Precut Biliary Sphincterotomy Research Articles

Tu1546 Prospective, Comparative Evaluation of the Utility of a Simple Ex-Vivo, Biologic ERCP Training Model for Standard and Precut Biliary Sphincterotomy and Stent Placement

Tu1546 Prospective, Comparative Evaluation of the Utility of a Simple Ex-Vivo, Biologic ERCP Training Model for Standard and Precut Biliary Sphincterotomy and Stent Placement

A Simple ex vivo, Biologic ERCP Training Model for Standard and Precut Biliary Sphincterotomy

A Simple ex vivo, Biologic ERCP Training Model for Standard and Precut Biliary Sphincterotomy

Evaluation of Early Precut with Needle-Knife in Difficult Biliary Cannulation During ERCP

There is scarce information on whether performing the precut procedure early rather than after several cannulation attempts is associated with different success and complication rates. The aim of this retrospective study was is to compare the early precut technique with the standard one in terms of the results and complications. The contemporary success rate and postoperative complications in 792 endoscopic retrograde cholangiopancreatography cases were frequently observed during the period from June 2007 to May 2011, and 56 of these cases were carried out with precut biliary sphincterotomy after the standard sphincterotomy had failed. The success rate for standard sphincterotomy was 89.8%: 51 out of 56 cases were carried out with precut biliary sphincterotomy and succeeded. The total success rate was 96.3%. The difference was significant (χ2=25.62, p<0.01) compared to the success rate of first cannulation, while the difference in complication rates between precut and standard sphincterotomy was minor (9.9 vs. 12.5%, p>0.05). Early precut with a needle-knife in a difficult biliary cannulation was safe and effective if performed by experienced endoscopists.

Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy–associated pancreatitis? A randomized, prospective study

Pancreatitis is the most common major complication of ERCP and precut endoscopic sphincterotomy (ES). Prophylactic pancreatic duct (PD) stent placement has been shown to reduce the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk settings. To determine whether leaving a main PD stent in place after precut ES would reduce the incidence and severity of PEP. Single-center, randomized, prospective study. Tertiary care ERCP referral center. Consecutive patients who underwent ERCP with a clear indication for biliary access and standard biliary ES whereby free cannulation of the bile duct was not possible and precut ES was undertaken. When free bile duct cannulation for ES was not possible and selective PD cannulation was achieved, a PD stent was placed. Using the PD stent as a guide, we used a needle-knife sphincterotome to perform precut ES. The patients were then randomized to either leaving the PD stent in place for 7 to 10 days (stent group) or immediate removal after the procedure (stent removed group). The remaining patients who did not undergo selective PD cannulation and stent placement were not randomized (no stent group) and had a free-hand needle-knife ES performed. Patients were prospectively followed for the development of complications. Standardized criteria were used to diagnose and grade the severity of PEP. A total of 151 patients were enrolled. The groups were similar with regard to patient demographics and patient and procedure risk factors for PEP. The overall incidence of PEP was 13.2% (20/151). It occurred in 4.3% (2/46), 21.3% (10/47), and 13.8% (8/58) of patients in the stent, stent removed, and no stent groups, respectively. The stent group had a significantly lower frequency and severity of PEP compared with the stent removed group (4.3% vs 21.3%; P = .027 for frequency and 0% vs 12.8%; P = .026 for moderate and severe pancreatitis). Single center. Randomization scheme not optimal. These data suggest that placing and maintaining a PD stent for needle-knife precut ES reduces the frequency and severity of postprocedure pancreatitis.

Safety and success of precut biliary sphincterotomy: Is it linked to experience or expertise

To determine the rates of success and complications of precut biliary sphincterotomy (PBS) based on prior experience and to compare the complication rates between PBS and standard endoscopic sphincterotomy (ES). A retrospective evaluation of prospectively collected non-randomized data at an academic tertiary referral center. The study included all patients in an eight-year period who underwent PBS and ES by a single endoscopist who had no formal training in PBS. The main outcome measures of the study were success and complications of PBS with a comparison to complications of ES. A total of 2939 endoscopic retrograde cholangiopancreatographies (ERCPs) were performed during the study period, including 818 (28%) ES and 150 (5%) PBS procedures. Selective biliary cannulation via PBS was successful at the first attempt in 75% of the patients. Cannulation was achieved in an additional 13% of the patients at a subsequent attempt (total 87%). Complication rate from PBS was 45% higher than ES, but did not differ significantly [7% (10/50) vs 5% (38/818), P = 0.29]. None of the complications from PBS was severe. A significant trend towards increasing success existed with regard to the endoscopistos first attempt at precut (P = 0.0393, Cochran-Armitage exact test for trend, Z = -1.7588). Despite the lack of specific training in this technique, PBS was performed with a high success rate and a complication rate similar to or less than reports from other experienced centers. These results suggest that endoscopic experience and perhaps innate endoscopic skill may play an important role in the outcome of this procedure.

