Littérature scientifique sur le sujet « Traction sphincterotomy »

Background. Transpancreatic precut sphincterotomy (TPS) is an option for difficult common bile duct (CBD) access, and the reports are few, with immediate success rate varying from 60 to 96%. The description of relation between the size of TPS and the immediate success rate of CBD cannulation was not found in the literature. The Aim of the Study. To evaluate the relation of large TPS to immediate success rate of CBD cannulation. Methods. A retrospective analysis was performed in prospectively collected data of 20 patients. TPS was performed with traction papillotome in the main pancreatic duct (MPD) directing towards 11 o’clock. Needle knife (NK) was used to enlarge TPS in five patients, and the other 15 cases had large TPS from the beginning of sphincterotomy. Prophylactic pancreatic stent was inserted in 18 cases, with diclofenac given in 12 cases. Results. The immediate success rate of CBD cannulation was 90% and with an eventual success rate of 100%. The failure in one immediate CBD cannulation with large TPS was due to atypical location of CBD orifice, and the other failed immediate CBD cannulation was due to inadequate size of TPS. Complications included 3 cases of post-TPS bleeding and 3 cases of mild pancreatitis. Conclusion. TPS is an effective procedure in patients with difficult biliary access and can have high immediate success rate with large TPS.

BACKGROUND: La colangiografia retrograda endoscopica (ERCP) con intento terapeutico richiede l’incannulazione selettiva della via biliare principale e/o del dotto pancreatico. Se tale incannulazione fallisce, si pone la scelta se utilizzare tecniche più invasive (es. precut della papilla) o interrompere l’esame e procedere con metodiche alternative (es. PTBD). OBIETTIVI: Confrontare il tasso di successo e di complicanze della papillotomia-precut e della sfinterotomia endoscopica (EST) standard. In caso di insuccesso dell’ERCP, valutare i trattamenti utilizzati e le complicanze ad essi correlate. METODI: Nel nostro centro ospedaliero e universitario di riferimento per la patologia pancreatica, tra gennaio 2007 e aprile 2010 è stato condotto uno studio prospettico osservazionale sui pazienti sottoposti a ERCP. Sono stati considerati due gruppi: a) tutti i pazienti sottoposti a papillotomia precut; b) un sottogruppo di pazienti sottoposti a EST standard (selezionando consecutivamente un paziente ogni quattro). La misura di esito primaria è stata considerare il tasso di successo e di complicanze della varie metodiche. RISULTATI: Sono state eseguite in totale 783 ERCP, delle quali 755 con intento terapeutico. La papillotomia precut è stata praticata nel 17.3% di tutte le ERCP terapeutiche (131/755; 51.1% femmine; età media 65.5±13.7 anni). Il tasso di successo globale è stato del 73.3% (96/131) con una variabilità tra operatori che va dal 63.1% all’83.3%. Il tasso di complicanze è stato del 5.3% (7/131); non c’è stata mortalità correlata alla procedura. Le procedure endoscopiche, in questo gruppo, sono risultate essere ad elevato grado di difficoltà nel 46.6% dei casi (grado 3 sec. la classificazione di Cotton). Il grado di difficoltà era inversamente correlato al tasso di successo (p<0.01), ma non correlato al tasso di complicanze. Il precut non è stato coronato da successo in 35 pazienti, che sono stati quindi sottoposti a: PTBD in 18 casi (51.4%), trattamento medico e follow-up radiologico in 11 casi (31.4%), trattamento chirurgico negli altri 6 (17.2%). Il PTBD ha registrato il 22.2% di complicanze (2 colangiti e 2 sanguinamenti con necessità di emotrasfusione). La EST standard è stata eseguita in 151 casi (corrispondenti al 20% di tutte le ERCP terapeutiche): il 56.3% erano femmine; l’età media era 63.5±17.6 anni. Il tasso di successo globale è stato del 92.7% (140/151), con una variabilità tra operatori che va dall’88.8% al 97.2%. Il tasso di complicanze è stato del 7.3% (11/151). Le procedure endoscopiche, in questo gruppo, sono risultate essere ad elevato grado di difficoltà nel 25% dei casi (grado 3 sec. la classificazione di Cotton). Se si considerano solamente le complicanze severe, si evidenzia una lieve prevalenza di casi nel gruppo dei precut (2.3%) rispetto al gruppo delle EST standard (1.3%) (p=ns). CONCLUSIONI: in una serie consecutiva di pazienti, con un’alta proporzione di casi difficili, il precut della papilla risulta essere una tecnica efficace e associata ad un accettabile tasso di complicanze.
BACKGROUND: Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) involves selective cannulation of the common bile and/or pancreatic ducts. If the cannulation fails, there is the choice whether to use more invasive procedures (i.d. precut papillotomy) or stop the esamination and proceed with alternative methods (i.d. percutaneous transhepatic biliary drainage - PTBD). OBJECTIVES: To compare the success and complication rates of precut papillotomy and of standard endoscopic sphincterotomy (EST). In cases of ERCP failure, to identify treatments used and its complications. METHODS: A prospective observational study was carried out on patients who underwent ERCP in a tertiary referral university hospital between January 2007 and April 2010. Two groups were studied: a) all the patients who underwent precut papillotomy; b) a subgroup of patients who underwent a standard EST (consecutively selecting a patient every four). The success and complication rates associated to the various methods were considered the main outcome measurements. RESULTS: A total of 783 ERCPs were performed, 755 with therapeutic intent. A precut papillotomy was carried out in 17.3% of total therapeutic ERCP (131/755; 51.1% females; mean age 65.5±13.7). The overall success rate was 73.3% (96/131) with an intra-operator variability between 63.1% and 83.3%. The complication rate was 5.3% (7/131); there were no cases of death. In this group 46.6% of cases were classified as presenting a high grade of difficulty (grade 3 of Cotton’s classification). The grade of difficulty was found to be inversely correlated with the success rate (p<0.01) but not with the complication rate. Papillotomy failed in 35 patients who then underwent: PTBD in 18 cases (51.4%), medical treatment and radiological follow-up in 11 (31.4%), and surgery in 6 (17.2%). PTBD was associated to a 22.2% rate of complications (2 cholangitis and 2 bleeding requiring blood transfusion). A standard EST was carried out in 151 cases (corresponding to 20% of the total therapeutic ERCPs): 56.3% female; mean age 63.5±17.6. The overall success rate was 92.7% (140/151) with an intra-operator variability between 88.8% and 97.2%. The complication rate was 7.3% (11/151). Twenty-five percent of standard EST were graded as presenting a high degree of difficulty (grade 3 of Cotton’s classification). If only severe complications are considered, there is only a slight prevalence in the precut group (2.3%) with respect to the standard EST group (1.3%) (p=ns). CONCLUSION: In a consecutive series of patients with a high proportion of difficult cases, papilla precutting is an useful technique with an acceptable complication rate.