3395 Clinical usefulness of primary endoscopic choledochoduodenal fistulotomy in patients with ampullary cancer.

Abstract

Background: In patients with ampullary cancer, the use of endoscopic choledochoduodenal fistulotomy (endoscopic fistulotomy) between the bulged suprapapillary intraduodenal part of the bile duct and the duodenum by needle-knife sphincterotome (NKS) has been reported sporadically as an alternative to failed bile duct cannulation and subsequent endocopic biliary drainage such as biliary stenting or endoscopic sphincterotomy (EST). However, endoscopic fistulotomy can be performed primarily, for both successful biliary drainage and avoidance of recurrent symptoms by possible stent dysfunction or fatal bleeding by EST, in patients especially with suprapapillary bulged, distorted, or friable to bleeding papilla causing failed endoscopic biliary drainage procedures. Aim: To evaluate safety and clinical usefulness of primary endoscopic fistulotomy in patients with ampullary cancer. Methods: Of the 29 patients with ampullary cancer requiring biliary drainage, 13 patients(44.8%) with suprapapillary bulged papilla underwent fistulotomy using NKS (HPC-2, Wilson-Cook Medical Co, NC) alone or followed by upward extension of the fistulous orifice using standard sphincterotome (fistulotomy group). The remaining 16 patients underwent transpapillary stenting with standard techniques (transpapillary stenting group). In both groups, the success rate of bile duct cannulation and effective biliary drainage was assessed and compared. Results: Bile duct cannulation was successful in 12 patients (92.3%) of the fistulotomy group and 13 patients (81.3%) of the transpapillary stenting group (p>0.05), and complication was mild bleeding in 1 patient (7.7%) and cholangitis by stent occlusion in 1 patient (6.3%), respectively (p>0.05). The success rate of initial biliary drainage by endoscopic fistulotomy and transpapillary stenting was 100% and 84.6% (p>0.05), respectively. In 13 patients, biliary drainage was used as a definite treatment and the symptom-free duration was 3.2 months in 7 patients (52.8%)of the fistulotomy group and 3.9 months in 6 patients (37.5%) of the transpapillary stenting group (p>0.05). Conclusions: Endoscopic fistulotomy is as effective as transpapillary stenting in preoperative or palliative decompression of the obstructed bile duct due to the ampullary cancer. Without the need of biliary stenting, this can be employed primarily with safety in selective patitients when bulged suprapapillary intraduodenal part of the bile duct is observed definitely.