Precut sphincterotomy: Another perspective on indications and techniques
- 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/papillotomy refers to a variety of endoscopic techniques used to gain access to the bile (and occasionally pancreatic) ducts 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 guidewire cannulation. Many authors have taken issue with this nomenclature, preferring instead to call the maneuver "access papillotomy"  or "fistulotomy" . Regardless of semantics, the term "precut" is popularly accepted and will be used here.
This topic review will focus on the commonly used techniques for performing precut sphincterotomy, while providing the authors' perspective on this controversial technique. A discussion on the efficacy and complications of precut sphincterotomy is presented separately (see "Precut sphincterotomy: Another perspective on efficacy and complications"). Because of the controversy surrounding this area, this topic is also presented separately from the perspective of another authority. (See "Precut (access) papillotomy".)
Precut sphincterotomy is widely considered to be a risky procedure that should be used only by experts and only when all reasonable efforts at gaining access to the biliary tree by conventional methods have failed . Most authorities believe that unless there is an absolute need, failure to gain biliary access by itself is not an indication for precut sphincterotomy. Precut sphincterotomy should not be undertaken for a purely diagnostic endoscopic retrograde cholangiopancreatography with low likelihood of therapeutic intervention [1,4].
On the other hand, precut sphincterotomy is reasonable if attempts at conventional cannulation have failed and if there is a compelling need to have biliary access (suspected malignant jaundice, common duct stones, cholangitis, etc). The decision must be made after an honest appraisal of one's own endoscopic skill, the skill of others immediately available, and the availability of percutaneous or surgical methods. In experienced hands and in highly selected cases, precut sphincterotomy can be safe and effective [1,2,5-7].
At least five different methods are commonly used by experts to perform precut sphincterotomy, which can be broadly grouped into needle knife and non-needle-knife techniques.
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