The significance of the sphincterotomy techniques in the occurance of the complications of endoscopic retrograd cholangiopancreatography

Introduction and Aim: Endoscopic retrograde cholangiopancreatography is an important method for diagnosis and treatment of benign and malignant diseases of biliary tract and pancreas. Recently, it has been used mostly for therapeutic interventions. It may be related with some complications, particularly pancreatitis, and rarely with mortality. The prediction of complications and their severity is important to decrease risc and mortality. Precut sphincterotomy is a new technique which is used after conventional methods of biliary cannulation have failed. In previous studies, the frequency of complications in precut technique is not similar. In our study, we aimed to examine if the precut techniue increases the complication frequency or not.Material and Method: 215 patients, to whom ERCP was performed, were prospectively evaluated. The patients with obstruction in the gastric outlet, koagulopathies, Bilroth II gastrectomi and the ones under the age of 18 and whom had been performed papillatomy before were excluded. 185 patients included to the study were divided in 3 groups due to the cannulation techniques.Grup 1: Deep bilier cannulation or cannulation by guide wire; with or without opaque injectionGroup 2: Precut technique is performed, using long or short nosed sphincterotoms with guidewire and double-lumen due to the choice of the endoscopist.Cannulation was being attempted for 10 minutes with these two methods.Group 3: If cannulation was not possible with these two techniques in 10 minutes, precut with needle-knife sphincterotom was done and these patients were included into the group 3.1-5 attempts were defined simple, 6-15 moderate and more than 15 difficult cannulation. It was noted if cannulation and pancreatic opaque injection was done. Complete blood count, blood serum amylase and lypase levels were checked before and 12-24 hours after the procedure. The patients were monitored for 30 days for the development of any complications.Results: Complication was seen in 26 (14%) of 185 patients included to the study. The complications seen were pancreatitis in 18 (9,7%) patients, cholangeitis in 6 (3,2%) and hemorrhage in 2 (1,1%). The frequency of complication was 9,2% (7 of 76 patients) in group 1, 9,3% (7 of 75 patients) in group 2 and 35,3% (12 of 34 patients) in group 3 respectively (p<0.05).While complication was observed in only 1 of 71 patients (1,4%) in easy cannulation group, the ratio was 15% (9 of 60 patients) in moderate and 29.6% (16 of 54 patients) in difficult cannulation group (p<0.05).If evaluated in terms of pancreatic cannulation existence; the complication rates were 25.3% (20/79 patients) in the group the pancreatic cannulation had done and 5.7% (6/106 patients) not done (p<0.05).While in the group opaque injection into pancreatic duct had done, the complication rate was 31.4% (16/51 patients), it was 7.5% (10/134 patients) in the other group opaque injection had not done (p<0.05).When multivariate analysis was used, it was seen that 2 parameters; the difficulty of cannulation (Odds ratio: 3.108) and opaque injection into pancreatic duct (Odds ratio: 3.220) were correlated with elevation of complication rate among the 4 parameters mentioned above.Conclusion: Difficult cannulation and opaque injection into pancreas are risk factors for the complications after ERCP, while precut technique is safe. So it?s recommended to prefer precut method earlier, instead of insisting on conventional techniques, for avoiding the complication risk.