Abstract

Background: Pancreatitis is the most common and serious complication to occur after endoscopic retrograde cholangiopancreatography (ERCP) resulting in substantial morbidity and occasional mortality. Biliary cannulation is unsuccessful during 5%–10% of ERCP procedures. Needle knife sphincterotomy (NKS) can improve success of cannulation but is often used as a last resort. Repeated attempts at cannulating the papilla of Vater and “needle-knief” precut sphincterotomy are independent risk factors for post-ERCP pancreatitis (PEP). Whether precut alone or repeated attempts at cannulation are the culprit factor in the development of post-ERCP pancreatitis remains controversial.

Aim: The aim of this study is to assess the role of precutting and multiple cannulations in the occurrence of post-ERCP pancreatitis in patients with bile duct stone disease.

Patients and methods: This prospective randomized study was performed at two referral centers, between June 2010 and June 2013. It included 515 patients with bile duct stone disease who subjected to ERCP. Pancreatitis rate was assessed in relation to the number of cannulation attempts (<10 and ≥10) and precutting.

Results: Cannulation was done without precutting in 467 cases (90.68%) and with precutting in 48 cases (9.32%). Pancreatitis occurred in 9.21% of patients who had undergone biliary cannulation without precutting and in 18.75% of patients who had undergone biliary cannulation with precutting (p=0.006). It was lower with <10 attempts than with ≥10 (p < 0.0001), either without (p < 0.0001) or with precutting (p < 0.01). Pancreatitis rate did not differ without and with precutting when <10 attempts at cannulation were done, whilst it was lower when precut was done before 10 attempts than when 10 or more attempts were made without precutting (p = 0.02).

Conclusions: Pancreatitis rate was lower when precut was done with <10 attempts than when ≥10 attempts were made without precutting. In experienced hands precut biliary sphincterotomy does not seem to be an independent risk factor for post-ERCP pancreatitis in patients undergoing endoscopic retrograde cholangio-pancreatography for bile duct stones.