Wire-assisted access sphincterotomy of the minor papilla

Abstract

Background Recommended techniques for minor papilla sphincterotomy include performing a standard pull-type sphincterotomy (PTS) or using a needle-knife over a stent. A wire-assisted access sphincterotomy (WAAS) technique may hold some technical advantages over these accepted methods, but has not been robustly described.

Objective To describe the safety and efficacy of WAAS compared with PTS in a series of patients from our institution.

Design Retrospective audit of initial minor papilla sphincterotomies over a 6-year period. Demographic and procedural data were abstracted, and the medical record was reviewed for clinical follow-up.

Setting A large tertiary referral center.

Patients One hundred twenty-eight consecutive patients with pancreas divisum who underwent ERCPs between April 2001 and April 2007, 64 of whom underwent an initial minor papilla sphincterotomy.

Interventions WAAS was performed by deeply cannulating the dorsal duct with a guidewire and then passing a needle-knife sphincterotome alongside the wire and cutting the minor papilla by inserting the needle-knife beside the wire and cutting away from the wire.

Main Outcome Measurements Clinical procedural success and reported adverse events.

Results Thirty-two patients had recurrent acute pancreatitis, 15 had pain only, and 13 had chronic pancreatitis. Thirty-two underwent WAAS, 24 had PTS, and 8 had other types of sphincterotomies. Patients undergoing WAAS (32) versus PTS (24) were similar in age, sex, and procedural indication. Mild post-ERCP pancreatitis and mild intraprocedural bleeding occurred more commonly in the WAAS group, although the differences were not statistically significant.

Limitations Retrospective, nonrandomized study.

Conclusions WAAS is an effective technique that may be used either to begin a minor papilla sphincterotomy or to perform the entire sphincterotomy. Complications appear similar to those seen with conventional methods but require a larger patient sample to fully evaluate.