Benefits and risks of needle-knife papillotomy.

BACKGROUND

The objective of the present investigation was to assess the risks and benefits of pre-cutting with the needle knife at the papilla of Vater and to compare the findings with the results of classic endoscopic sphincterotomy.

METHODS

From January 1973 to December 1993, 2752 endoscopic cutting procedures-biliary or pancreatic sphincterotomy (EST) or needle-knife papillotomy (NKP)-were performed. Since 1981 the pre-cut technique with the needle knife has been used alone or in combination with standard sphincterotomy. Indications, success, and complications of NKP and EST were analyzed retrospectively. To demonstrate changes in indications and technique, the study period was divided into two time periods: period A, 1981 to 1987; and period B, 1988 to 1993.

RESULTS

Between 1981 and 1993, diagnostic or therapeutic access to the biliary or pancreatic duct system was attempted in 2105 patients by means of EST or related procedures (period A 1093 patients; period B 1012 patients). The overall success rate was 95.1% (2001 of 2105). In 694 of 2105 cases (33.0%) an EST was not possible or not attempted and an NKP was performed (period A 31.9%; period B 34.1%). This was successful in 590 of 694 cases (85.2%). The rate of NKP in relation to EST varied depending on the different indications for EST: 22.8% NKP in classic indications like choledocholithiasis and over 40% in newer indications such as chronic pancreatitis. In these novel indications NKP alone was often sufficient, and EST to complete the procedure was not necessary (151 patients). In period B, NKP (63 patients) and EST (23 patients) were also used to achieve endoscopic retrograde imaging of the biliary or pancreatic duct system when primary cannulation was not possible. Visualization was achieved in 81.4% (70 of 86) and pathologic findings were noted in 68.6% (59 of 86). The total complication rate of primary EST was 6.8% (96 of 1411) and 7.3% (51 of 694) for all procedures in which NKP was involved (NS). In period B the complication rate was 4.6% for NKP without subsequent EST and 7.6% for NKP in combination with EST. Compared with the complication rate of primary standard EST (6.1%) there was no statistically significant difference.

CONCLUSIONS

Needle-knife papillotomy increases the success of diagnostic and therapeutic procedures at the papilla of Vater. This pre-cut technique is safe and does not increase the overall complication risk of sphincterotomy.