title: Needle-knife precut papillotomy with a small incision over a pancreatic stent improves the success rate and reduces the complication rate in difficult biliary cannulations.
abstract: BACKGROUND
  Successful precut sphincterotomy (PS) in difficult biliary cannulation (DBC) requires a large incision for deroofing the papilla. However, the high complication rate poses a substantial problem, in addition to the need for expert skills. Pancreatic stent placement could facilitate this procedure. Needle-knife precut papillotomy with a small incision using a layer-by-layer method over a pancreatic stent (NKPP-SIPS) could potentially improve the success rate and reduce the complication rate of PS.
  
  
  OBJECTIVE
  To validate the efficacy, feasibility and safety of NKPP-SIPS in DBC.
  
  
  METHODS
  Therapeutic endoscopic retrograde cholangiopancreatography with a naïve papilla was performed in 1619 cases between May 2004 and July 2011. We prospectively divided the patients chronologically, in terms of the period during which the procedure was performed, into two groups: group A; needle-knife precut papillotomy (NKPP) performed between April 2004 and October 2006; group B; NKPP-SIPS performed between November 2006 and July 2011. The success rates and complication rates were evaluated. NKPP was performed without pancreatic stent placement and the cut was made starting at the papillary orifice, extended upward over a length of more than 5-10 mm for deroofing the papilla. On the other hand, in NKPP-SIPS, a pancreatic stent was placed initially as a guide, and to prevent post-ERCP pancreatitis, the incision was begun at the papillary orifice in a layer-by-layer fashion and extended upward in 1-2 mm increments, not going beyond the oral protrusion, finally measuring less than 5 mm in length.
  
  
  RESULTS
  PS was performed in 8.3 % of the patients (134/1619). The cannulation success rate of PS in the entire group was 94.0 % (126/134). NKPP and NKPP-SIPS were performed in 36 and 98 of the patients, respectively. There was one case of major bleeding in group A, and no severe complications in group B. The success rates of bile duct cannulation increased from 86.1 % (31/36) in group A to 96.9 % (95/98) in group B (p = 0.0189). The overall complication rate of PS was YC 33 % (12/36) in group A (major bleeding 8.3 %; mild to moderate pancreatitis 19.4 %; perforation requiring surgery 2.8 %), and 7.1 % (7/98) in group B (mild to moderate pancreatitis 6.1 %; minor perforation 1 %) (p < 0.001).
  
  
  CONCLUSIONS
  NKPP-SIPS has significantly improved the success rate and reduced the complication rate of DBC, proving that a small incision starting at the orifice of the PS is sufficient, feasible and safe in DBC, when a pancreatic stent is inserted at the outset.
authors.affiliation: Division of Gastroenterology, Yokohama City University Graduate School of Medicine, Fukuura 3-9, Kanazawa, Yokohama, 236-0004, Japan. kubotak@yokohama-cu.ac.jp
authors.forename: Kensuke
authors.initials: K
authors.lastname: Kubota
authors.forename: Takamitsu
authors.initials: T
authors.lastname: Sato
authors.forename: Shingo
authors.initials: S
authors.lastname: Kato
authors.forename: Seitaro
authors.initials: S
authors.lastname: Watanabe
authors.forename: Kunihiro
authors.initials: K
authors.lastname: Hosono
authors.forename: Noritoshi
authors.initials: N
authors.lastname: Kobayashi
authors.forename: Kantaro
authors.initials: K
authors.lastname: Hisatomi
authors.forename: Nobuyuki
authors.initials: N
authors.lastname: Matsuhashi
authors.forename: Atsushi
authors.initials: A
authors.lastname: Nakajima
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater / Q000601:surgery*; D001662:Biliary Tract Surgical Procedures / Q000295:instrumentation / Q000379:methods*; D002404:Catheterization / Q000295:instrumentation / Q000379:methods*; D016009:Chi-Square Distribution; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000517:prevention & control*; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D015607:Stents; D016896:Treatment Outcome