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1. Primary Precutting Versus Conventional
Over-the-Wire Sphincterotomy For
Management of Large Common Bile
Duct Stones
Ahmed Bahaa Abd El-Azeam
M.B.B.Ch
Assistant lecturer in Tropical Medicine and
Gastroenterology
Sohag University Hospital

2. Under supervision of:
Pof. Asmaa Naser Mohamed
Professor of Tropical Medicine and Gastroenterology
Faculty of Medicine
Sohag University
Dr. Mohamed Fakhry Mohamed
Assisstant Professor of Hepatology, Gastroenterology and infectious disease
Faculty of Medicine
Azhar Assiut University
Dr. Mona Mohammed Abdelrahman
Lecturer of Tropical Medicine and Gastroenterology
Faculty of Medicine
Sohag University

3. Primary Precutting Versus Conventional
Over-the-Wire Sphincterotomy For
Management of Large Common Bile Duct
Stones

9. Introduction
During the last decades, endoscopic retrograde
cholangiopancreatography (ERCP) has become the
standard of care for the treatment of many
pancreaticobiliary diseases [Canena et al., 2014].
However, ERCP is a challenging technique with a
slow learning curve and is associated with
complications, some of them life-threatening
[Chandrasekhara et al., 2017].

10. Post-ERCP pancreatitis (PEP) is the most common and
serious complication after ERCP [Testoni et al.,
2016].
Selective cannulation of the common bile duct (CBD)
is still considered to be a prerequisite for biliary
sphincterotomy. Despite the use of various endoscopic
retrograde cholangiopancreatography (ERCP)
catheters and wire−guided sphincterotomes, CBD
cannulation has been reported to fail in 5 % - 20 % of
cases [Larkin and Huibregtse, 2001].

11. Precut sphincterotomy can allow access to the bile
duct in such cases and is widely performed by expert
endoscopists when there is a clear indication for
endoscopic intervention.
However, the use of precut sphincterotomy remains
controversial because reported complication rates of
the widely practiced needle−knife sphincterotomy
(NKS) technique vary between 5 % and 20 %
[Shakoor and Geenen, 1992].

12. The definition of difficult biliary access (DBA) varied
widely [Mariani et al., 2016]. The latest guidelines for the
definition of DBA differed widely from the latest guideline
of The European Society of Gastrointestinal Endoscopy
(defining DBA as the presence of ≥1 of the following: >5
contacts with the papilla while attempting to cannulate; >5
minutes spent attempting to cannulate following
visualization of the papilla; >1 unintended pancreatic duct
cannulation ) [Testoni et al., 2016].

13. • And the International Consensus Panel (defining
DBA as the inability to achieve selective biliary
cannulation by the standard ERCP technique within
10 minutes or up to 5 attempts or failure of access to
the major papilla) [Liao et al., 2017 ].

14. Aim of the work
Comparing the efficacy and complication rate of
precut used as a method of CBD access with the
efficacy and safety of the conventional technique.

15. Patients and methods
Place of the study: Hepatology, Gastroenterology, and
Infectious disease department, at Azhar Assiut University.
Type of the study: Cross-sectional study.
Study period: Duration of the study will be 18 months
after acceptance of The Ethical Committee Of The
Medical Research.

16. Patients
During the 18−month study period, consecutive patients
who will be scheduled for first−time endoscopic
sphincterotomy (ES) for a variety of biliary disorders
admitted at Hepatology, Gastroenterology, and Infectious
disease department, at Azhar Assiut University will be
randomized into two groups:
Patients in group A : will do conventional wire−guided
biliary cannulation followed by ES.

17. Patients
Patients in group B: precut will be used when
conventional wire−guided biliary cannulation to gain
biliary access fails, followed by wire−guided ES. We
will use a specially designed, modified Erlangen type
of sphincterotome for precutting.

18. Inclusion/exclusion criteria
Inclusion criteria : Patients with difficult biliary access
(DBA) consenting to randomization in an interventional
design randomized controlled trials (RCTs) that
compare precut sphincterotomy (EPS) with persistent
cannulation attempts (PCA).
Patients who required biliary cannulation but without
previous sphincterotomy.
The exclusion criteria: Patients with coagulopathy or
acute pancreatitis.

19. Methods
1- Complete history taking with stress on:
 age, sex, presence of abdominal pain, nausea, fever,
vomiting, constipation, jaundice, change of colour of urine
and stool, itching, GIT bleeding, previous history of GIT
endoscopy, disturbance of conscious level, lethargy,
weight loss, the drug history and alcohol consumption.
history suggesting other significant co-morbid conditions
and their treatment.

20. 2- Thorough clinical examination:
General examination, vital signs, conscious level,
nutritional status, signs of dehydration, body mass
index, abdominal examination with stress on
jaundice, organomegaly, ascites, and manifestations
suggesting other system affection.

21. 3- Laboratory investigations:
1. Complete blood count (CBC)
2. Liver function tests
3. Serum amylase and lipase level (preoperative and 3
days postoperative)
4. Prothrombin time and concentration
5. Alpha feto protein

22. 6. CA 19-9
7. CEA
8. Serum creatinine
9. Serum electrolyte
10. ESR
11. CRP
12. Serology for HBsAg and HCV antibodies

23. 4- Abdominal ultrasonography:
Size of the liver, biliary tree, hepatic focal lesion,
portal vein diameter, portal vein thrombosis, CBD
diameter
Size of the spleen, portosystemic collaterals.
Size and echogenicity of pancreas
Presence or absence of ascites
5- Magnetic resonance cholangiopancreatography
(MRCP)

24. Thank You