Gaining competence in needle-knife fistulotomy – can I begin on my own?

Background: While there are guidelines for appropriate training in ERCP, these are non-existent for needle-knife precut. The aim of this study was: (1) evaluate the experience curve of three endoscopists in needle-knife fistulotomy (NKF); (2) propose a minimum number of NKF procedures to attest proficiency.

Methods: Between November 1997 and March 2011, the first 120 consecutive NKF performed by three endoscopists (A, B, and C) were selected (360 patients) from three centers. Each group of 120 patients was chronologically ordered into three subgroups of 40. The main outcomes were: NKF use, NKF success, and post-ERCP adverse events.

Results: The need for NKF did not decrease over time. The NKF success rate in the first attempt for endoscopist A and C in each of the three subgroups was 85 %/85 %, 87.5 %/87.5 %, and 87.5 %/90 %, respectively. Furthermore, both demonstrated a high NKF success in their initial 20 NKFs (85 % and 80 %, respectively). Endoscopist B however presented a different pattern as the success rate initiated at 60 %, then rose to 82.5 % and 85 % for the last group (P = 0.03). Adverse events were mild (28 of the 32 occurrences) with no clear reduction with increased experience.

Conclusions: A skillful endoscopist may expect to master NKF easily with few adverse events. While some endoscopists could begin on their own because of their innate skills, a minimal training is needed for all, as we cannot predict skills in advance. We propose a minimum of 20 NKF precuts to attest a trainee’s competence in this procedure.

• References

• 1 Freeman ML, Guda NM. ERCP cannulation: a review of reported techniques. Gastrointest Endosc 2005; 61: 112-125
• 2 Bjorkman DJ, Popp JW. Measuring the quality of endoscopy. Gastrointest Endosc 2006; 63: 1-2
• 3 Freeman ML. Adverse outcomes of endoscopic retrograde cholangiopancreatography. Rev Gastroenterol Disord 2002; 2: 147-168
• 4 Petersen BT. ERCP outcomes: defining the operators, experience, and environments. Gastrointest Endosc 2002; 55: 953-958
• 5 Bruins Slot W, Schoeman MN, DiSario JA et al. Needle-knife sphincterotomy as a precut procedure: a retrospective evaluation of efficacy and complications. Endoscopy 1996; 28: 334-339
• 6 Testoni PA, Testoni S, Giussani A. Difficult biliary cannulation during ERCP: How to facilitate biliary access and minimize the risk of post-ERCP pancreatitis. Dig Liver Dis 2011; 43: 596-603
• 7 Sriram PVJ, Rao GV, Nageshwar Reddy D. The precut – when, where and how? A review. Endoscopy 2003; 35: 24-30
• 8 Gong B, Hao L, Bie L et al. Does precut technique improve selective bile duct cannulation or increase post-ERCP pancreatitis rate? A meta-analysis of randomized controlled trials. Surg Endosc 2010; 24: 670-680
• 9 Cennamo V, Fuccio L, Zagari RM et al. Can early precut implementation reduce endoscopic retrograde cholangiopancreatography-related complication risk? Meta-analysis of randomized controlled trials. Endoscopy 2010; 42: 381-388
• 10 Lopes L, Dinis-Ribeiro M, Rolanda C. Early precut fistulotomy for biliary access: time to change the paradigm of “the later, the better?”. Gastrointest Endosc 2014; 80: 634-641
• 11 Harewood GC, Baron TH. An assessment of the learning curve for precut biliary sphincterotomy. Am J Gastroenterol 2002; 97: 1708-1712
• 12 Chutkan RK, Ahmad AS, Cohen J et al. ERCP core curriculum. Gastrointest Endosc 2006; 63: 361-376
• 13 Ang TL, Cheng J, Khor JLC et al. Guideline on training and credentialing in endoscopic retrograde cholangiopancreatography. Singapore Med J 2011; 52: 654-657
• 14 Rollhauser C, Johnson M, Al-Kawas FH. Needle-knife papillotomy: a helpful and safe adjunct to endoscopic retrograde cholangiopancreatography in a selected population. Endoscopy 1998; 30: 691-696
• 15 Fukatsu H, Kawamoto H, Harada R et al. Quantitative assessment of technical proficiency in performing needle-knife precut papillotomy. Surg Endosc 2009; 23: 2066-2072
• 16 Akaraviputh T, Lohsiriwat V, Swangsri J et al. The learning curve for safety and success of precut sphincterotomy for therapeutic ERCP: a single endoscopist’s experience. Endoscopy 2008; 40: 513-516
• 17 Robison LS, Varadarajulu S, Wilcox CM. Safety and success of precut biliary sphincterotomy: Is it linked to experience or expertise?. World J Gastroenterol 2007; 13: 2183-2186
• 18 Cotton PB, Eisen GM, Aabakken L et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 19 Johanson JF, Cooper G, Eisen GM et al. Quality assessment of ERCP. Endoscopic retrograde cholangiopancreatography. Gastrointest Endosc 2002; 56: 165-169
• 20 Cotton PB, Lehman G, Vennes J et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-393
• 21 NIH. state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy. NIH Consens State Sci Statements 2002; 19: 1-26
• 22 ASGE Standards of Practice Committee. Anderson MA, Fisher L, Jain R et al. Complications of ERCP. Gastrointest Endosc 2012; 75: 467-473
• 23 Ang TL, Kwek ABE, Lim KBL et al. An analysis of the efficacy and safety of a strategy of early precut for biliary access during difficult endoscopic retrograde cholangiopancreatography in a general hospital. J Dig Dis 2010; 11: 306-312
• 24 Siegel JH. Precut papillotomy: a method to improve success of ERCP and papillotomy. Endoscopy 1980; 12: 130-133
• 25 Huibregtse K, Katon RM, Tytgat GN. Precut papillotomy via fine-needle knife papillotome: a safe and effective technique. Gastrointest Endosc 1986; 32: 403-405
• 26 Kasmin FE, Cohen D, Batra S et al. Needle-knife sphincterotomy in a tertiary referral center: efficacy and complications. Gastrointest Endosc 1996; 44: 48-53
• 27 Kaffes AJ, Sriram PVJ, Rao GV et al. Early institution of pre-cutting for difficult biliary cannulation: a prospective study comparing conventional vs. a modified technique. Gastrointest Endosc 2005; 62: 669-674
• 28 Rabenstein T, Ruppert T, Schneider HT et al. Benefits and risks of needle-knife papillotomy. Gastrointest Endosc 1997; 46: 207-211
• 29 Dumonceau J-M, Andriulli A, Devière J et al. European Society of Gastrointestinal Endoscopy (ESGE) Guideline: prophylaxis of post-ERCP pancreatitis. Endoscopy 2010; 42: 503-515