“DELAYED” NEEDLE-KNIFE FISTULOTOMY VERSUS STANDARD BILIARY SPHINCTEROTOMY FOR CHOLEDOCHOLITHIASIS: RECURRENCE OF COMMON BILE DUCT STONES AND RATE OF POST-ERCP PANCREATITIS

Aims:

In Common Bile Duct (CBD) stones the access to CBD can be achieved through the papilla orifice followed by endoscopic sphincterotomy (ES), or through a precut fistulotomy (PF) in case of difficult cannulation; the two methods alter papilla anatomy differently, therefore intuitively leading to a different rate of post-ERCP acute pancreatitis (PEP) and stone recurrence. Although some studies suggested that the use of PF might be related to a higher PEP risk, when performed early it isn't. No data on either PEP risk or stones recurrence in patients with CBS stones after PF has been published. The aim was to evaluate CBD stone recurrence, re-intervention and PEP rate after PF versus ES.

Methods:

Retrospective single-center cohort study including patients undergoing for the first time ERCP for CBD stones with PF in case of failed repeated cannulation attempts, matched for sex and age to ES patients randomly extracted from our database. T-test and Fisher's tests were used for continuous and categorical variable comparison. Recurrence probability was calculated with Kaplan-Meier curve, and Cox analysis was employed to calculate hazard ratios (HR).

Results:

85 PF patients were included, with 85 matched controls (mean age 68.7 years, 45.9% males). Compared to ES, patients undergoing PF had a higher rate of PEP (17.2% vs. 8.6%), although not statistically significant. PF patients had the same overall reintervention rate of ES (14.1% vs. 12.9%) with a HR of 1.11 (95% CI 0.49 – 2.50; p = 0.81), but mean time to reintervention was significantly lower (74.9 ± 74.6 vs. 765.6 ± 961.3 days; p < 0.0001). HR of ERCP repetition raised to 2.52 (95% CI 1.02 – 6.24; p = 0.03) if the analysis was therefore limited to the first 1000 days. The only factor associated to ERCP repetition risk was incomplete clearing.

Conclusions:

Risk of PEP was not associated to PF use; nevertheless, the higher rate of PEP after “delayed”PF compared to ES in patients with CBD stones might suggest that this technique should be avoided, possibly in favor of an “earlier” PF. Reintervention risk was significantly higher in the short-term after PF. Therefore, patients undergoing PF should undergo closer follow-up in the first years after ERCP.