Background:
EUS guided biliary access has been advocated more and more in the recent past and has been proposed to replace ERCP cannulation and in one study EUS Rendezvous has been proved better than freehand precut. We attempted to search from our data what number of patients would not be cannulated in patients having normal anatomy and would require any other for of biliary access.
Aim:
To analyze the efficacy of freehand precut for selective cannulation in difficult ERCP and the need for EUS guided/other rendezvous techniques for biliary cannulation.
Material and methods
Retrospective analysis of 3000 patients undergoing ERCP from 2017 till date for varied etiologies in patients with normally accessible papilla. Number of patients requiring precut accessotomy were noted and technical success measured. ERCP was performed by two renowned endoscopists and two young associates at a tertiary endoscopy centre in western India. Our protocol was attempted biliary cannulation with a sphincterotome and a guide wire with standard techniques for 5 minutes or three attempts. If not successful, then go for a precut.
Results
No. of patients analyzed- 3000
Selective biliary cannulation- 2452 (81.74%)
Difficult cannulation requiring freehand precut accessotomy- 548 (18.26%)
Technical success after precut achieving biliary access- 539 (98.36%)
Failure of biliary cannulation even after precut- 09 (1.64%)
Most common etiology in precut cases- stone disease 360 (65.70%) followed by malignant lesions 118 (21.53%), benign strictures 28 (5.11%), post cholecystectomy biliary leak 28 (5.11%), post traumatic biliary leak 10 (1.82%), post hydatid surgery biliary leak 02 (0.36%), post central hepatectomy biliary leak 02 (0.36%).
Most common cause for failure in precut cases was extensive edema and eccentric location of the papilla and duodenal deformity.
Failed cases were subjected to EUS guided procedures (7) with malignant etiology and (2) underwent surgery for gall stones with CBD stones
Conclusion
Free hand precut technique is an art to mastered by the young endoscopists. It increases the success rate of selective biliary cannulation significantly avoiding the need for other costlier techniques such as EUS guided/Rendezvous techniques.

Ritesh Prajapati

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