Precut papillotomy is often employed as a rescue technique when conventional methods fail to establish biliary access at endoscopic retrograde cholangiopancreatography (ERCP). This can be performed using either the needle-knife or pull-papillotome. Varying rates of technical success and complication have been reported for this technique in the medical literature.1–4 These reports are mainly from large-volume ERCP centers where ERCPs are performed by dedicated endoscopists. In this issue of Journal of Clinical Gastroenterology, Jukka et al5 from Finland report their experience with 1044 consecutive ERCPs performed over a 4-year period. The authors evaluated the safety and effectiveness of Erlangen precut papillotomy in achieving biliary access. The Erlangen papillotome is a covex plastic catheter with a cutting wire designed to establish contact only with roof of the papilla. When the papillotome is bent, the cutting wire orients itself to the 11o' clock position of the common bile duct and with electrocautery an incision at the papillary orifice would facilitate biliary access. The authors resorted to use of this technique in 20% (121 of 602 patients) of their patients and report a deep cannulation rate of 98.2%. Indication for ERCP was biliary obstruction in 80% of the study cohort; 20% of patients underwent ERCP for reasons other than biliary obstruction. Precut papillotomy was performed in only 17 cases in the cohort of patients who underwent ERCP for reasons other than biliary obstruction. The rates of complication between the precut and standard papillotomy techniques were not significantly different (8.3% vs. 7.1%).
Being retrospective, it is unclear when exactly during ERCP the authors resorted to use of precut techniques. Twenty percent, at first glance, appears to be a high number. However, most of the patients had biliary obstruction, the most valid indication for undergoing an ERCP. The authors have subjected the “correct” cohort of patients for undergoing precut papillotomy. Not surprisingly, their rates of success and complications are enviable. The authors seem to be very comfortable with use of this technique as evident by the numbers: 20% of the entire cohort was subjected to precut papillotomy with a success rate of 98.2%. They appear to resort to use of precut early during the procedure when conventional techniques fail. All procedures were performed in a large-volume ERCP center (>200 cases/y) by the 2 dedicated endoscopists. The institutional and individual provider volumes support these favorable outcomes.
Most therapeutic endoscopists attempt precut as a last resort when conventional methods fail. This usually happens after multiple cannulation attempts when the papilla is “red and angry” and the endoscopist is “burnt-out” and almost “ready to quit.” Not surprisingly, the rates of failure and complications are higher. Reasons for reluctance to undertake precut papillotomy are multifactorial: Lack of adequate training in fellowship, inadequate procedural volume to maintain competence in advanced techniques, not feeling comfortable to deal with procedural complications, and inherent risk for potential law suits. All 4 reasons are valid and justifiable. Proficiency in precut papillotomy involves a learning curve that can be completed only with adequate training and procedural exposure.4 In a recent study, only 35% of graduating GI fellows in the United States met ASGE requirements for procedural competence in ERCP.6 It is very likely that a majority of these graduates were not trained in advanced techniques such as precut papillotomy. Even if exposed, they may not have the adequate procedural volume to maintain proficiency. This is evident from a recent analysis of the National Inpatient Sample (NIS) database. Only 5% of community hospitals in the United States performed >200 ERCP/y. Only patients who underwent ERCP at high-volume centers had better outcomes: shorter length of hospital stay and lower procedural failure rates.7
ERCP is technically challenging. It is a matter of great satisfaction when the outcomes are successful. However, the desire to achieve this satisfaction should not drive one to desperation. If not proficient, when the papilla turns red and angry, the wise physician will know that it is “time to quit” and to refer the patient to someone more apt to getting the “job done.” Such referral does not exhibit incompetence but rather demonstrates genuineness on the part of the endoscopist in doing what is correct for the patient. Techniques such as precut papillotomy yield good results only when performed in the right patient for the right reason by the right person.
1. Tang SJ, Haber GB, Kortan P, et al. Precut papillotomy versus persistence in difficult biliary cannulation: a prospective randomized trial. Endoscopy. 2005;37:58–65.
2. Larkin CJ, Huibregtse K. Precut sphincterotomy: indications, pitfalls, and complications. Curr Gastroenterol Rep. 2001;3:147–153.
3. Mavrogiannis C, Liatsos C, Romanos A, et al. Needle-knife fistulotomy versus needle-knife precut papillotomy for the treatment of common bile duct stones. Gastrointest Endosc. 1999;50:334–339.
4. Harewood GC, Baron TH. An assessment of the learning curve for precut biliary sphincterotomy. Am J Gastroenterol. 2002;97:1708–1712.
5. Jukka P, Arto S, Jyrki M. Safety of Erlangen precut papillotomy-an analysis of 1044 consecutive ERCP examinations in a single institution. J Clin Gastroenterol. In press.
6. Kanchana TP, Pungpapong S, Kowalski T. Perceptions of gastroenterology fellows regarding ERCP competency and training (abstract). Gastrointest Endosc. 2002;55:AB 77.
7. Varadarajulu S, Kilgore ML, Wilcox CM, et al. Relationship among hospital ERCP volume, length of stay and technical outcomes. Gastrointest Endosc. 2006;64:338–347.