Pure cut electrocautery current for sphincterotomy causes less post-procedure pancreatitis than blended current

doi:10.1016/S0016-5107(98)70348-7

Gastrointestinal Endoscopy

Volume 47, Issue 2, February 1998, Pages 149-153

Presented in part at the annual meeting of the ASGE, May 1995, San Diego, California (Gastrointest Endosc 1995;41:395).

https://doi.org/10.1016/S0016-5107(98)70348-7 Get rights and content

Abstract

Background: Complications after endoscopic biliary sphincterotomy occur in 8% to 10% of patients when studied prospectively. It is not known whether the type of electrocautery current affects this rate. Theoretically, less edema of the ampulla after a pure cutting current sphincterotomy could decrease the risk of pancreatitis although the risk of postsphincterotomy hemorrhage might be greater. Methods : One hundred seventy patients undergoing sphincterotomy were prospectively randomized to either a blended or pure cut current on the Valleylab electrosurgical unit. The settings were a blended three current at a power setting of 30 watts/sec for both the cut and coagulation currents or a pure cut current at a power setting of 30 watts/sec. The individual determining whether a complication occurred was blinded to the type of current used, and all patients were hospitalized for 24 hours post-procedure. Pancreatitis was defined as mild if fewer than 5 days, moderate if 5 to 14 days, and severe if more than 14 days of hospitalization were required. Results: Indications for sphincterotomy were choledocholithiasis in 111 patients, sphincter of Oddi dysfunction in 36 patients, stent placement in 15 patients, and miscellaneous in 8 patients. There were a total of 16 complications in 170 patients (9%); 4 (5%) were in the pure cut current group of 86 patients (one episode of bleeding that required transfusion of 4 U and three episodes of mild pancreatitis), and 12 (14%) were in the blended current group of 84 patients (7 mild, 2 moderate, and 1 severe pancreatitis; 1 case of cholangitis; and one episode of bleeding that required transfusion of 2 U). There were significantly fewer complications in the pure cut group (p < 0.05 by chi-square). Conclusion: The use of pure cut current is associated with a lower incidence of pancreatitis, the most common ERCP complication, than with blended current sphincterotomy. An insufficient number of patients were studied to comment on the relative risk of hemorrhage. However, because the complication of hemorrhage is much less common than pancreatitis, pure cut current is safer overall. (Gastrointest Endosc 1998;47:149-53)

Section snippets

Methods

All patients undergoing biliary endoscopic sphincterotomy between November 1994 and June 1995 were randomized to either blended or pure cut current. Patients having sphincterotomy performed on even calendar dates received blended current, whereas patients undergoing sphincterotomy on odd calendar dates received pure cutting current. Five attending gastroenterologists either performed or closely supervised gastroenterology fellows in the performance of the procedures. This study was approved by

Results

One hundred seventy consecutive patients undergoing biliary sphincterotomy were entered into the trial. There were 56 women and 30 men in the pure cut group and 54 women and 30 men in the blended current group. The age range was 19 to 96 years (mean 51 years) in the blended current group and 21 to 92 years (mean 55 years) in the pure cut group. The study was stopped after interim analysis showed a lower pancreatitis rate in the pure cut group. The indications for sphincterotomy are listed in

Discussion

Since the introduction of endoscopic sphincterotomy over 20 years ago, the indications and use of this procedure have grown steadily. It is now generally recognized as the preferred method of treatment for many biliary disorders, including choledocholithiasis, papillary stenosis, and cholangitis. 4, 5 The complications of endoscopic sphincterotomy are similar to those for diagnostic ERCP but occur more frequently. A large prospective multicenter trial of 2347 patients undergoing biliary

References (15)