A Retrospective Comparison of Outcomes Using Three Different Precut Needle Knife Techniques for Biliary Cannulation

To assess the outcome differences following different precut biliary sphincterotomy needle-knife techniques. Precut biliary needle-knife sphincterotomy (NKS) allows biliary access when standard cannulation techniques fail. Little comparative data exist on the outcome of precut NKS. Retrospective comparison of outcome differences of three NKS techniques performed by three pancreaticobiliary endoscopists at a tertiary referral center. A total of 139 consecutive biliary NKS were performed. In 44 cases (technique A), NKS was performed using a precut fistulotomy technique avoiding the papillary orifice, with pure cutting current, and occasional pancreatic duct (PD) stenting (6 of 44). In 47 cases (technique B), NKS was performed starting from the papillary orifice cutting upward with blended current, and no PD stenting. In 48 cases (technique C), NKS was performed as B but using pure cutting current and frequent PD stenting (15 of 48). NKS was successful in 95.5%, 95.7%, and 89.6% at initial endoscopic retrograde cholangiopancreatography and 100%, 97.8%, and 95.6% after a second endoscopic retrograde cholangiopancreatography. Total complications were not significantly different between the three groups; however, a lower incidence of pancreatitis occurred using technique A compared with techniques B and C (not significant). NKS techniques result in a high success rate of biliary cannulation with a similar overall complication rate. Avoiding cutting at the papillary orifice may reduce the risk of pancreatitis. When cutting at the papillary orifice, pancreatic duct stenting, pure cutting current, or both may reduce the incidence of pancreatitis.

Safety and Success of Precut Biliary Sphincterotomy: Is it Linked to Experience or Expertise

Safety and success of precut biliary sphincterotomy: Is it linked to experience or expertise?

Success and Complications After Precut Biliary Sphincterotomy

Precut sphincterotomy may be necessary to secure biliary access when standard techniques fail. Researchers compared two precut techniques for gaining

An assessment of the learning curve for precut biliary sphincterotomy.

Precut sphincterotomy is considered unsafe when used by inexperienced endoscopists. We sought to determine whether procedural experience with precut sphincterotomy predicted either successful cannulation or development of complications in these patients. We describe the experience of 253 consecutive patients who underwent precut biliary sphincterotomy done by one endoscopist between September, 1993 and April, 2001. Data were prospectively collected on procedure indication and outcome. All patients were contacted by phone 30 days after the procedure to determine outcome. We also described precut utilization over time. All 253 precut procedures were divided chronologically into five groups of 50, with 53 in the final group. The rates of successful cannulation after precutting were 88%, 94%, 90%, 88%, and 98%, respectively (p = 0.05 for groups 1-4 vs group 5). Overall complication rates were similar in all groups (12%, 18%, 20%, 12%, and 14%), with no difference in complication severity. Female gender predicted successful cannulation (OR = 2.9 [p = 0.02]), whereas an indication of sphincter of Oddi dysfunction predicted development of complications (OR = 1.7 [p = 0.03]). The total number of ERCP procedures performed increased over time, whereas the proportion of precut sphincterotomies performed decreased. Although the success rate for precut sphincterotomy may increase with procedural experience, the complication rate does not seem to decrease. Precut sphincterotomy continues to carry an increased complication rate over standard sphincterotomy even when performed by an experienced biliary endoscopist. The need for precut sphincterotomy appears to decrease with increasing ERCP experience.

An assessment of the learning curve for precut biliary sphincterotomy

OBJECTIVE: Precut sphincterotomy is considered unsafe when used by inexperienced endoscopists. We sought to determine whether procedural experience with precut sphincterotomy predicted either successful cannulation or development of complications in these patients. METHODS: We describe the experience of 253 consecutive patients who underwent precut biliary sphincterotomy done by one endoscopist between September, 1993 and April, 2001. Data were prospectively collected on procedure indication and outcome. All patients were contacted by phone 30 days after the procedure to determine outcome. We also described precut utilization over time. RESULTS: All 253 precut procedures were divided chronologically into five groups of 50, with 53 in the final group. The rates of successful cannulation after precutting were 88%, 94%, 90%, 88%, and 98%, respectively ( p = 0.05 for groups 1–4 vs group 5). Overall complication rates were similar in all groups (12%, 18%, 20%, 12%, and 14%), with no difference in complication severity. Female gender predicted successful cannulation (OR = 2.9 [ p = 0.02]), whereas an indication of sphincter of Oddi dysfunction predicted development of complications (OR = 1.7 [ p = 0.03]). The total number of ERCP procedures performed increased over time, whereas the proportion of precut sphincterotomies performed decreased. CONCLUSIONS: Although the success rate for precut sphincterotomy may increase with procedural experience, the complication rate does not seem to decrease. Precut sphincterotomy continues to carry an increased complication rate over standard sphincterotomy even when performed by an experienced biliary endoscopist. The need for precut sphincterotomy appears to decrease with increasing ERCP experience.

