Learning curve for precut biliary sphincterotomy

Academic Article

Abstract

  • INTRO: Precut sphincterotomy is considered unsafe when used by inexperienced endoscopists. We sought to determine if both overall ERCP experience and precut experience influenced need for and complication rate of precut biliary sphincterotomy. METHODS: All ERCPs and precut were performed by one endoscopist completing third tier ERCP training without precut training. The total # ERCPs performed prior to 1st precut was 217. From 9/7/93 until 11/30/97, 1624 ERCPs were performed. After failed biliary cannulation using standard techniques including specialty guidewires, precut biliary sphincterotomy was performed for diagnostic and therapeutic purposes. A standardized technique of needle knife biliary fistulotomy was performed without insertion of pancreatic duct stents. Pancreatic duct precut was excluded. Data collected prospectively and analyzed retrospectively. All patients had phone contact at 30 days post-procedure. Complications were as defined by Cotton, et al. 1991. RESULTS: The number of precut procedures was divided chronologically equally into groups of 46. The indications for precut were similar in each group as follows: INDICATIONS FOR PRECUT (CHRONOLOGICAL ORDER) N precut Stones Jaundice/tumor SOD/pain Bile leak Other 1-46 16 (35%) 10 (22%) 8 (17%) 4 (9%) 8 (17-%) 47-92 11 (24%) 10 (22%) 8 (17%) 3 (7%) 14 (30%) 93-138 13 (28%) 10 (22%) 7 (15%) 4 (9%) 12 (26%) 139-184 15 (33%) 16 (35%) 7 (15%) 2 (4%) 6 (13%) OVERALL OUTCOME FOR PRECUT (CHRONOLOGICAL ORDER) N precut N ERCPs (% precut) Success ‡ Bleeding Perforation Pancreatitis Total complication 1-46 359 (13) 89% 2 (4%) 2 (4%) 4 (9%) 8/46 (17%) 47-92 360 (13) 93% 0 (0%) 3 (7%) 4 (9%) 7/46 (15%) 93-138 465 (10) 91% 4 (8%) 1 (2%) 5 (11%) 10/46 (21%) 139-184 440 (10) 98% 2 (4%) 1 (2%) 4 (9%) 7/46 (15%) TOTAL 184 1624(11) 92% 8(4%) 7(4%) 17(9%) 32/184(17%) ‡Success defined as successful cannulation at time of precut or 2nd attempt (6 patients). There were no statistical differences in rate of precut usage or complications during the four periods. There was a trend toward higher success rate for biliary cannulation using precut after the first 44 precut procedures (p = 0.25). CONCLUSIONS: 1) The need for precut sphincterotomy at a tertiary referral center remained constant despite increased ERCP experience. 2) While the success rate for biliary cannulation using precut may increase with increased ERCP and precut experience, the complication rate of precut biliary sphincterotomy does not decrease. 3) Precut fistulotomy continues to carry an increased complication rate over standard techniques even when performed by experienced biliary endoscopists.
  • Published In

    Author List

  • Baron TH; Geels WJ; Heudebert G
  • Volume

  • 47
  • Issue

  • 4