PD Cotton et al.
Endoscopic sphincterotomy complications and their management: an attempt at consensus
Gastrointest Endosc
(1991)
S Sherman et al.
Complications of endoscopic sphincterotomy
Gastroenterology
(1991)
JE. Geenen
ASGE distinguished lecture—endoscopic therapy of pancreatic disease: a new horizon
Gastrointest Endosc
(1988)
A Smithline et al.
Effect of prophylactic main pancreatic duct stenting on the incidence of biliary endoscopic sphincterotomy-induced pancreatitis in high risk patients
Gastrointest Endosc
(1993)
JE Geenen et al.
Resume of a seminar on endoscopic retrograde sphincterotomy (ERS)
Gastrointest Endosc
(1981)
PB Cotton et al.
Therapeutic endoscopic retrograde cholangio-pancreatography (ERCP)
SE Silvis et al.
Introduction to endoscopic retrograde cholangiopancreatography

There are more references available in the full text version of this article.

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Citation Excerpt :
The initial bleeding analysis involved 3 studies [14,30,31] with 540 patients, which showed fewer adverse events with blend mode (RD: 0.18 [0.11, 0.24], P < 0.00001, I2 = 98%). The funnel plot revealed an outlier [14], which was excluded, allowing an analysis with low heterogeneity (I2 = 0%). Thus, the analysis of the remainder two articles[30,31] (370 patients) was favorable to the blend modality (RD: 0.26 [0.61, 0.35], P < 0.00001, I2 = 0%).
Biliary sphincterotomy is an invasive method that allows access to the bile ducts, however, this procedure is not exempt of complications. Studies in the literature indicate that the mode of electric current used for sphincterotomy may carry different incidences of adverse events such as pancreatitis, hemorrhage, perforation, and cholangitis.
To evaluate the safety of different modes of electrical current during biliary sphincterotomy based on incidence of adverse events.
We searched articles for this systematic review in Medline, EMBASE, Central Cochrane, Lilacs, and gray literature from inception to September 2019. Data from studies describing different types of electric current were meta-analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The following electric current modalities were evaluated: endocut, blend, pure cut, pure cut followed by blend, monopolar, and bipolar.
A total of 1791 patients from 11 randomized clinical trials evaluating the following comparisons: 1. Endocut vs Blend: No statistical difference in the incidence of bleeding (7% vs 13.4%; RD: −0.11 [−0.31, 0.08], P = 0.27, I² = 86%), pancreatitis (4.4% vs 3.5%; RD: 0.01 [−0.03, 0.04], P = 0.62, I² = 48%) and perforation (absence of cases in both arms). 2. Endocut vs Pure cut: Higher incidence of mild bleeding (without drop in hemoglobin levels, clinical repercussion or need for endoscopic intervention) in the pure cut group (9.2% vs 28.8%; RD: −0.19 [−0.27, −0.12], P < 0.00001, I² = 0%). No statistical difference regarding pancreatitis (5.2% vs 0.9%; RD: 0.05 [−0.01, 0.11], P = 0.12, I² = 57%), perforation (0.4% vs 0%; RD: 0.00 [−0.01, 0.02], P = 0.7, I² = 0%) or cholangitis (1.8% vs 3.2%; RD: −0.01 [−0.09, 0.06], P = 0,7). 3. Pure cut vs blend: higher incidence of mild bleeding in the pure cut group (40.4% vs 16.7%; RD: 0.24 [0.15, 0.33], P < 0.00001, I² = 0%). No statistical difference concerning incidence of pancreatitis or cholangitis. 4. Pure cut vs Pure cut followed by Blend: No statistical difference regarding incidence of bleeding (22.5% vs 11.7%; RD: −0.10 [−0.24, 0.04], P = 0.18, I² = 61%) and pancreatitis (8.9% vs 14.8%; RD 0.06 [−0.02, 0.13], P = 0.12, I² = 0%). 5. Blend vs pure cut followed by blend: no statistical difference regarding incidence of bleeding and pancreatitis (11.3% vs 10.4%; RD −0.01 [−0.11, 0.09], P = 0.82, I² = 0%). 6. Monopolar vs bipolar: higher incidence of pancreatitis in the monopolar mode group (12% vs 0%; RD 0.12 [0.02, 0.22], P = 0.01).
Pure cut carries higher incidences of mild bleeding compared to endocut and blend. However, this modality might present a lower incidence of pancreatitis. The monopolar mode elicits higher rates of pancreatitis in comparison with the bipolar mode. There is no difference in incidence of cholangitis or perforation between different types of electric current. There is a lack of evidence in the literature to recommend one method over the others, therefore new studies are warranted. As there is no perfect electric current mode, the choice in clinical practice must be based on the patient risk factors.
