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.
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- 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