Comparison between needle-knife fistulotomy and standard cannulation in ERCP

Abstract

Aim: To compare the rates of success and complications of two different methods of access into the common bile duct (CBD).

Methods: Between October 2007 and November 2008, 173 consecutive patients (71 men, 102 women, mean age 68.6 years) requiring endoscopic retrograde cannulation of the papilla and endoscopic treatment were studied. In the first 88 patients CBD cannulation was performed through supra-papillary fistulotomy (group F); in the following 85 patients standard cannulation was performed through the Oddi sphincter (group S). Indications for the procedure were: choledocholithiasis, biliary obstruction, postoperative leak, sclerosing cholangitis, and Mirizzi's syndrome.

Results: Deep CBD cannulation was successful in 85/88 patients (96.5%) in group F vs 60/85 patients (70.6%) in group S (P < 0.0001). The remaining 25 group S patients in whom cannulation failed were shifted to fistulotomy. Fistulotomy was successful in 21/25 patients (84%). As for complications, hyperamilasemia occurred in 7 (7.9%) group F patients vs 7 (8.2%) group S patients (P = NS); mild pancreatitis in 1 (1.1%) group F patient vs 5 (5.8%) group S patients (P = NS); bleeding in 3 (3.4%) group F patients vs 3 (3.5%) group S patients (P = NS).

Conclusion: Needle-knife fistulotomy should represent either the first approach to therapeutic cannulation or rescue therapy after unsuccessful standard cannulation.

Keywords: Biliary stones; Common bile duct; Fistulotomy; Pancreatitis; Papillotomy.

Figures

Figure 1

Needle-knife fistulotomy in Billroth II and removal of stone.

Figure 2

The starting point of the fistulotomy on the papilla.

Figure 3

Needle-knife fistulotomy and placement of 10 Fr plastic stent.

Figure 4

Needle-knife fistulotomy and removal of large stone.

Figure 5

Papilla, needle-knife fistulotomy, deep cannulation and papillotomy.

Figure 6

Needle-knife fistulotomy and placement of metallic stent.