Luís Lopes, MD from Hospital de Santa Luzia in Viana do Castelo, Portugal discusses his Original Article “Early precut fistulotomy for biliary access: time to change the paradigm of ‘the later, the better’?” from the October issue.
We assessed the efficacy and safety of 2 alternative strategies in the setting of a difficult biliary cannulation: an early precut fistulotomy versus the standard late precut fistulotomy.
Selective cannulation of the common bile duct is the most important and demanding step in a biliary ERCP. However, even in experienced hands, biliary cannulation may fail in up to 15%-35% of cases using a standard approach alone, in the first ERCP. If the decision is to continue with the procedure, needle-knife precut has become the method of choice in achieving a CBD cannulation. The two most common variations are the classic precut and the needle-knife fistulotomy (NKF). This rescue method is however one of the most debatable issues in endoscopy in terms of safety, success and optimal timing in the cannulation.
In this study we assessed an early fistulotomy strategy against the current practice of a late precut after multiple biliary attempts. This prospective cohort study, between January 2011 and February 2012, involved 350 patients with naive papilla, equally assigned to one of the two strategies by an independent person not involved in the study. Biliary cannulation rate, NKF success, post-ERCP complications and ERCP duration were the main outcomes. We conclude that an early precut strategy significantly decreases the duration of an ERCP, while being at least as safe and effective as the late fistulotomy approach. Moreover, results suggest that the risk of post-ERCP pancreatitis may originate from the difficult biliary cannulation and not the fistulotomy itself. If the endoscopist is experienced in ERCP and NKF, a fistulotomy should be the first choice if a successful biliary cannulation is not achieved within the first 5 minutes. The first 5 minutes of a standard cannulation could be considered an optimal timing for NKF. This results needs validation by other ERCP endoscopists with experience in NKF from high-volume centers.
These recommendations are not applicable outside high-volume centers, experienced in NKF.
Read the abstract for this article here.
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