Clinical Usefulness of the Mucosa-Tracking-Technique (MTT) with the Iso-Tome in Precut Papillotomy

Abstract

Background/Aims: This study was done to evaluate the clinical usefulness of MTT in precut papillotomy using the Iso-Tome, an isolated-tip needle-knife papillotome (which was firstly introduced in Gastrointest Endosc 2005;62:588-591). Methods: From September 2004 to June 2006, there were 59 patients (35 choledocholithiasis, 10 malignancies, 7 pancreatitis, 7 others) who underwent precut papillotomy with the Iso-Tome consecutively when biliary cannulation failed by the conventional method. The intrapapillary (common channel, bile and pancreatic duct) mucosa of the ampulla of Vater (AV) contacted with the isolated-tip of the Iso-Tome was scathelessly preserved on precut papillotomy starting from the orifice of the AV. The intactly exposed intrapapillary mucosa was carefully tracked and classified into four groups; fully exposed and oriented toward the direction of the bile duct (group A) or the pancreatic duct (group B), partially exposed (group C), and submucosa only exposed (group D). Initial success rates of bile duct cannulation (ISRBC), time (minutes) required for bile duct cannulation from placing the Iso-Tome into the orifice of the AV (TBC), and complications were compared between four groups. Results: see table. Summary; (1) ISRBC was 86.4% (51/59) in total and higher in the mucosa-exposed groups (group A, B, C) than in group D, (2) ISRBC was 100% in group B even though primary incision was incorrectly oriented toward the direction of the pancreatic duct, (3) TBC was the shortest in the group A, (4) Complications occurred totally in 6.8% (4/59) and consisted of 4 pancreatitis (3 mild; 1 moderate). There was no difference of complication rates between four groups and all 4 patients with complications were managed medically. Conclusion: It is critical for successful precut papillotomy to expose the intrapapillary mucosa of the AV intactly and sufficiently as possible and then to track the orientation of the exposed intrapapillary mucosa carefully. MTT with the Iso-Tome is a useful method to improve the efficiency of precut papillotomy. Tabled 1 Group A (n = 29) Group B (n = 4) Group C (n = 19) Group D (n = 7) p value Gender (female/male) 8/21 3/1 9/10 5/2 0.07 Age (yrs; mean ± SD) 63.5 ± 16.2 69.8 ± 11.9 67.8 ± 12.1 62.4 ± 14.8 0.65 ISRBC (%) 96.6%(28/29) 100% (4/4) 84.2% (16/19) 42.9% (3/7) 0.002 TBC (minutes;mean ± SD) 4.3 ± 2.8 23.9 ± 10.6 12.4 ± 13.6 16.3 ± 14.4 0.0003 Complications (%) 0% 25% (1/4;1 moderate pancreatitis) 10.5% (2/19; 2 mild pancreatitis) 14.3% (1/7; 1 mild pancreatitis) 0.15 Open table in a new tab