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An assessment of the learning curve for precut biliary sphincterotomy

OBJECTIVE:Precut sphincterotomy is considered unsafe when used by inexperienced endoscopists. We sought to determine whether procedural experience with precut sphincterotomy predicted either successful cannulation or development of complications in these patients.METHODS:We describe the experience of 253 consecutive patients who underwent precut biliary sphincterotomy done by one endoscopist between September, 1993 and April, 2001. Data were prospectively collected on procedure indication and outcome. All patients were contacted by phone 30 days after the procedure to determine outcome. We also described precut utilization over time.RESULTS:All 253 precut procedures were divided chronologically into five groups of 50, with 53 in the final group. The rates of successful cannulation after precutting were 88%, 94%, 90%, 88%, and 98%, respectively (p = 0.05 for groups 1–4 vs group 5). Overall complication rates were similar in all groups (12%, 18%, 20%, 12%, and 14%), with no difference in complication severity. Female gender predicted successful cannulation (OR = 2.9 [p = 0.02]), whereas an indication of sphincter of Oddi dysfunction predicted development of complications (OR = 1.7 [p = 0.03]). The total number of ERCP procedures performed increased over time, whereas the proportion of precut sphincterotomies performed decreased.CONCLUSIONS:Although the success rate for precut sphincterotomy may increase with procedural experience, the complication rate does not seem to decrease. Precut sphincterotomy continues to carry an increased complication rate over standard sphincterotomy even when performed by an experienced biliary endoscopist. The need for precut sphincterotomy appears to decrease with increasing ERCP experience.