Is peripapillary choledochoduodenal fistula an indication for endoscopic sphincterotomy?
BACKGROUND
Most patients with a peripapillary choledochoduodenal fistula undergo fistulotomy by endoscopic sphincterotomy for the treatment of bile duct stones. However, whether sphincterotomy should be performed in patients with the fistula but without stones is controversial.


METHODS
Among 165 patients in whom a benign peripapillary choledochoduodenal fistula was diagnosed at ERCP, the clinical outcome was retrospectively analyzed and compared between those who underwent fistulotomy by endoscopic sphincterotomy (group 1) and those whose fistula was left untreated (group 2). All patients with hepatolithiasis, residual stones, biliary diversion, or transduodenal papilloplasty were excluded (32, leaving 133). Fistulas were divided into types I and II according to the location of the fistula (Ikeda classification).


RESULTS
Follow-up data collected during a median period of 124 months were available for 127 of 133 patients (95%), 76 in group 1 and 53 in group 2. Late complications were bile duct stone recurrence (17 patients), acute cholangitis (7 patients), and biliary carcinoma (2 patients). The incidence of stone recurrence was not significantly different between the 2 groups (p = 0.1). In group 2, 4 patients (8%) with an untreated type II fistula had 1 to 3 episodes of presumed reflux cholangitis, which resolved quickly with conservative treatment.


CONCLUSIONS
Endoscopic sphincterotomy is not always necessary for peripapillary choledochoduodenal fistulas if bile duct stones are absent because reflux cholangitis is a relatively rare complication that can be easily managed.
Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
T
T
Ohtsuka
M
M
Tanaka
K
K
Inoue
T
T
Nabae
S
S
Takahata
K
K
Yokohata
K
K
Yamaguchi
K
K
Chijiiwa
S
S
Ikeda
D000328:Adult; D000368:Aged; D001658:Biliary Fistula / Q000175:diagnosis / Q000601:surgery*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods; D003137:Common Bile Duct Diseases / Q000175:diagnosis / Q000601:surgery*; D004378:Duodenal Diseases / Q000175:diagnosis / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007412:Intestinal Fistula / Q000175:diagnosis / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D012016:Reference Values; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D016717:Sphincterotomy, Endoscopic / Q000379:methods*; D016896:Treatment Outcome