful after 12-15 min, a NKF was performed. The main outcomes were biliary cannulation rate, NKF success and post-ERCP complications. RESULTS. Biliary cannulation by standard methods was successful in 883 patients (81%). In the remaining 204 patients, NKF was performed and allowed CBD access in 166 (81%), leading to a 96% cannulation rate. A second ERCP was performed in 25 patients, with an NKF success of 90% and an overall biliary cannulation rate of 98%. The post-ERCP complication rate was 7.9% (n = 16) with a 6.4% pancreatitis rate and no deaths. The complication for patients with a CBD ≤ to 4 mm was 13.9% compared with 4.5% in the remaining patients (OR = 3.39, p = 0.024). CONCLUSIONS. NKF is a safe and highly useful method of accessing the CBD in the setting of a difficult biliary cannulation. Despite its safety profile, extra caution is needed when applying NKF to patients with thin bile ducts.

ERCP in Portugal: A Wide Survey on the Prevention of Post-ERCP Pancreatitis and Papillary Cannulation Techniques

“…Although most of the endoscopists reported a rate of use < 10%, there was a group of 23.1% who report a use rate between 16 and 20%. The variability on this indicator is comparable to the trend reported in other studies, resulting from personal preferences and policies of the centers about precut [25, 30, 31]. Regarding the most frequently used techniques, conventional precut (46.4%) and fistulotomy (46.4%) were the two most common precut techniques used by Portuguese endoscopists, with only 2 endoscopists reporting using another variant.…”

“…Precut is an advanced ERCP technique which significantly depends on the endoscopist’s skills [22, 23]. Although it is very safe and highly successful in the hands of skilled endoscopists, it is dangerous when performed by less experienced endoscopists [24, 25]. In a recent European survey, this was the first choice followed by 42 and 100% of the endoscopists, depending on whether the main pancreatic duct was cannulated or not, respectively [25, 26].…”

“…Although it is very safe and highly successful in the hands of skilled endoscopists, it is dangerous when performed by less experienced endoscopists [24, 25]. In a recent European survey, this was the first choice followed by 42 and 100% of the endoscopists, depending on whether the main pancreatic duct was cannulated or not, respectively [25, 26]. The high proportion of Portuguese endoscopists who chose precut may be associated with the high number of experienced endoscopists represented in our sample.…”

Transpapillary selective bile duct cannulation technique: Review of Japanese randomized controlled trials since 2010 and an overview of clinical results in precut sphincterotomy since 2004

“…One hundred twenty‐four articles were judged not suitable for pooled analysis based on their abstracts. After vetting was complete, 69 articles were reviewed.…”

Endoscopic retrograde cholangiopancreatography complications: Techniques to reduce risk and management strategies

“…However, the risk of NKF is likely higher in patients with small diameter bile ducts. 84 A lower risk of PEP with fistulotomy should also be weighed against the possibility of lower initial success and final success if/when repeat ERCP is attempted. 85 Risk of NKS is quite low when pancreatic stenting is employed (see below).…”