Needle-knife precut access papillotomy versus persistence in standard techniques for difficult bile duct cannulation and sphicterotomy

Introduction: In about 5–10% of patients standard biliary cannulation and endoscopic sphincterotomy (EST) is difficult or sometimes impossible, especially in patients having impacted stone, juxtapapillary diverticulum or sphincter of Oddi dysfunction. There is still controversy as to apply needle-knife precut techniques in such cases. The aim of the present study was to retrospectively analyse the safety and efficacy of needle-knife precut access papillotomy (NKP) in our patients.

Methods: During the period from 1999 to 2004, EST was performed in 1046 patients by the same endoscopist. In 224 individual cases the bile duct cannulation was noted as being difficult in the report. Out of these 224 patients, in 134 patients we persisted to cannulate the bile duct with standard techniques (guide-wire or papillotome), in contrast in 90 patients after 5–10 minutes of failed cannulation, an early NKP was performed longitudinally on the roof of the papilla with a pure cutting current at 15 Ws as far as selective biliary cannulation was achieved with a standard papillotome and the EST was completed. All patients observed in hospital for possible complications, amylase and Hb monitored routinely.

Results: The frequency of post-ERCP pancreatitis was significantly lower in the NKP group as compared to the persistence group, 5.6% vs. 11.9%, respectively (p=0.036). Other complications (bleeding 3.3% vs. 2.2%, infection 3.3% vs. 3.0%, and perforation 0% vs. 0%) did not differ significantly. No significant difference was noted between the initial success rates: 92% vs. 95.5%, respectively.

Conclusion: In experienced hands, early NKP is an effective method to achieve biliary access with a lover risk of post-ERCP pancreatitis in patients with difficult bile duct cannulation, which is probably due to the least oedema and mechanical insult of the papilla.