Suprapapillary fistulosphincterotomy at ERCP: a prospective study.

BACKGROUND AND STUDY AIMS

The role of the needle knife at endoscopic retrograde cholangiopancreatography (ERCP) remains controversial, with conflicting views being held on the value and safety of this device. The aim of the present study was to assess prospectively the value and safety of suprapapillary fistulosphincterotomy (FS) in the endoscopic management of biliary disease.

PATIENTS AND METHODS

Suprapapillary fistulosphincterotomy was performed when biliary cannulation had failed after attempting to opacify the bile duct for 30 minutes, initially with a standard diagnostic cannula and then by further attempts with a tapered cannula. The second indication for suprapapillary fistulosphincterotomy was inability to obtain satisfactory cannulation with the sphincterotome in patients in whom cholangiopancreatography showed pathology requiring endoscopic sphincterotomy. Using this technique, an opening was created into the intraduodenal segment of the common bile duct at a point on the vertical axis 3-5 mm proximal to the papillary orifice. The opening was then cannulated, and extended as required to facilitate clearance of stones or stent insertion.

RESULTS

Of 531 consecutive patients, 83 (16%) underwent suprapapillary fistulosphincterotomy, and biliary cannulation was achieved in 74 of the 83 (89%). If suprapapillary fistulosphincterotomy had not been used, the diagnostic success rate would have fallen from 513 out of 531 (97%) to 451 out of 531 (85%) (P = 0.0001); the clearance rate for duct stones would have fallen from 150 out of 156 (96%) to 130 out of 156 (83%) (P = 0.0003); and successful stent insertion would have fallen from 52 out of 59 (88%) to 38 out of 59 (64%) (P = 0.0044). There were no fatalities following suprapapillary fistulosphincterotomy. Complications occurred in five of the 83 patients (6%) who underwent fistulosphincterotomy, compared with five of the 448 patients (1%) who did not undergo the procedure (P = 0.01).

CONCLUSIONS

Our results suggest that suprapapillary fistulosphincterotomy is a valuable adjunct in the management of biliary disease at ERCP, but, in view of the increased risk of complications, it should be reserved for patients in whom the index of suspicion for biliary disease is high and further endoscopic treatment is likely.