1. Needle-knife sphincterotomy: factors predicting its use and the relationship with post-ERCP pancreatitis Adam A. Bailey, MBChB, FRACP, Michael J. Bourke, MBBS, FRACP, Arthur J. Kaffes, MBBS, FRACP, Karen Byth, PhD, Eric Y. Lee, MBBS, FRACP, Stephen J. Williams, MBBS, FRACP, MD Gastrointest Endosc 2010;71:266-71 소화기 내과 R1 강성욱 / prof. 동석호

2. BACKGROUND Conventional techniques of biliary cannulation Successful rate : 90% to 95% Remain an incidence of failure Needle-knife sphincterotomy(NKS) Used as a last-resort & improved success rates May increased incidence of post-RCP pancreatitis (PEP) The causative factor remains unclear

3. BACKGROUND Independently associated with an increased rate of PEP A greater number of attempts at cannulating the papilla multiple inadvertent pancreatic injections May be the dominant causative factor in the association between NKS and PEP Examine the relationship between NKS and ERCP complications including PEP

4. PATIENTS AND METHODS Two adequately powered, randomized ERCP trials The first study(2001.11~2003.5) : 5-mg transcutaneous glyceryl trinitrate (GTN) sustained-release patch with placebo in the prevention of PEP The second study(2003.8~2006.4) : primary guidewire-assisted cannulation with standard contrast material injection and the effect on PEP Incidence of PEP was not significantly different between arms and/or studies (GTN 7.4% vs placebo 7.7%; guidewire 7.9% vs contrast 6.2%).

5. PATIENTS AND METHODS Exclusion criteria Age below 18 years Severe acute illness (sBP < 90 mm Hg, SaO2 < 95%) inability or refusal to give informed consent Previous sphincterotomy Pancreatic or ampullary cancer Surgically altered anatomy (Billroth II, Roux-en-Y anastomosis)

6. PATIENTS AND METHODS The cannulation protocol Successful cannulation : free and deep instrumentation of the biliary tree Cannulation attempt : sustained contact between the cannulating device and the papilla for at least 5 seconds If these attempts at cannulation failed, an NKS was performed

7. PATIENTS AND METHODS

8. Follow-up Outpatients observed 4 hours after the procedure Significant abdominal pain  admitted for observation Amylase and lipase levels the day after ERCP Telephone interviews on day 1 and day 30 after ERCP If a diagnosis of PEP was made  data were collected prospectively to grade the severity of this complication

9. PATIENTS AND METHODS Statistical methods SPSS for Windows Version 14 The Mann-Whitney test : to compare continuous outcome variables The chi-square test, or Fisher exact test : to investigate associations between categorical variables The multivariate logistic regression analysis : to account unforeseen heterogeneity between two studies 5% significance level were used throughout

10. RESULTS

11. RESULTS

12. RESULTS

13. RESULTS

14. CONCLUSION The number of attempts at cannulating the papilla is independently associated with PEP, and the risk increases with an increasing number of attempts. NKS is not an independent predictor of PEP.