title: Prophylactic pancreas stenting followed by needle-knife fistulotomy in patients with sphincter of Oddi dysfunction and difficult cannulation: new method to prevent post-ERCP pancreatitis.
abstract: BACKGROUND
  The aim of the present study was to reduce post-endoscopic retrograde cholangiopancreatography (ERCP) complications with a combination of early needle-knife access fistulotomy and prophylactic pancreatic stenting in selected high-risk sphincter of Oddi dysfunction (SOD) patients with difficult cannulation.
  
  
  METHODS
  Prophylactic pancreatic stent insertion was attempted in 22 consecutive patients with definite SOD and difficult cannulation. After 10 min of failed selective common bile duct cannulation, but repeated (>5x) pancreatic duct contrast filling, a prophylactic small calibre (3-5 Fr) pancreatic stent was inserted, followed by fistulotomy with a standard needle-knife, then a standard complete biliary sphincterotomy followed. The success and complication rates were compared retrospectively with a cohort of 35 patients, in which we persisted with the application of standard methods of cannulation without pre-cutting methods.
  
  
  RESULTS
  Prophylactic pancreatic stenting followed by needle-knife fistulotomy was successfully carried out in all 22 consecutive patients, and selective biliary cannulation and complete endoscopic sphincterotomy were achieved in all but two cases. In this group, not a single case of post-ERCP pancreatitis was observed, in contrast with a control group of three mild, 10 moderate and two severe post-ERCP pancreatitis cases. The frequency of post-ERCP pancreatitis was significantly different: 0% versus 43%, as were the post-procedure (24 h mean) amylase levels: 206 U/L versus 1959 U/L, respectively.
  
  
  CONCLUSIONS
  In selected, high-risk, SOD patients, early, prophylactic pancreas stent insertion followed by needle-knife fistulotomy seems a safe and effective procedure with no or only minimal risk of post-ERCP pancreatitis. However, prospective, randomized studies are awaited to lend to support to our approach.
authors.affiliation: First Department of Internal Medicine, Fejér Megyei Szent György Hospital, Székesfehérvár, Hungary. lmadacsy@mail.fmkorhaz.hu
authors.forename: László
authors.initials: L
authors.lastname: Madácsy
authors.forename: Gábor
authors.initials: G
authors.lastname: Kurucsai
authors.forename: Roland
authors.initials: R
authors.lastname: Fejes
authors.forename: András
authors.initials: A
authors.lastname: Székely
authors.forename: Iván
authors.initials: I
authors.lastname: Székely
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002404:Catheterization; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects*; D015331:Cohort Studies; D003135:Common Bile Duct; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010183:Pancreatic Ducts / Q000601:surgery*; D010195:Pancreatitis / Q000209:etiology / Q000517:prevention & control*; D019919:Prosthesis Implantation / Q000379:methods*; D012189:Retrospective Studies; D046628:Sphincter of Oddi Dysfunction / Q000628:therapy*; D016717:Sphincterotomy, Endoscopic; D015607:Stents; D055815:Young Adult