Factors influencing the use of precut technique at endoscopic sphincterotomy

Endoscopic sphincterotomy (EST) is a prerequisite for invasive procedures in the biliary tract or the pancreas. Access to the desired duct system may be facilitated by a precut in the papilla but this has also been described as a risk factor of the procedure. The present study is focused on the clinical situation and anatomical conditions which may increase the need for a precut procedure.

During a 2-year period, (2001-2002), 562 patients underwent EST. The precut was performed with a papillotome knife when cannulation failed using standard techniques.

EST was successful in 545 (97.0%) of the patients, and in 522 (92.8%) in the first session. 173 patients (30.8%) were subjected to precutting. Precutting was used less frequently in patients with biliary stone disease, in 39 of 183, than in those without (P < 0.01). In the presence of a tumor, precut technique was warranted more often, in 62 of 143, as compared to benign disease, 111 of 419 (P < 0.01). Changed anatomical conditions at the papilla increased precut use, in 79 of 143 (P < 0.001), as well as duodenal stenosis, 15 of 22 (P < 0.001). The complication rates were equal, 13.3% using precut and 12.4% in standard EST. The 30-day mortality was higher in the precut group: 8 (4.6%) as compared to 5 (1.3%) using standard EST (P < 0.05) but it was mainly caused by advanced malignancies or severe underlying acute pancreatitis.

The need for precut technique seems to be related to the diagnosis and was decreased in the presence of bile duct stones, while it was increased in malignancies. The precut procedure was used more frequently when the anatomical conditions at the papilla were abnormal and in duodenal stenosis.