SUPRAPAPILLARY PUNCTURE OF THE COMMON BILE DUCT FOR SELECTIVE BILIARY ACCESS IN ERCP

Abstract

Background and Rationale :Getting directly into the common bile duct (CBD) is the most important
step for successful therapeutic endoscopic retrograde cholangiopancreatography (ERCP). In 5% - 10%
of cases, the CBD remains inaccessible, necessitating suprapapillary puncture or fistulotomy with a
needle-knife. The aim of this study was to evaluate and compare the safety and efficacy of the
suprapapillary puncture technique using the needle-knife with other methods used for biliary access
after failure of these methods as regard immediate and long term outcomes.
Methods : From December 2008 to December 2009, out of 112 patients who were candidates for
ERCP, 70 patients were selected satisfying the inclusion criteria, they were exposed to clinical
assessment, laboratory and radiological investigations, they were divided according to the technique
used during ERCPinto four groups ; group A (15 patients underwent a suprapapillary puncture or
fistulotomy using the needle-knife), group B (15 patients underwent a precut using the standard pull
sphincterotome), group C (20 patients who underwent a conventional transpapillary wire-guided
cannulation without sphincterotomy), group D (20 patients underwent a conventional transpapillary
wire-guided cannulation with standard sphincterotomy). The cannulation times, success rates and post-
ERCP complications were evaluated and compared among the studied groups.
Results :Seventy patients (33 males and 37 females with a mean ± SD age of 56.3 ± 11.5 years)
underwent ERCP during this period of time. The overall success rate in group A was 93.3%, while in
group B was 86.6%, 85% in group C and 70% in group D. There were no cases of post-ERCP
pancreatitis in group A, while there were one case in group B and C and two cases in group D. The
total incidence of pancreatitis was 5.7%. There were 3 cases of bleeding in group A, while two cases
in group B and C and 4 cases in group D. There was one case of cholangitis in group D. One case of
mortality in group C. Perforation was not occurred in any of the groups.
Conclusion :Suprapapillary needle-knife fistulotomy is an effective method for accessing the biliary
system in expert hands after failed standard cannulation. Despite a higher rate of bleeding, fistulotomy
was not associated with an increased risk of serious complications.
Keywords :Suprapapillary puncture, Common bile duct, Endoscopic retrograde
cholangiopancreatography, Fistulotomy, Needle-knife, Cannulation, Complications.