title: Early precut fistulotomy for biliary access: time to change the paradigm of "the later, the better"?
abstract: 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).
  
  
  METHODS
  Single-center, prospective cohort study.
  
  
  METHODS
  University-affiliated hospital.
  
  
  METHODS
  A total of 350 patients with a naïve papilla.
  
  
  METHODS
  Standard biliary cannulation followed by needle-knife fistulotomy (NKF).
  
  
  METHODS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Gastroenterology, Hospital of Santa Luzia, Viana do Castelo, Portugal; Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal.
authors.forename: Luís
authors.initials: L
authors.lastname: Lopes
authors.affiliation: Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal; Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal.
authors.forename: Mário
authors.initials: M
authors.lastname: Dinis-Ribeiro
authors.affiliation: Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Portugal; Department of Gastroenterology, Hospital of Braga, Braga, Portugal.
authors.forename: Carla
authors.initials: C
authors.lastname: Rolanda
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001658:Biliary Fistula / Q000503:physiopathology / Q000601:surgery*; D002404:Catheterization / Q000295:instrumentation / Q000379:methods*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000379:methods*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D018579:Patient Selection; D011300:Preoperative Care / Q000379:methods; D011446:Prospective Studies; D018570:Risk Assessment; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome