Needle knife sphincterotomy: a necessary tool

Needle knife sphincterotomy: a necessary tool To the Editor: We have carefully read the letter by Conio et aP concerning their initial experiences with precut papillotomy (PP). In our opinion, generalizing the results from only 16 patients can be misleading. We would like to present our current experience with pre-cut papillotomy performed during diagnostic and therapeutic ERCP in a group of 62 patients. Our Department of Gastroenterology has performed ERCP since 1984 at an annual frequency of approximately 450 cases per year. Initially, PP was used only in patients with bulging ampullas (impacted stones). Later, we also used the needle knife in patients with normal-appearing papillas. The results in the latter cases are presented. We performed PP in 62 patients with a normal-appearing papilla. As a needle knife, we initially used a modified diathermic snare and later the needle-tipped sphincterotome by Olympus. We used the technique described by Huibregtse et al. 2 and Siegel et al. 3 In 30 patients among this group of62 (48.39%), there was icterus. The remainder of the patients had laboratory evidence of cholestasis. Sonographic dilation of biliary ducts was found in 35 patients. PP technique was successful in allowing entry into the common bile duct (CBD) in 57 of 62 patients (91.93%). In 34 patients, the cannulation was made during the initial PP. In those cases, in which there was initial failure of cannulation, due to edema or bleeding, we successfully repeated the procedure after an interval of 3 days (4 patients) and 7 days (19 patients). The diagnoses in 57 patients in whom there was successful PP were: CBD stones, 38 (66.66%); stenosis of proximal part CBD, 3 (5.26%); stenosis of distal part CBD, 4 (7.02%); cinhosis, 3 (5.26%); and metastasis in liver, 3 (5.26%). In six patients we did not find any anatomical bile duct abnormalities, and we assume that in this group (10.53%) papillary stenosis was due to dysfunctional sphincter of Oddi syndrome. PP was followed by a therapeutic biliary endoscopic procedure in 39 patients (68.42%); 37 patients had concrement extractions and 2 patients had implantation of a biliary endoprosthesis. Bleeding was a direct complication in three patients. In two of these patients, transfusion was not necessary, and they had a successful repeat procedure after 7 days. The third patient required blood transfusion and after cessation of bleeding underwent surgical treatment of choledocholithiasis. We observed one patient in whom following an apparent successful PP with patent images of the biliary tree, there was an episode of acute pancreatitis (4-fold increase of serum amylase and epigastric pain) which resolved within 12 hours. Since 1988, we have used the PP technique during initial fistulotomy and with an "in and downward" directed incision,· which we prefer. This technique was used in 39 patients and was successful in 37 (94.87%). We continue to perform PP without fistulotomy when we encounter a case of small papilla lacking a prominence associated with an intraduodenal segment of common bile duct, the presence of peripapillary diverticula, or other anatomical variants in the papillary region. VOLUME 37, NO.4, 1991

Based on our experiences with the PP technique, we find that PP performed with the needle knife is a necessary accessory technique in ERCP which increases the effectiveness of diagnostic and therapeutic ERCP in icteric as well as non-icteric patients. PP is a safe method as well in patients with a normal-appearing papilla. The methodologic choices for this technique depend upon anatomy. We do not share the opinion that PP with fistulotomy is a very risky procedureI but instead consider that it should be familiar at least to one team member performing ERCP. Igor Katuscak, Marta Horakova, Peter Frlicka, Vlado Straka, Jan Macko,

MD MD MD MD MD

Department of Gastroenterology Surgery Clinic Faculty Hospital Martin, Czechoslovakia

REFERENCES 1. Conio M, Saccomanno S, Aste H, Pugliese V. Precut papillotomy: primum non nocere. Gastrointest Endosc 1990;36:544.

2. Huibregtse K, Katon RH, Tytgat GNJ. Precut papillotomy via fme-needle knife papillotome: a safe and effective technique. Gastrointest Endosc 1986;32:403-5. 3. Siegel JH, Ben-Zvi JS, Pullano W. The needle knife: a valuable tool in diagnostic and therapeutic ERCP. Gastrointest Endosc 1989;35:499-503.

4. Pullano WE, Siegel JH. Needle knife sphincterotomy: a safe diagnostic and therapeutic addition to ERCP [Abstract). Gastrointest Endosc 1988;34:208.

ERCP before laparoscopic cholecystectomy To the Editor: I read with great interest the report by Salky et aLI describing the initial experience with laparoscopic cholecystectomy by the Mt. Sinai Group. Their report is a welcome addition to the rapidly accumulating data on this emerging technique. Moreover, I strongly agree with their principle of preoperative cholangiography in patients with either abnormal liver enzymes or dilated common bile duct (CBD) on ultrasound to rule out choledocholithiasis. Unfortunately, the authors have chosen the wrong imaging modality to view the CBD, namely, intravenous cholangiography (IVC). Although IYC was the state of the art in biliary tract imaging after its introduction in 1953,2 it has been supplanted by ERCP and percutaneous transhepatic cholangiography, and for good reason. The diagnostic error rate for IVC has been reported to be as high as 40% compared with definitive studies. 3 Often the CBD does not opacify with IVC, and even when it does visualize, the study is frequently inadequate to interpret. The lack of sensitivity of IYC is such that it has been recommended that in a post-cholecystectomy patient with a dilated CBD on ultrasound and/or abnormal alkaline phosphatase, ERCP should be performed even in the face of a normal IVC" 495