Introduction
Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the treatment of choledocholithiasis. The key step for successful ERCP is selective biliary cannulation, however this fails in about 5-35% of cases. Pre-cut techniques emerged as a rescue for access to the biliary tract. As the length of biliary sphincterotomy after a fistulotomy (NKF) is shorter compared to standard cannulation, there is a theoretical possibility that treatment success will be lower when access is performed by NKF.
In this study, we intend to compare the efficacy and safety of biliary calculi removal between accesses by fistulotomy and standard cannulation.
Aims & Methods
Retrospective cohort study of 379 consecutive patients who underwent ERCP for choledocholithiasis between 2005 and 2022. Patients were selected from a prospective database and allocated into two groups (sample size assuming an effect size of 10%).
179 consecutive patients with choledocholithiasis who underwent NKF after failed cannulation (Group A), compared with 180 patients who underwent standard cannulation (Group B), adjusted for year of ERCP, stone size and number of stones.
Demographic data related to the procedure, adverse effects and the need for a new ERCP were evaluated.
Results
379 patients, 59.1% women, mean age 75.10 (26-97) years. Overall success rate of 87.07% on the CPRE index. 56 patients repeated ERCP with a success rate of 97.89%.
The success rate in group A was significantly lower compared to group B (p<0.003). Adverse events occurred in 6.60% of patients and did not differ significantly between the two techniques (p=0.307). Pancreatitis occurred in 3.7% of patients in group A and 5.1% in group B (p=0.340).
In the regression analysis (table 6) NKF cannulation was associated with a lower stone removal success rate compared with standard cannulation in the initial ERCP (odds ratio [OR] 0.34; 95% CI: 0.14-0.81; p=0.015). Stone size (10-15mm and >15mm) and having 4 or more stones were also predictors for a lower rate of stone removal in the initial ERCP (stone size 10-15 mm: OR 0.20, p=0.000; stone size >15 mm: OR 0.05, p=0.000; 4 or more stones: OR 0.4, p=0.040, respectively).
Conclusion
NKF is a rescue and expertise demanding technique, emerging has a savage approach when standard cannulation fail. However, was less effective than standard cannulation in the treatment of choledocholithiasis. Complications were similar in both groups.
References
- Buxbaum JL, Abbas Fehmi SM, Sultan S, Fishman DS, Qumseya BJ, Cortessis VK, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc [Internet]. 2019 Jun 1 [cited 2022 Sep 16];89(6):1075. Available from: /pmc/articles/PMC8594622/
- Livia Archibugi A, Mariani A, Capurso G, Traini M, Chiara Petrone M, Rossi G, et al. Needle-knife fistulotomy vs. standard biliary sphincterotomy for choledocholithiasis: common bile duct stone recurrence and complication rate. Endosc Int Open [Internet]. 2019 Dec [cited 2022 Sep 7];07(12):E1733–41. Available from: http://www.thieme- connect.com/products/ejournals/html/10.1055/a-1024-3789
- Al-Haddad M. ERCP for common bile duct stone extraction: Sphincterotomy, balloon dilation, or both? Vol. 21, Saudi Journal of Gastroenterology. Medknow Publications; 2015. p. 181–2.
- Testoni PA, Mariani A, Aabakken L, Arvanitakis M, Bories E, Costamagna G, et al. Electronic reprint
for personal use Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. 2016 [cited 2022 Sep 7]; Available from: http://dx.doi.org/ - Ryozawa S, Itoi T, Katanuma A, Okabe Y, Kato H, Horaguchi J, et al. Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy. Digestive Endoscopy. 2018 Mar 1;30(2):149–73.