Journal Article

P218 Needle knife fistulotomy (NKF) is safe and effective in endoscopic retrograde cholangiopancreatography (ERCP)

Ding, Michael, Prawiradiradja, Roderick, Hebbar, Srisha, Yau, Chia Chuin, Lam, Wai Liam

2024

Overview

IntroductionERCP carries risks of pancreatitis, perforation and bleeding. Extensive studies have been carried out in a bid to reduce these risks and to modify procedural related risk factors to minimise the risk of pancreatitis. One of these methods is utilising the needle knife fistulotomy (NKF) early into gaining biliary access.MethodsAll the cases with NKF, either early or primary, during ERCP by a single operator over a ten-year period from January 2013 to December 2023 were identified. The notes and endoscopy reports were reviewed for:rate of biliary cannulation in initial ERCP and subsequent attempts for failed procedures following NKFpapillary morphology (according to Haraldsson classification) and associated biliary cannulation ratecomplication rate of ERCP where NKF was attemptedResultsThere were 329 cases of ERCP had NKF done by a single operator. There was 298 cases of early NKF and 31 cases of primary NKF. The overall biliary cannulation rate was 88.5% (n=291) on first attempt ERCP with NKF. Among the unsuccessful first ERCPs (n=38), 17 patients were brought back for re-attempt ERCP and success rate was 82.4% (n=14). The cumulative biliary cannulation rate is 92.7% (n=305). The success rate was the highest in bulged papillae (Haraldsson Type 3) at 96.5% with the lowest complication rate at 1.8%, all of which were pancreatitis. There were 31 cases of primary NKF with 93.5% (n=29) biliary cannulation with no complications. Most cases of primary NKF was done on bulged papilla (n=19) all of which were successful in biliary cannulation. The complication rate of NKF was 3.0% (n=10). Post-procedure bleeding was at 0.3% (n=1) and 0.3% (n=1) for perforation. The rate of pancreatitis was 2.4% (n=8). The mortality rate in this study was 0.3% (n=1) from severe pancreatitis.ConclusionsIn difficult ERCP, NKF is effective in in experienced hands, as evidenced by 88.5% biliary cannulation rate on first attempt. After a failed initial ERCP, repeat ERCP should be re-considered as supported by 82.4% success rate on second ERCP following initial NKF, alongside a cumulative success rate of 92.7%. In suitable cases, primary NKF should be considered as there is a 93.5% success rate and no complications in our small group of patients. Analysis of papillary morphology showed that bulged papillae (Haraldsson Type 3) had the most success with 96.5% cannulation rate and 1.8% complication rate, all of which were pancreatitis. NKF is a safe modality in experienced hands with low rates of complications (3.0%) and specifically pancreatitis (2.4%).

• Publisher: BMJ Publishing Group LTD
• Subject: Bleeding / Cannulation / Endoscopy / Morphology / Pancreatitis / Papillae / Risk factors / Success