Precut sphincterotomy: Another perspective on efficacy and complications
- David J Desilets, MD, PhD
David J Desilets, MD, PhD
- Assistant Professor of Clinical Medicine
- Tufts University School of Medicine
- Douglas A Howell, MD, FASGE, FACG
Douglas A Howell, MD, FASGE, FACG
- Section Editor — EUS/ERCP
- Assistant Clinical Professor of Medicine, Tufts Medical School Director,
- Pancreaticobiliary Center Director, Advanced Interventional Endoscopy Fellowship, Maine Medical Center
Precut sphincterotomy refers to a variety of endoscopic techniques used to gain access to the bile duct and rarely the pancreatic duct during endoscopic retrograde cholangiopancreatography before deep cannulation has been achieved. The term "precut" has been used to describe this technique because an incision is made on the papilla prior to free cannulation and/or wire guidance. Most experts feel that precut sphincterotomy is risky and that it is a technique which should be performed by experts only [1,2]. This topic review will briefly discuss the efficacy of precut sphincterotomy while focusing on the risks and complications. A discussion of the technique is presented separately (see "Precut sphincterotomy: Another perspective on indications and techniques"). Because of the controversy surrounding this area, this topic is also presented separately from the perspective of another authority. (See "Precut (access) papillotomy".)
In most cases precut sphincterotomy is a method of last resort, to be used when all other attempts at cannulation during endoscopic retrograde cholangiopancreatography (ERCP) with standard cannulas, tapered cannulas, papillotomes, and guidewires have failed. There is ample support in the literature to show that precut sphincterotomy is effective at gaining biliary access. Numerous reports have demonstrated success rates of 65 to 100 percent, either in the first or subsequent attempts [2-6]. There is also little doubt that these published series represent the experience of the world's experts; relatively inexperienced endoscopists who rarely use precut techniques are unlikely to publish their data. The true cannulation rate among community gastroenterologists after attempted needle-knife papillotomy or other type of precut will probably never be known.
No one disputes the efficacy of precut sphincterotomy at improving the success rate in what would otherwise be failed ERCPs, but at what cost ? It is widely held that precut papillotomy raises the complication rate, at least compared with diagnostic ERCP alone, and probably compared with conventional sphincterotomy [2,8-14]. This controversial topic will be explored below.
Complications of precut sphincterotomy are the same as those encountered with conventional sphincterotomy, namely bleeding, perforation, pancreatitis, and cholangitis . Other complications related to the procedure (respiratory arrest, myocardial infarction, stroke, aspiration, etc), but which do not result directly from sphincterotomy, are discussed elsewhere and will not be addressed here . The crux of the matter is whether these sphincterotomy-related complications occur with increased frequency after precutting. (See "Endoscopic retrograde cholangiopancreatography: Indications, patient preparation, and complications".)
There appear to be two camps involved in this debate, and both have data to support their views. There are some who feel that precutting techniques are inherently more dangerous than standard sphincterotomy and should thus be left to the experts. Informal surveys of community gastroenterologists have demonstrated that only a few ever use precutting; even some experts avoid the needle knife entirely, while many use it as sparingly as possible. On the other hand, there are a number of authors who have concluded that precutting is effective and safe [5,17-23].
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