Past, Present, and Future of Endoscopic Retrograde Cholangiopancreatography: Perspectives on the National Institutes of Health Consensus Conference

Past, Present, and Future of Endoscopic Retrograde Cholangiopancreatography: Perspectives on the National Institutes of Health Consensus Conference

4603 Spontaneous dislodgment rates of long length, small diameter, “unflanged” pancreatic stents placed partially up the duct.

Pancreatic duct (PD) stent placement reduces pancreatitis rates following precut biliary sphincterotomy (ES) or pancreatobiliary ES in pts with sphincter of Oddi dysfunction (SOD). To limit ductal injury and need for endoscopic removal, spontaneous dislodgment is desirable after 1-2 weeks. Short (=3cm) unflanged stents dislodge 80% of the time. However, post- ERCP pancreatitis rates remain relatively high, ~10-15% in SOD pts. We hypothesized that these short stents might dislodge too quickly (ie

4611 Does placement of a small diameter, long length, unflanged pancreatic duct stent reduce the incidence of post-ercp pancreatitis?

Background: Temporary pancreatic duct (PD) stent placement reduces pancreatitis rates following needle-knife pre-cut biliary sphincterotomy (ES) or pancreatobiliary ES in pts with sphincter of Oddi dysfunction (SOD). Such stents have typically been 4-5F diameter and 2cm long.We hypothesized that a small diameter stent would cause less ductal irritation, but longer lengths might prevent premature dislodgment. Small diameter (3F), long length (8-10cm) unflanged PD stents have a high spontaneous dislodgment rate (83%), and they appear to be infrequently associated with PD injury. It has been suggested that the 3F luminal diameter may obstruct prematurely, resulting in increased pancreatitis rates. This study addresses this concern. Methods: From 1/94-10/99, 1087 pts had a 3/4-single pigtail unflanged PD stent (Wilson-Cook, Winston- Salem, NC) placed at ERCP for a variety of conditions. Stent diameter ranged from 3-7F. All 3F stents were 8-10cm long, while the other stents were 2-10cm, with a variable length remaining in the duodenal lumen. Results: See Table. Summary: 1.Pancreatitis rates remain relatively high (13.8%) in these high-risk patients. 2. Placement of a small diameter (3F), unflanged PD stent is no less effective than larger diameter stents in prevention of pancreatitis. Moderate to severe pancreatitis rates are lower than historical controls. Conclusion: Prospective randomized trials comparing 3F and larger diameter stents (of varying lengths) would be of interest. Further study addressing PD and parenchymal injury with these stents is ongoing.

Increased selective biliary cannulation rates in the setting of periampullary diverticula: main pancreatic duct stent placement followed by pre-cut biliary sphincterotomy

Background: Selective biliary cannulation is often difficult when there is a periampullary diverticulum, especially when the papilla is within the diverticulum. We report eight such cases in which a new technique was used to achieve biliary access. Methods: Among 4138 ERCPs, there were 246 cases (5.9%) with periampullary diverticula. Biliary cannulation initially failed in eight patients (3.3%), five of whom had previously undergone six failed attempts at other institutions. A technique was used whereby the papilla was kept out of the diverticulum by placement of a pancreatic duct stent. Needle-knife sphincterotomy was then performed followed by attempts to achieve biliary access. Results: Biliary entry was immediately successful in five patients and successful at a second ERCP in two (overall success 87.5%). Two patients developed post-ERCP pancreatitis. Conclusions: When the papilla is within the periampullary diverticulum, placement of a main pancreatic duct stent keeps the papilla out of the diverticulum, thereby facilitating pre-cut needle-knife sphincterotomy and selective biliary cannulation.

Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy (ES)-induced pancreatitis? a final analysis of a randomized prospective study

Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy (ES)-induced pancreatitis? a final analysis of a randomized prospective study

Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy (ES)-induced pancreatitis?: Randomized prospective study

Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy (ES)-induced pancreatitis?: Randomized prospective study