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April 2008, Volume 58, Issue 4

Original Article

Needle Knife Papillotomy for cannulating difficult papilla; Two years experience

Arif R. Siddiqui  ( Patel Hospital, Gulshan-e-Iqbal, Karachi. )
Saad Khalid Niaz  ( Patel Hospital, Gulshan-e-Iqbal, Karachi. )

Abstract

Objective: To evaluate the success rate and complications of precut-papillotomy using a needle knife, for cannulating difficult papilla during Endoscopic retrograde cholangiopancreatography.
Methods: Records of patients requiring a pre-cut with needle knife to access the common bile duct or pancreatic duct during a two year period were analyzed retrospectively. The success rates and complications of needle knife papillotomy were specifically looked for along with the underlying diagnosis.
Results: From January 2005 to December 2006, 515 ERCPs were performed at two private centers in Karachi by a single operator.  Of these 59 patients required needle knife papillotomy to access the common bile duct with a success rate of 95% (56 patients). In 39 cases, CBD was cannulated immediately while in 15, two attempts were required and in 2 cases successful cannulation was possible at the third attempt.
There were three failures. Among these one had a large duodenal diverticulum, one opted for a percutaneous drainage after first attempt and the third was lost to follow up after the first attempt.
No major complications occurred from needle knife pre-cut papillotomy in this series. Three patients (5%) had minor bleeding out of which one required Adrenaline injection for maintenance of haemostasis. Two patients (3.38%), developed mild pancreatitis requiring conservative management. There were no major bleeds, perforations, biliary sepsis or deaths.
Conclusion: Needle-knife papillotomy increases the success of diagnostic and therapeutic procedures during ERCP. In the present series, minimal complications occurred as a result of precut, papillotomy (JPMA 58:195;2008).

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be an accurate and reliable method to evaluate biliary and pancreatic disorders. Cannulating the common bile duct (CBD) is the most important step for successful therapeutic biliary endoscopy. In 10% of the cases CBD is inaccessible by the standard methods of using a cannula or a sphincterotome with various types of wires.1
Needle Knife Papillotomy has been introduced as an alternative method to access the CBD. This involves incising through the wall of the major papilla with an electrocautery needle-knife. Since its introduction, about 25 years back2, it has been used increasingly as a helpful tool for cannulation.3 A number of tertiary referral centers have reported their successful use of this technique for common bile duct cannulation and therapeutic procedures.4 Needle knife papillotomy has proven to be safe in experienced hands5, with minimal reported complications.6 Further, it has been shown that the success rate can be increased, if repeated attempts are made.7
To analyze the utility of needle knife papillotomy (NKP), we retrospectively reviewed our data of ERCP procedures performed over a 2-year period with particular emphasis on the success rates and complications of needle knife papillotomy.

Methods

A retrospective study was done to evaluate the use of Needle knife   papillotomy for gaining access to the biliary or pancreatic channel. A total of 515 ERCPs for various diagnostic and therapeutic indications were performed from January 2005 to December 2006 at two different centers by the same endoscopist. The records of these patients were reviewed looking specifically for the success rates and procedure related complications. The diagnosis of the cases and the therapeutic procedures made possible with the help of needle knife were also noted.
A set protocol was followed in all the patients. The procedures were performed under conscious sedation using Midazolam and Nalbuphine in the majority of cases.  All patients had their INR (International Normalization Ratio) checked and corrected to 1.5 or below and a dose of intra venous antibiotic was given at the time of the procedure. All the patients were monitored in the recovery room for a minimum of one hour post procedure. These patients were followed up in the clinic to evaluate the safety and efficacy of the procedure in one to two weeks.
A needle knife was used as a pre cut technique if cannulation was not possible in the standard way of using a cannula or sphincterotome.  Access to the biliary or pancreatic duct was tried and various therapeutic measures were undertaken. In unsuccessful attempts repeated procedures were advised and if felt necessary referral to the radiologist was made for a PTC.