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Electrosurgery uses high-frequency energy to create cellular heating and is a fundamental technology used in therapeutic flexible endoscopy. The heating effect can be manipulated to encourage a predominantly cutting or coagulating effect, and the balance between the two is the product of multiple variables. Variables can be patient or physician technique dependent; some depend on output selections made on an electrosurgery generator and the accessories attached to it. Much misunderstanding exists about the technology and its clinical use. This chapter uses accurate terminology, clear descriptions, and the best available science to clarify, enlighten, and encourage physician understanding of this important topic.
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Endoscopic retrograde cholangiopancreatography (ERCP) requires several years of dedicated training and continuous refinement of knowledge and skill. With the dissemination of endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP), ERCP has evolved from a diagnostic to an almost purely therapeutic procedure. General issues on cannulation have already been highlighted in Chapter 40. This chapter concentrates on variations of standard techniques to overcome challenges to standard cannulation and sphincetrotomy, including in patients with anatomic variations, gastric outlet obstruction, and surgically altered anatomy.
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The use of pancreatic sphincterotomy in the management of pancreaticobiliary diseases has been practiced since the 1970s in various forms and techniques. It is the cornerstone of pancreatic endoscopic therapy and in some cases may provide initial access to the main pancreatic duct. It may be used as a single therapeutic maneuver (e.g., in the treatment of recurrent acute pancreatitis with evidence of ampullary stenosis involving the pancreatic orifice) or as an adjunct to other therapeutic techniques, such as pancreatic stone extraction or pancreatic duct stricture dilation. This chapter focuses on the endoscopic techniques and channel accessories used in performing pancreatic sphincterotomy. In addition, the indications and contraindications are described in detail, as well as the published evidence that supports its use in practice. Finally, the adverse events associated with pancreatic sphincterotomy (and their management) are discussed in detail.
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Endoscopic sphincterotomy (EST) of the biliary sphincter can be indicated to treat of disorders of the papilla of Vater or to facilitate diagnostic and therapeutic procedures in patients with biliary diseases. Selection of cases should consider alternative measurements and potential adverse events of EST. The choice of accessories and the procedural techniques depend on the individual anatomy and the preference of the endoscopist. The application of technical guidelines is important, but many recommendations are based on a low level of evidence. Adverse events of EST occur in up to 10% of the cases. They are mainly related to bleeding, post-ERCP pancreatitis, cholangitis, and (rarely) perforation. Pancreatitis can also occur due to a difficult cannulation before EST. A variety of measurements helps minimize the risk of EST and manage adverse events conservatively. Success and complication rates of EST depend on the expertise of the endoscopist. Difficult procedures and previous failures of biliary cannulation or EST should be referred to advanced operators.

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^☆: From the Division of Gastroenterology, Department of Internal Medicine, University of Michigan at Ann Arbor

^☆☆: Reprint request: Grace H. Elta, MD, 3912 Taubman Center, University of Michigan, Ann Arbor, MI 48109-0362.

^★: 37/1/86726

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Pure cut electrocautery current for sphincterotomy causes less post-procedure pancreatitis than blended current☆,☆☆,★

Abstract

Section snippets

Methods

Results

Discussion

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Therapeutic endoscopic retrograde cholangio-pancreatography (ERCP)

Introduction to endoscopic retrograde cholangiopancreatography