Early precut fistulotomy for biliary access: time to change the paradigm of "the later, the better"?

Background: The precut timing during the biliary cannulation algorithm is a subject of controversy. Some studies suggest that early institution of precut is a safe and effective strategy even though the extent to which this approach may affect the duration of the ERCP is seldom addressed. Objective: To assess the success, safety, and procedure duration of an early precut fistulotomy (group A) versus a classic precut strategy after a difficult biliary cannulation (group B). Design: Single-center, prospective cohort study. Setting: University-affiliated hospital. Patients: A total of 350 patients with a naive papilla. Interventions: Standard biliary cannulation followed by needle-knife fistulotomy (NKF). Main Outcome Measurements: Biliary cannulation rate, NKF success, adverse events, and ERCP duration. Results: The overall cannulation rate was similar, at 96% and 94% for groups A and B, respectively. The adverse event rate was 6.2% and 6.4%, respectively, with pancreatitis as the most frequent adverse event (group A, 3.9%; group B, 5.2%). The mean ERCP duration was, however, significantly shorter in group A, both when biliary cannulation was achieved without precutting (14 minutes vs 25 minutes, P < .001) as well as when biliary cannulation was attempted after NKF (18 minutes vs 31 minutes, P < .0001). Limitations: Single-center study design, referral center. Conclusions: If the endoscopist is experienced in ERCP and precut techniques, an early precut strategy should be the preferred cannulation strategy because this approach is as safe and effective as the late fistulotomy approach and substantially reduces ERCP duration.