Precut (access) papillotomy
- Martin L Freeman, MD
Martin L Freeman, MD
- Professor of Medicine
- University of Minnesota
- Kapil Gupta, MD, MPH
Kapil Gupta, MD, MPH
- Associate Director: Pancreatic & Biliary Diseases
- Cedars-Sinai Medical Center
Precut papillotomy (or sphincterotomy) refers to a variety of endoscopic techniques used to gain access to the bile (or occasionally the pancreatic) duct. In most patients, precut papillotomy is followed by conventional sphincterotomy, which permits completion of therapies such as stone extraction and biliary drainage. However, precut papillotomy is sometimes used to gain access to the bile (or the pancreatic) duct for diagnostic cholangiography (or pancreatography) alone, a practice of increasingly uncertain justification given the availability of magnetic resonance cholangiopancreatography (MRCP) endoscoping ultrasound (EUS) and intraoperative laparoscopic cholangiography to diagnose biliary disease. Thus, the alternative term access papillotomy is probably more accurate .
Precut techniques are most often used after conventional methods of biliary cannulation have failed or, in a few centers, as a preferential technique for performing biliary and pancreatic sphincterotomy over a pancreatic stent in patients with sphincter of Oddi dysfunction . Use of precut varied from none to as many as 38 percent of all biliary cannulation attempts in different reports [3-24].
Use of access papillotomy is highly controversial, with widely variable opinions as to its appropriateness, safety, and preferred technique. With advances in techniques and equipment for biliary cannulation, access papillotomy is seldom necessary. When it is performed, it should generally be limited to patients with a definitive indication for biliary therapy. There are emerging data that in patients with difficult biliary cannulation, early adoption of precut biliary sphincterotomy is advantageous, although these studies are from centers with expert endoscopists and cannot be applied universally .
There are several techniques to perform precut papillotomy. Success and complication rates of precut techniques are highly variable and depend heavily upon the experience and skill of the endoscopist, the indication for the procedure, the risk profile of the patient, anatomic variations among patients, and technique-related factors such as use of pancreatic stents .
Free-hand needle-knife — The most widely practiced technique is the free-hand needle-knife, in which an incision is made starting at the orifice and extending cephalad for a variable distance. The original description of the technique involved using an upward sweeping motion with the elevator. However, improved control and safety can be achieved by loading the needle-knife by upward traction on the endoscope. Performing practice movements with the needle out (in the direction of anticipated cut) but not in contact with the mucosa can help in making sure of the direction of the cutting needle (figure 1). Having the duodenoscope in a shorter position can also assist in controlled transfer of movements.
- Vandervoort J, Carr-Locke DL. Needle-knife access papillotomy: an unfairly maligned technique? Endoscopy 1996; 28:365.
- Fogel EL, Eversman D, Jamidar P, et al. Sphincter of Oddi dysfunction: pancreaticobiliary sphincterotomy with pancreatic stent placement has a lower rate of pancreatitis than biliary sphincterotomy alone. Endoscopy 2002; 34:280.
- Akashi R, Kiyozumi T, Jinnouchi K, et al. Pancreatic sphincter precutting to gain selective access to the common bile duct: a series of 172 patients. Endoscopy 2004; 36:405.
- Binmoeller KF, Seifert H, Gerke H, et al. Papillary roof incision using the Erlangen-type pre-cut papillotome to achieve selective bile duct cannulation. Gastrointest Endosc 1996; 44:689.
- Boender J, Nix GA, de Ridder MA, et al. Endoscopic papillotomy for common bile duct stones: factors influencing the complication rate. Endoscopy 1994; 26:209.
- Bolzan HE, Spatola J, González J, et al. [Precut Vater's papilla. Prospective evaluation of frequency of use, effectiveness, complication and mortality. Cooperative study in the northwest of the province of Buenos Aires]. Acta Gastroenterol Latinoam 2001; 31:323.