Results

A total of 515 ERCPs were performed over a two year period. In 59 patients a needle knife papillotomy had to be performed, in an attempt to cannulate the common bile duct (CBD), which makes 11.5% of the group. The overall success rate was 95 %.
In 39 patients (66%), the cannulation was possible in the first attempt, with subsequent therapeutic procedures. Rest of the patients were advised a repeat attempt within a week's time.  One patient with Proximal CBD stricture on CT scan opted to go for PTC drainage instead of a second attempt and one patient was lost to follow up. Eighteen patients followed up for a repeat procedure. Of whom 15 (83%) had a successful second procedure, with therapeutic interventions. In one patient with an intradiverticular papilla no further attempts were made after further extension of the pre cut at second attempt. A third successful attempt was made in two patients, yielding an overall success rate of 94% of repeated procedures.
In the 56 successful cases the commonest cause was found to be a proximal stricture in 22 (39%) cases either post surgical or malignant, followed by distal strictures in 15 (27%). Other diagnoses were choledocholithiasis (8 cases), ampullary growths (5 cases), normal CBD (4 cases); one patient had an external compression due to porta-hepatis lymph nodes and one had a dilated duct but no stones. In the repeated procedures proximal strictures were found in 7 cases and distal strictures in 4 cases. Metallic or plastic stents were placed in strictures and stones were retrieved in choledocholithiasis patients. 
There were no major complications. Two of the patients (3.4%) developed mild pancreatitis which improved with conservative treatment. Three patients (5%) had minor bleeding during the procedure. In two of these, bleeding stopped without any therapeutic interventions while in one patient Adrenaline was injected for haemostasis. All the three patients recovered with no any further bleeding episodes. There was no mortality, perforations or biliary sepsis associated with the procedure in our series.

Discussion

Cannulation of the CBD remains the most important and challenging aspect of diagnostic and therapeutic ERCPS. Even in experienced hands the failure rate of cannulating via the orifice of the papilla approaches 10%.1 Several techniques have therefore been developed to facilitate cannulation of the papilla during endoscopic retrograde cholangiopancreatography (ERCP).8
Since 1981 the pre-cut technique has been used alone or in combination with standard sphincterotomy. It has since emerged as a valuable method, which allows a high success rate for cannulation, with a low complication rate.9
  In this technique the papilla is dissected to expose the bile duct, with the help of a diathermy needle. A sphincterotomy is not usually planned during a pre cut, but it can occur10 and for that reason, some people use the term.  Pre cut sphincterotomy.11
In our retrospective analysis biliary cannulation was successful in the majority of patients by standard way of using a papillotome, which is routinely used in our practice for CBD cannulation and saves cost, time and radiographic exposure.12 This is comparable to studies from various big centers.13 However using  a needle-knife for a pre-cut papillotomy to access the CBD increased our success to 95% which is comparable to most international centres.14,15 It is important to note that although most of our patients (39/59) were successful in the primary session, the remaining of the patients required a second procedure within a week which has shown to increase the success rate.16 Only two patients required a third attempt which was successful with one failure in a patient who had an intradiverticular papilla.17 This shows that patients after precut papillotomy may require repeated procedures although most can be successful in the first attempt. Our success of 94% in those undergoing precut papillotomy is again similar to those reported in the literature.18,19
Pancreatitis has been reported to be the commonest complication of ERCP20, with 10 to 15% being severe.21 The risk is being studied in cases of needle knife papillotomy with conflicting results. Earlier studies had shown increased risk, while more recent studies have proved no additional risk of pancreatitis.22 In fact some authors have concluded that earlier use of needle knife by an expert endoscopist can reduce the risk of Pancreatitis in difficult cannulation.23 In our patients only two developed mild pancreatitis which resolved with conservative management.
Other complications of ERCPs like perforation, bleeding and cholangitis should hypothetically be more with the use of needle knife, but in experienced hands these are not much different.24 Three of our patients had minor bleeding during the procedure, of whom one required adrenaline injection, with no major sequelae.
The procedure related complications and success rates have been attributed to technique related risk factors, including the endoscopist's skill.25 Pre cut technique differs from standard techniques and is more difficult. An endoscopist should have control over even subtle movements of the endoscope and the needle knife. Unfortunately, when used by inexperienced endoscopists, this technique can have disastrous effects, and should therefore be reserved for use by endoscopists with good training and extensive experience, to achieve a high success rate with minimal complications.26
In our study the use of needle knife as a pre cut technique has proven to be effective and safe. It improved the success rate for both diagnostic and therapeutic procedures. Although the complications were significantly low, this method should still be considered as potentially dangerous, and should be employed by personnel with expertise in therapeutic procedures.

References

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