Sa1126 Ten Year Data on Needle Knife Fistulotomy in a University Teaching Hospital

Abstract

Introduction: Selective deep biliary cannulation fails in 15-30% of cases even in experienced hands. Repeated and prolonged attempts at cannulation increases risk of post ERCP pancreatitis. Supra papillary needle knife fistulotomy (NKF) is a very useful, yet controversial rescue technique in cases of difficult biliary cannulation. This allows access when cannulation via the orifice cannot be achieved. Concerns have been expressed about its safety. Aims/ Background: The aim of this retrospective study was to evaluate efficacy and safety of NKF by a gastroenterologist, with experience in this technique. Method: This was a single centre study of data from a single operator who uses NKF. A needle knife is used to enter the intramural duct clear of the orifice. The cut is then extended if necessary with a standard sphincterotome. The study was retrospective, looking at data from January 2000 to May 2011, by searching the data available on the endoscopy software ‘ENDOSCRIBE', medical notes and radiology reports. Results: All the patients fulfilled either clinical or radiologic criteria for ERCP. A total of 2639 ERCP were done in this period, with 82.75% (2184/ 2639) performed by the endoscopist who uses NKF. 200 (7.5% of all and 9.1% of the operator's procedures) involved NKF. The age group of the patients ranged from 20 to 96 (mean age 67.5years). The majority 52.5% (105/200) were above 70 years, with only 5% (9/200) being less than 30 years. 63.5% (127/200) were women, 64% (128/200) jaundiced and 70% (140/200) had a dilated common bile duct. Overall biliary cannulation rate in this extremely difficult cohort of patients was 58% (116/200) and 80.17% (93/116) had definitive treatment. NKF was successful, in 82.9% (39/47) of patients with choledocholithiasis who had dilated ducts and in 81.25% (26/32) of strictures with dilated ducts. 0.5% (1/200) had bleeding, mild pancreatitis (3xelevation of amylase) in 3.5% (7/200), necrotising pancreatitis (CT proven) in 1% (2/200) and perforation in 1% (2/200). The overall complication rate, considering each of the above as a separate event, was 15% (15/100) for the first 100 procedures and 6% (6/100) for the latter half of the study group. Conclusion: This is one of the largest data from UK looking at needle knife fistulotomies in ERCP, in difficult to access common bile ducts, often being referred after several previously failed attempts. NKF is a safe and effective procedure in a selected group of patients, as long as it is done by an experienced endoscopist. The learning curve for the procedure is steep and complication rate goes down as the technique improves with experience, which has a pivotal role in the success of the procedure. Gender Distribution