Precut Fistulotomy for Difficult Biliary Cannulation: Is It a Risky Preference in Relation to the Experience of an Endoscopist?

Several studies have reported on the correlation between the experience level of an endoscopist and the outcomes of precut procedures. However, there are limited data on the early use of the precut fistulotomy in relation to the experience of an endoscopist. To evaluate the efficacy and safety of precut fistulotomy in difficult biliary cannulation after ERCP training. Two endoscopists, one at each tertiary referral center, performed the precut fistulotomy for difficult biliary cannulation between September 2008 and February 2010. The technical success, complications, and clinical outcomes in three groups were recorded prospectively over time. A total of 159 (23.1%) patients underwent precut fistulotomy. The mean procedure time was decreased as the number of procedures increased (p < 0.01). The success rates of selective biliary cannulation in the three groups were 86.8, 86.8, and 88.7% respectively, for the first attempt (p = 0.77) and 93.7% for the second attempt. Post-ERCP pancreatitis developed in nine (5.7%) patients, which was not statistically significant between the three groups. As the frequency of papillary contacts increased, post-ERCP pancreatitis tended to increase (p = 0.017). In the multivariate analysis, more than 15 attempts at cannulating the major papilla prior to fistulotomy was a risk factor for pancreatitis (odds ratio 4.8, 95% CI 1.178-19.580, p = 0.029). After therapeutic ERCP training involving at least 100 ERCPs, including at least half that were therapeutic cases and more than ten that were precut papillotomies, a precut fistulotomy can be performed safely and effectively in low-risk patients.