- Booth FV, Doerr RJ, Khalafi RS, et al. Surgical management of complications of endoscopic sphincterotomy with precut papillotomy. Am J Surg 1990; 159:132.
- Bruins Slot W, Schoeman MN, Disario JA, et al. Needle-knife sphincterotomy as a precut procedure: a retrospective evaluation of efficacy and complications. Endoscopy 1996; 28:334.
- Dowsett JF, Polydorou AA, Vaira D, et al. Needle knife papillotomy: how safe and how effective? Gut 1990; 31:905.
- Foutch PG. A prospective assessment of results for needle-knife papillotomy and standard endoscopic sphincterotomy. Gastrointest Endosc 1995; 41:25.
- Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335:909.
- Goff JS. Common bile duct pre-cut sphincterotomy: transpancreatic sphincter approach. Gastrointest Endosc 1995; 41:502.
- Goff JS. Long-term experience with the transpancreatic sphincter pre-cut approach to biliary sphincterotomy. Gastrointest Endosc 1999; 50:642.
- Harewood GC, Baron TH. An assessment of the learning curve for precut biliary sphincterotomy. Am J Gastroenterol 2002; 97:1708.
- Huibregtse K, Katon RM, Tytgat GN. Precut papillotomy via fine-needle knife papillotome: a safe and effective technique. Gastrointest Endosc 1986; 32:403.
- Kasmin FE, Cohen D, Batra S, et al. Needle-knife sphincterotomy in a tertiary referral center: efficacy and complications. Gastrointest Endosc 1996; 44:48.
- Katsinelos P, Mimidis K, Paroutoglou G, et al. Needle-knife papillotomy: a safe and effective technique in experienced hands. Hepatogastroenterology 2004; 51:349.
- Leung JW, Banez VP, Chung SC. Precut (needle knife) papillotomy for impacted common bile duct stone at the ampulla. Am J Gastroenterol 1990; 85:991.
- Loperfido S, Angelini G, Benedetti G, et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 1998; 48:1.
- Mavrogiannis C, Liatsos C, Romanos A, et al. Needle-knife fistulotomy versus needle-knife precut papillotomy for the treatment of common bile duct stones. Gastrointest Endosc 1999; 50:334.
- O'Connor HJ, Bhutta AS, Redmond PL, Carruthers DA. Suprapapillary fistulosphincterotomy at ERCP: a prospective study. Endoscopy 1997; 29:266.
- Rabenstein T, Ruppert T, Schneider HT, et al. Benefits and risks of needle-knife papillotomy. Gastrointest Endosc 1997; 46:207.
- Rollhauser C, Johnson M, Al-Kawas FH. Needle-knife papillotomy: a helpful and safe adjunct to endoscopic retrograde cholangiopancreatography in a selected population. Endoscopy 1998; 30:691.
- Tweedle DE, Martin DF. Needle knife papillotomy for endoscopic sphincterotomy and cholangiography. Gastrointest Endosc 1991; 37:518.
- Lopes L, Dinis-Ribeiro M, Rolanda C. Early precut fistulotomy for biliary access: time to change the paradigm of "the later, the better"? Gastrointest Endosc 2014; 80:634.
- Horiuchi A, Nakayama Y, Kajiyama M, Tanaka N. Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla. Clin Gastroenterol Hepatol 2007; 5:1113.
- Linder S, Söderlund C. Factors influencing the use of precut technique at endoscopic sphincterotomy. Hepatogastroenterology 2007; 54:2192.
- Kapetanos D, Kokozidis G, Christodoulou D, et al. Case series of transpancreatic septotomy as precutting technique for difficult bile duct cannulation. Endoscopy 2007; 39:802.
- Weber A, Roesch T, Pointner S, et al. Transpancreatic precut sphincterotomy for cannulation of inaccessible common bile duct: a safe and successful technique. Pancreas 2008; 36:187.
- Halttunen J, Keränen I, Udd M, Kylänpää L. Pancreatic sphincterotomy versus needle knife precut in difficult biliary cannulation. Surg Endosc 2009; 23:745.
