title: Failed biliary access following needle knife fistulotomy: is repeat interval ERCP worthwhile?
abstract: OBJECTIVE
  Needle knife fistulotomy is a useful alternative in gaining access to the biliary system when standard cannulation techniques have been exhausted. Where access cannot be achieved following fistulotomy the convention has been to abandon further endoscopic attempts. Recent experience at our center suggests that repeat ERCP is frequently successful. This study assesses the utility of repeat ERCP in a cohort of patients for whom biliary access could not be achieved despite needle knife fistulotomy during the initial procedure.
  
  
  METHODS
  Patients who had undergone needle knife fistulotomy without successful biliary access were identified over a 3-year period. Primary endpoint was success of repeat ERCP in gaining biliary access without further intervention. Secondary endpoints were repeat ERCP time interval and findings and interventions at repeat ERCP.
  
  
  RESULTS
  Thirty-six patients were identified (mean age 60.2 years; 47% male). ERCP indications were: jaundice 60%, dilated biliary system 32%, choledocholithiasis 35%, gallstone pancreatitis 3%, bile leak 3%. 53% (19 of 36 patients) had a repeat ERCP and 68% (13 of 19) of repeat ERCPs were successful. Median time to repeat ERCP was 6 days (range 1-21 days). Repeat ERCP findings were: choledocholithiasis 46%, pancreatic cancer 15% and cholangiocarcinoma 39%. Interventions at repeat ERCP were as follows: plastic stent insertion 46%, metal stent insertion 39% and balloon trawl 15%.
  
  
  CONCLUSIONS
  Follow-up ERCP after a short interval is worthwhile in patients for whom initial ERCP and fistulotomy is unsuccessful as biliary access is frequently obtained without further intervention and definitive management is facilitated in the majority of cases.
authors.affiliation: Department of Gastroenterology, St. Luke's Hospital, Kilkenny, Ireland. dave_kevans@yahoo.co.uk
authors.forename: David
authors.initials: D
authors.lastname: Kevans
authors.forename: Faisal
authors.initials: F
authors.lastname: Zeb
authors.forename: Fergal
authors.initials: F
authors.lastname: Donnellan
authors.forename: Gary
authors.initials: G
authors.lastname: Courtney
authors.forename: Abdur R
authors.initials: AR
authors.lastname: Aftab
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater / Q000601:surgery; D001650:Bile Duct Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery; D001653:Bile Ducts, Intrahepatic / Q000601:surgery; D001662:Biliary Tract Surgical Procedures / Q000379:methods; D002404:Catheterization / Q000379:methods; D018281:Cholangiocarcinoma / Q000000981:diagnostic imaging / Q000601:surgery; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods; D042883:Choledocholithiasis / Q000000981:diagnostic imaging / Q000601:surgery; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009339:Needles; D010190:Pancreatic Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery; D016717:Sphincterotomy, Endoscopic / Q000295:instrumentation / Q000379:methods; D015607:Stents; D013525:Surgical Instruments; D016896:Treatment Outcome