Department of Gastroenterology, Santa Luzia Hospital - Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal.
Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal; Department of Gastroenterology, Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal; University Center of Gastrenterology - Hospital Cuf Tejo, Lisbon, Portugal.
Hepatobiliary Pancreat Dis Int. 2022 Apr;21(2):175-181. doi: 10.1016/j.hbpd.2021.11.001. Epub 2021 Nov 5.
European Society of Gastrointestinal Endoscopy (ESGE) recommends needle-knife fistulotomy (NKF) as the preferred precut technique in cases when standard cannulation techniques fail. Despite scarce scientific evidence, flat and diverticular papillae are thought not to be ideal for NKF, as they are associated with poor outcomes. The present study aimed to determine the outcomes of the use of NKF in relation to flat and intradiverticular papillae.
This prospective multicenter study enrolled consecutive patients, evidencing naïve flat (group A, n = 49) or diverticular papilla (group B, n = 28), who underwent NKF after failure of standard cannulation techniques. Diverticular morphology was subdivided into intradiverticular (group B1, n = 14) and diverticular border papillae (group B2, n = 14), using a previously validated endoscopic classification of the major papilla. The success of biliary cannulation at initial endoscopic retrograde cholangiopancreatography (ERCP), overall biliary cannulation, overall cannulation time, and the rate of adverse events were assessed in the study.
The initial cannulation rates were 93.9%, 64.3% and 71.4% for group A, B1, and B2, respectively (P = 0.005); overall cannulation rates after a second ERCP were 98.0%, 92.9% and 85.7%, respectively (P = 0.134). Adverse events occurred in 11.7% of patients, with post-ERCP pancreatitis (PEP) being the most common adverse event (10.4%). Although there was a trend towards a higher incidence of PEP in flat papillae, univariate and multivariate analyses did not show any significant relationship between pancreatitis and trainee involvement, papillary morphology, nor overall cannulation time.
Although flat papillae are associated with high success rates of biliary cannulation using NKF, the rate of PEP is not negligible. NKF is feasible in diverticular papillae, but it is associated with a modest success rate in the initial ERCP.
欧洲胃肠道内镜学会（ESGE）建议，在标准插管技术失败的情况下，将针刀切开术（NKF）作为首选的预切开技术。尽管科学证据有限，但人们认为平坦和憩室乳头不适合 NKF，因为它们与不良结果相关。本研究旨在确定与平坦和憩室乳头相关的 NKF 使用结果。
这项前瞻性多中心研究纳入了连续患者，这些患者表现为初次出现平坦（A 组，n=49）或憩室乳头（B 组，n=28），在标准插管技术失败后接受 NKF。使用先前验证的主要乳头内镜分类，将憩室形态分为憩室内（B1 组，n=14）和憩室边缘乳头（B2 组，n=14）。研究评估了初始内镜逆行胰胆管造影（ERCP）时胆管插管的成功率、总体胆管插管率、总体插管时间和不良事件发生率。
A、B1 和 B2 组的初始插管率分别为 93.9%、64.3%和 71.4%（P=0.005）；第二次 ERCP 后的总体插管率分别为 98.0%、92.9%和 85.7%（P=0.134）。11.7%的患者发生了不良事件，其中最常见的不良事件是 ERCP 后胰腺炎（PEP）（10.4%）。尽管平坦乳头的 PEP 发生率有升高趋势，但单因素和多因素分析均未显示胰腺炎与实习医生参与、乳头形态或总体插管时间之间存在任何显著关系。
尽管 NKF 用于胆管插管时平坦乳头的成功率较高，但 PEP 的发生率不容忽视。NKF 适用于憩室乳头，但在初始 ERCP 中的成功率适中。
