Department of Gastroenterology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey.
Surg Laparosc Endosc Percutan Tech. 2022 Dec 1;32(6):700-706. doi: 10.1097/SLE.0000000000001123.
Endoscopic retrograde cholangiopancreatography (ERCP) is an important therapeutic tool for many biliary diseases. Selective biliary cannulation is the first step of the treatment process. Needle knife fistulotomy (NKF) and conventional precut sphincterotomy (CPS) are widely used in difficult biliary cannulation. However, there are different results in their effectiveness and safety. This study aimed to compare both methods regarding cannulation success and adverse event profile.
All eligible consecutive patients with naive papillae who underwent biliary ERCP by a single experienced endoscopist over a 3-year period were included retrospectively. The standard cannulation method with a guidewire-loaded sphincterotome was initially used for biliary cannulation in all patients. Cannulation was accepted as difficult in the case of failure of standard cannulation within 5 minutes or despite 5 attempts or insertion of the guidewire to the pancreatic duct 5 times. Three modalities in patients with difficult biliary cannulation were employed according to the structure and configuration of the papillae in addition to unintentional pancreatic cannulation: (1) NKF, (2) CPS, (3) Double guidewire technique or guidewire orientation/precut following pancreatic stenting. Latter was excluded to enable direct comparison between NKF and CPS groups.
A total of 644 patients were recruited. Analyses were performed with 541 patients after the exclusion of 103 patients. Mean (SD) age was 60.4 (18.2) years, and 257 (47.5%) patients were male. While standard cannulation was successful in 366 (67.6%), difficult biliary cannulation was observed in 175 (32.4%) patients. NKF was performed in 101 (57.7%) patients, and cannulation success was 100% in the first ERCP session. In contrast, CPS was performed in 74 (42.3%) patients with a lower cannulation success rate (79.7%) than NKF ( P <0.001). Post-ERCP pancreatitis rate was higher in CPS (9.5%) than NKF group (3.0%, P =0.063). Bleeding and cholangitis were similar in both groups.
In patients with difficult biliary cannulation with appropriate papillary structure and configuration, NKF should be used as the first choice in experienced hands because of high biliary cannulation success and low Post-ERCP pancreatitis risk.
内镜逆行胰胆管造影术（ERCP）是许多胆道疾病的重要治疗手段。选择性胆管插管是治疗过程的第一步。针状刀乳头切开术（NKF）和传统预切开乳头括约肌切开术（CPS）广泛应用于困难的胆管插管。然而，它们的有效性和安全性存在不同的结果。本研究旨在比较两种方法在插管成功率和不良事件谱方面的差异。
回顾性纳入 3 年内由同一位经验丰富的内镜医生进行胆管 ERCP 的所有符合条件的初治乳头患者。所有患者均采用带导丝的括约肌切开刀进行标准胆管插管。如果标准插管在 5 分钟内失败，或者尽管尝试了 5 次，或者导丝插入胰管 5 次，均认为插管困难。对于困难的胆管插管患者，根据乳头的结构和形态，除了意外的胰管插管外，还采用了三种方法：（1）NKF，（2）CPS，（3）双导丝技术或导丝定向/预切开后胰管支架置入。排除后者是为了能够直接比较 NKF 和 CPS 组。
共纳入 644 例患者，排除 103 例患者后，对 541 例患者进行了分析。平均（SD）年龄为 60.4（18.2）岁，257（47.5%）例患者为男性。366 例（67.6%）患者标准插管成功，175 例（32.4%）患者胆管插管困难。101 例（57.7%）患者行 NKF，首次 ERCP 成功率为 100%。相比之下，74 例（42.3%）患者行 CPS，插管成功率（79.7%）低于 NKF（P<0.001）。CPS 组（9.5%）的 post-ERCP 胰腺炎发生率高于 NKF 组（3.0%）（P=0.063）。两组的出血和胆管炎发生率相似。
在具有适当乳头结构和形态的困难胆管插管患者中，在有经验的医生手中，NKF 应作为首选，因为它具有较高的胆管插管成功率和较低的 post-ERCP 胰腺炎风险。