- Burdick JS, London A, Thompson DR. Intramural incision technique. Gastrointest Endosc 2002; 55:425.
- Misra SP, Dwivedi M. Intramural incision technique: a useful and safe procedure for obtaining ductal access during ERCP. Gastrointest Endosc 2008; 67:629.
- Seifert H, Binmoeller KF, Schmitt T, et al. [A new papillotome for cannulation, pre-cut or conventional papillotomy]. Z Gastroenterol 1999; 37:1151.
- Hashiba K, D'Assunção MA, Armellini S, et al. Endoscopic suprapapillary blunt dissection of the distal common bile duct in cases of difficult cannulation: a pilot series. Endoscopy 2004; 36:317.
- Heiss FW, Cimis RS Jr, MacMillan FP Jr. Biliary sphincter scissor for pre-cut access: preliminary experience. Gastrointest Endosc 2002; 55:719.
- Farrell RJ, Khan MI, Noonan N, et al. Endoscopic papillectomy: a novel approach to difficult cannulation. Gut 1996; 39:36.
- Freeman ML, Guda NM. Prevention of post-ERCP pancreatitis: a comprehensive review. Gastrointest Endosc 2004; 59:845.
- Masci E, Mariani A, Curioni S, Testoni PA. Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a meta-analysis. Endoscopy 2003; 35:830.
- Kaffes AJ, Sriram PV, Rao GV, et al. Early institution of pre-cutting for difficult biliary cannulation: a prospective study comparing conventional vs. a modified technique. Gastrointest Endosc 2005; 62:669.
- Kahaleh M, Tokar J, Mullick T, et al. Prospective evaluation of pancreatic sphincterotomy as a precut technique for biliary cannulation. Clin Gastroenterol Hepatol 2004; 2:971.
- Lehman GA, Sherman S. Pancreatic stones: to treat or not to treat? Gastrointest Endosc 1996; 43:625.
- Catalano MF, Linder JD, Geenen JE. Endoscopic transpancreatic papillary septotomy for inaccessible obstructed bile ducts: Comparison with standard pre-cut papillotomy. Gastrointest Endosc 2004; 60:557.
- Kubota K, Sato T, Kato S, et al. Needle-knife precut papillotomy with a small incision over a pancreatic stent improves the success rate and reduces the complication rate in difficult biliary cannulations. J Hepatobiliary Pancreat Sci 2013; 20:382.
- Cha SW, Leung WD, Lehman GA, et al. Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy-associated pancreatitis? A randomized, prospective study. Gastrointest Endosc 2013; 77:209.
- Dhir V, Bhandari S, Bapat M, Maydeo A. Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access (with videos). Gastrointest Endosc 2012; 75:354.
- Cennamo V, Fuccio L, Zagari RM, et al. Can early precut implementation reduce endoscopic retrograde cholangiopancreatography-related complication risk? Meta-analysis of randomized controlled trials. Endoscopy 2010; 42:381.
- Singh P, Das A, Isenberg G, et al. Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials. Gastrointest Endosc 2004; 60:544.
- Hookey LC, RioTinto R, Delhaye M, et al. Risk factors for pancreatitis after pancreatic sphincterotomy: a review of 572 cases. Endoscopy 2006; 38:670.
- Varadarajulu S, Kilgore ML, Wilcox CM, Eloubeidi MA. Relationship among hospital ERCP volume, length of stay, and technical outcomes. Gastrointest Endosc 2006; 64:338.
- Common techniques
- - Free-hand needle-knife
- - Traction sphincterotome
- Novel techniques
- - Intramural incision
- - Ultra-small sphincterotome
- - Suprapapillary blunt dissection
- - Endoscopic scissors
- - Endoscopic ampullectomy
- Complications rates with different techniques
- Are complications due to the precut?
- PANCREATIC STENTING
- ENDOSCOPIST'S EXPERIENCE
- SUMMARY AND RECOMMENDATIONS