Precut sphincterotomy for selective biliary duct cannulation during endoscopic retrograde cholangiopancreatography

Tomas Davee, Jairo A Garcia, Todd H Baron, Tomas Davee, Jairo A Garcia, Todd H Baron

Abstract

Selective biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP) is required to perform all therapeutic biliary procedures. Despite major advances in imaging, guidewires and sphincterotome catheter designs, the success rate for biliary cannulation by experienced endoscopists during ERCP is approximately 85% when standard cannulation techniques are applied. Precut sphincterotomy, also known as access sphincterotomy, is performed when standard techniques fail to achieve selective biliary cannulation. Precut sphincterotomy significantly increases the rate of biliary cannulation up to 98%. However, precut sphincterotomy has traditionally been considered a risk factor for adverse events following ERCP, especially concerning is post-ERCP pancreatitis which results in significant morbidity and financial burden. Recent evidence suggests that precut sphincterotomy alone may not be a risk factor for pancreatitis; rather repeated attempts ( ≥ 10) at biliary cannulation prior to precut sphincterotomy may be the actual cause of post-ERCP pancreatitis. In this paper, we review the different variations of the precut sphincterotomy technique and their corresponding rates of success and adverse events.

Keywords: fistulotomy; needle-knife; papillotomy; precut sphincterotomy.

Conflict of interest statement

Conflict of Interest: None

Figures

Figure 1
Figure 1
Normal anatomy of the major duodenal papilla
Figure 2
Figure 2
Standard ERCP technique for biliary cannulation
Figure 3
Figure 3
Precut fistulotomy with the aid of a pancreatic duct stent
Figure 4
Figure 4
Precut papillotomy
Figure 5
Figure 5
Precut fistulotomy
Figure 6
Figure 6
Precut fistulotomy. The major duodenal papilla is visible below the prominent mucosal fold. A peri-ampullary diverticula is present in the left upper corner
Figure 7
Figure 7
Transpancreatic precut sphincterotomy
Figure 8
Figure 8
Precut papillotomy via intramural incision. The guidewire is noted to have inadvertently passed through the mucosa of the intraluminal portion of the major duodenal papilla. Incision of the mucosa using the sphincterotome will follow
Figure 9
Figure 9
Precut papillotomy via the intramural incision. The sphincterotome is used to incise the intraluminal portion of the major duodenal papilla following the guidewire's path

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