title: Early 'shallow' needle-knife papillotomy and guidewire cannulation: an effective and safe approach to difficult papilla.
abstract: BACKGROUND
  Needle-knife sphincterotomy (NKS), known as 'precut', is used worldwide to facilitate access to the common bile duct when standard cannulation has failed. This procedure is considered hazardous because it is burdened with high procedural related complications (bleeding and perforation). Its right timing is still debated. In this study we report our results using a modified precut approach, early shallow needle-knife papillotomy (eSNKP) coupled with guidewire cannulation in case of difficult papilla. We evaluated its safety and effectiveness.
  
  
  METHODS
  From 2012 to 2014, 1034 patients underwent therapeutic ERCP. A total of 138 of them presented difficult papilla and were treated with eSNKP performed after 5 failed attempts of standard guidewire cannulation. Deep biliary cannulation rate was recorded, as well as intraoperative and postoperative complication rate.
  
  
  RESULTS
  Successful biliary deep cannulation was achieved in 132/138 patients (95.7%) by means of eSNKP. In 6 patients (4.3%), cannulation failed even after eSNKP. ERCP was newly performed 72 hours later with successful and immediate guidewire biliary cannulation. Overall morbidity was 10.1% (14/138). No perforation occurred. Minor bleeding occurred in 4/138 cases (2.9%) and 10/138 patients (7.2%) developed mild pancreatitis.
  
  
  CONCLUSIONS
  In case of difficult papilla, eSNKP followed by guidewire cannulation increases the successful deep biliary cannulation with low rate of complications.
authors.affiliation: Unit of Interventional Endoscopy, Department of General Surgery 'Paride Stefanini', 'Sapienza' University of Rome, Italy.
authors.forename: Fausto
authors.initials: F
authors.lastname: Fiocca
authors.affiliation: Surgical Sciences Department, 'Sapienza' University of Rome, Italy.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Fanello
authors.affiliation: Unit of Interventional Endoscopy, Department of General Surgery 'Paride Stefanini', 'Sapienza' University of Rome, Italy.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Cereatti
authors.affiliation: Unit of Interventional Endoscopy, Department of General Surgery 'Paride Stefanini', 'Sapienza' University of Rome, Italy.
authors.forename: Roberta
authors.initials: R
authors.lastname: Maselli
authors.affiliation: Unit of Interventional Endoscopy, Department of General Surgery 'Paride Stefanini', 'Sapienza' University of Rome, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Ceci
authors.affiliation: Unit of Interventional Endoscopy, Department of General Surgery 'Paride Stefanini', Sapienza Univeristy of Rome, Viale del Policlinico 155, 00161, Rome, Italy Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, 75013 Paris, France.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Donatelli
keywords: early shallow needle-knife papillotomy; endoscopic retrograde cholangiopancreatography; guidewire cannulation; needle-knife papillotomy; precut sphincterotomy