Two Stage Precut Endoscopic Sphincterotomy (ED) for Non-Emergent Bile Duct (BD) Access: Safe and Reliable Alternative to Aggressive or Persistant BD Access Attempts at Index ERCP

Abstract

Background: BD ductal access during ERCP may be difficult in certain cases. Operators may persist in attempts to gain BD access despite increasing procedure-related ampullary swelling and distorted ampullary anatomy. Precut ES may be used to gain BD access, but if done aggressively, it can be complicated by retroperitoneal perforation, bleeding and pancreatitis. However, by waiting several days after failed precut ES, ampullary tissue edema will resolve and BD access may actually be easier than in the native (uncut) papilla. Aim: To evaluate safety and efficacy of repeat ERCP for BD access within several days after initial failed precut ES. Methods: Retrospective analysis. Intent to treat. 1997-2004. Procedures were done by a single experienced biliary endoscopist. Inclusion criteria: patients undergoing ERCP for non-emergent BD access where BD access failed despite precut endoscopic sphincterotomy (ES) and where repeat ERCP for BD access was attempted several days later. Outcomes were: Success at repeat ERCP and ERCP-related complications. All patients received prophylactic antibiotics during and after ERCP. Results: 26 patients met inclusion criteria. 18/26 had a prophylactic narrow caliber pancreatic stents placed at index ERCP. Successful BD access was obtained in 20/26 patients. Failed repeat BD access occurred in 6/20 due to: fungating ampullary carcinoma (1), BD orifice found to be widely patent on repeat endoscopic view and ERC therefore not neccessary (1), failure to re-identify ampullary orifice (1), perforation (2). There were no complications following index ERCP. Complications from follow-up ERCP included one duodenal bulb perforation requiring surgical repair, with complete recovery; one self-contained duodenal wall perforation, treated conservatively. There were no cases of pancreatitis, bleed, cardiopulmonary events or deaths. One patient was ASA IV. The remainder were ASA III. Median time between ERCPs was 7 days. Conclusions: A two-stage attempt to gain desired non-emergent BD access that includes precut biliary ES at index ERCP appears safe, and may facilitate BD access at the follow-up ERCP. Prophylactic pancreatic stenting is likely to reduce complications after index ERCP. Expertise in precut ES is mandatory.