Esfinterotomía de aguja como técnica de acceso a la vía biliar: estudio prospectivo

Biliary cannulation effectiveness and pancreatitis risk using two early precut techniques

INTRODUCTION

Precut techniques allow for successful biliary cannulation rates approaching 100% but there may be an associated increase in the risk of complications. Recently, early needle-knife precut has been shown to be a safe procedure and is now used as a pancreatitis prevention resource for difficult cannulation cases. The goal of the present study was to assess cannulation and pancreatitis rates using two early precut techniques.

PATIENTS AND METHODS

This was a retrospective study of endoscopic retrograde cholangio-pancreatography (ERCP) procedures performed from 2013 to 2016. The efficacy and safety of simple cannulation, needle-knife precut and transpancreatic precut were assessed.

RESULTS

Simple cannulation was achieved in 369 (73.4%) of 503 evaluable ERCP procedures. Needle-knife precut was successful in 51 (96.2%) of 53 attempts and transpancreatic precut was successful in 75 (96.2%) of 78 attempts. The overall cannulation rate was 98.4%. There were eleven (2.4%) pancreatitis events, six (1.8%) with simple cannulation (two severe, one fatal), five (6.3%) with transpancreatic precut (two severe) and zero events with the needle-knife precut procedure. Among the patients undergoing the precut procedure, seven experienced perforations (two severe) and there were seven bleeding events. The overall complication rate was 14.4%.

CONCLUSIONS

The complementary use of either precut technique provides a satisfactory biliary cannulation rate. However, the rates of pancreatitis and other severe complications are higher for transpancreatic versus needle-knife precut, therefore the indications for both techniques should be modified.

Failed biliary access following needle knife fistulotomy: is repeat interval ERCP worthwhile?

OBJECTIVE

Needle knife fistulotomy is a useful alternative in gaining access to the biliary system when standard cannulation techniques have been exhausted. Where access cannot be achieved following fistulotomy the convention has been to abandon further endoscopic attempts. Recent experience at our center suggests that repeat ERCP is frequently successful. This study assesses the utility of repeat ERCP in a cohort of patients for whom biliary access could not be achieved despite needle knife fistulotomy during the initial procedure.

MATERIALS AND METHODS

Patients who had undergone needle knife fistulotomy without successful biliary access were identified over a 3-year period. Primary endpoint was success of repeat ERCP in gaining biliary access without further intervention. Secondary endpoints were repeat ERCP time interval and findings and interventions at repeat ERCP.

RESULTS

Thirty-six patients were identified (mean age 60.2 years; 47% male). ERCP indications were: jaundice 60%, dilated biliary system 32%, choledocholithiasis 35%, gallstone pancreatitis 3%, bile leak 3%. 53% (19 of 36 patients) had a repeat ERCP and 68% (13 of 19) of repeat ERCPs were successful. Median time to repeat ERCP was 6 days (range 1-21 days). Repeat ERCP findings were: choledocholithiasis 46%, pancreatic cancer 15% and cholangiocarcinoma 39%. Interventions at repeat ERCP were as follows: plastic stent insertion 46%, metal stent insertion 39% and balloon trawl 15%.

CONCLUSION

Follow-up ERCP after a short interval is worthwhile in patients for whom initial ERCP and fistulotomy is unsuccessful as biliary access is frequently obtained without further intervention and definitive management is facilitated in the majority of cases.

Suprapapillary needleknife fistulotomy: a safe and effective method for accessing the biliary system

BACKGROUND

Suprapapillary needleknife fistulotomy is performed when standard biliary cannulation methods have failed. However, its role is controversial, with conflicting reports on its use. This study aimed to determine the efficacy and safety of needleknife fistulotomy after failure of conventional cannulation techniques.

METHODS

All patients who underwent needleknife fistulotomy were identified from a single tertiary referral center database prospectively maintained from 1997 to 2007.

RESULTS

A total of 2,603 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) over the 10-year period. Fistulotomy was performed for 352 patients (13.5%), with 317 of these patients (90.1%) experiencing successful biliary cannulation. With the use of fistulotomy, the total cannulation success rate increased from 79.0 to 91.2% (P < 0.0001). Endoscopic management of choledocholithiasis and hepatobiliary malignancy increased from 48.9 to 55.1% (P < 0.001), and from 12.0 to 16.0% (P < 0.001) for all cases. The complication rate was significantly higher for the patients who underwent fistulotomy than for those who did not (4.8% vs. 2.1%; P < 0.001), which can be explained by a higher rate of mild bleeding in the fistulotomy group. However, no significant difference in pancreatitis or perforation between the two groups was observed. In addition, no fatalities occurred after fistulotomy.

CONCLUSION

Suprapapillary needleknife fistulotomy is an effective method for accessing the biliary system after failed standard cannulation. Despite a higher rate of mild bleeding, fistulotomy was not associated with an increased risk of serious complications.

[Access to the biliary tract through trans-pancreatic sphincterotomy]

OBJECTIVE

Several pre-cut procedures have been used in patients with inaccessible bile ducts. Trans-pancreatic sphincterotomy (TS) has been demonstrated to be a valid, but little used technique. We describe our experience with TS with a prospective analysis of its results.

PATIENTS AND METHODS

Twenty patients who underwent TS due to the impossibility of cannulating the biliary tract using routine methods between November 2004 and October 2005 were included. CT-25 sphincteromes (Cook) were used, introducing the tip into the common bile duct or pancreatic duct, performing the cut toward the bile duct, and sectioning the roof of the common bile duct.

RESULTS

We performed 298 ERCP, 176 sphincterotomies and 20 TS (11.3% of sphincterotomies). Cannulation was achieved in 90% of the patients overall and immediate cannulation was achieved in 85%. The percentage of complications was 15% and none were severe. There were no cases of post-ERCP pancreatitis or mortality due to complications.

CONCLUSIONS

TS is an effective technique in gaining immediate access to the biliary tract in a high percentage of patients when access cannot be obtained using routine methods. The risk of complications in not higher than that of other pre-cut techniques.