Post written by Sudhir Maharshi, MD, DM, and Shyam Sunder Sharma, DNB, DM, from the Department of Gastroenterology, SMS Medical College and Hospitals, Jaipur, India.

The focus of our study was to assess the safety and efficacy of primary precut. It is well known that precut sphincterotomy, usually considered after repeated and failed cannulation, is considered as one of the risk factors for post-ERCP pancreatitis (PEP). There were no data on primary needle-knife precut for the prevention of PEP. For the first time in the literature, our study has compared primary precut with very early precut for the development of post-ERCP adverse events using needle knife and proved that primary precut by an experienced endoscopist results in a low risk of PEP, and the risk is even less than early precut.

Precut sphincterotomy facilitates access to the bile duct and has been considered as the last available method after failed cannulation. As precut sphincterotomy is usually done after the failure of repeated cannulation attempts, it is difficult to say whether it is a considerable risk factor for PEP. None of the available measures for the prevention of PEP are very effective. A few recent studies have revealed that the incidence of PEP with early precut is less than the late precut. So, we thought if early precut can reduce the incidence of PEP, then why should we not study primary precut for the prevention of PEP.

In our study, the development of PEP and asymptomatic hyperamylasemia were lower in the primary precut group as compared to the very early group. We compared primary precut to very early precut because we wanted to eliminate the effect of ampullary manipulation in causation of PEP as it has been reported earlier that PEP increases with the number of cannulation attempts.We presumed that an experienced endoscopist could cannulate the bile duct in 2 attempts, and if he fails, then there is no assurance of his success in further attempts. In our study, the rate of PEP is low, and it is significantly lower in he tprimary precut group compared to the very early precut group. These results are in concordance with previous studies, where primary precut was done in the form of needle-knife fistulotomy, which resulted in lower risk of PEP. A multicenter study with large sample size is required to further validate our data.

Primary precut by an experienced endoscopist results in a low risk of PEP. Repetitive cannulation attempts should be avoided, as it may lead to PEP. Hopefully, our study data will motivate the experienced endoscopists to consider primary precut to reduce the risk of PEP, while keeping in mind that precut sphincterotomy is safe and effective only in an expert’s hands.

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