Needle-knife fistulotomy vs. standard biliary sphincterotomy for choledocholithiasis: common bile duct stone recurrence and complication rate

Abstract

Background and study aims With common bile duct (CBD) stones, access to the CBD can be achieved through the papilla orifice followed by standard biliary sphincterotomy (SBS), or through precut fistulotomy (PF) in case of difficult cannulation. The two methods alter papilla anatomy differently, potentially leading to a different rate of stone recurrence. No data have been published on stone recurrence after PF in patients with CBD stones. The aim of this study was to evaluate CBD stone recurrence, reintervention rate after PF versus SBS, and complications. Patients and methods This was a retrospective single-center cohort study including patients undergoing for the first time endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones with PF in case of failed repeated cannulation attempts, matched for sex/age to patients with SBS randomly extracted from our database. T -test and Fisher’s tests were used for continuous and categorical variable comparison. Recurrence probability was calculated with Kaplan–Meier curve. Factors associated with ERCP repetition were evaluated with logistic regression through a Cox’s proportional hazards model. Results Eighty-five patients with PF were included, with 85 matched controls (mean age 68.7 years, 45.9 % males). Overall, patients with PF had the same reintervention rate as those with SBS (14.1 % vs. 12.9 %) with a hazard ratio (HR) of 1.11 (95 % CI 0.49 – 2.50; P = 0.81), but mean time to reintervention was significantly lower (74.9 ± 74.6 vs. 765.6 ± 961.3 days; P < 0.0001), with 100 % of stones recurring within the first year in the PF group vs. 54.5 % in the SBS group ( P = 0.01). The only factor associated with ERCP repetition risk was incomplete CBD clearing. Complications, including pancreatitis, did not differ significantly. Conclusions The reintervention rate was significantly higher in the short term after PF. Therefore, closer follow-up in the first 6 to 12 months after ERCP might be appropriate for patients underoing PF.

Difficult Biliary Cannulation: Should We Always Try a Second Ercp After a Failed Needle-Knife Fistulotomy?

“…Studies showed that NKF is effective in achieving biliary access when difficult biliary cannulation is present (13) . Recent studies defend its early implementation during challenge cases (14) . Another common technique is the needle-knife precut sphincterotomy when the incision is initiated from the papillary orifice.…”

Predictive factors of needle-knife pre-cut papillotomy failure in patients with difficult biliary cannulation

“…Both patient and technique factors were used to identify the predictors associated with the failure of initial NKP 25 . Patient factors were similar to those of difficult biliary cannulation, including age, sex, the diameter of CBD, major papilla status, and indications of ERCP 4 , 5 .…”

“…The indications of ERCP included choledocholithiasis, malignant or benign biliary stricture, bile leak, and suspected Sphincter of Oddi dysfunction. Technique factors, based on few individual reports, were decided on consensus by the authors, including the endoscopists’ experience in NKP, bleeding during NKP, early vs. late pre-cut, and placement of a P-duct stent before NKP 25 – 27 . Bleeding during NKP was defined as bleeding induced by NKP, which could interfere with or eventually cause interruption of NKP (due to blocking of the endoscopic view, Fig.…”

Precut fistulotomy for choledocholithiasis: what about long-term efficacy?

“…Whether precut fistulotomy, by retaining integrity of the distal papillary sphincter, could also act as a potential risk factor for CBD stones recurrence remains unknown. This question is being elucidated in the current issue of Endoscopy International Open by Archibugi et al [9].…”

“…Whether precut fistulotomy, by retaining integrity of the distal papillary sphincter, could also act as a potential risk factor for CBD stones recurrence remains unknown. This question is being elucidated in the current issue of Endoscopy International Open by Archibugi et al [9].In their retrospective study the authors included 85 patients with a diagnosis of choledocholithiasis treated by CBD clearance after PF. These cases were age and sex matched with respective patients fulfilling inclusion criteria but undergoing conventional endoscopic biliary sphincterotomy (BS).…”