Standard Cannulation versus Fistulotomy for Biliary Access in Endoscopic Retrograde Cholangiopancreatography: Should We Expect the Same Success when Treating Choledocholithiasis?

Abstract

<b><i>Introduction:</i></b> To access the common bile duct in endoscopic retrograde cholangiopancreatography (ERCP), needle-knife fistulotomy (NKF) can be associated with a shorter sphincterotomy compared to standard cannulation. We aimed to compare the success and safety of NKF versus standard cannulation in the treatment of choledocholithiasis. <b><i>Methods:</i></b> A cohort of 379 naïve patients with choledocholithiasis who underwent ERCP between 2005 and 2022 was retrospectively analyzed. The patients were divided into two groups: group A (179 consecutive patients) underwent NKF, while group B (180 patients) received standard biliary access and were matched for stone characteristics and ERCP year. <b><i>Results:</i></b> Stone removal success rate for group A was significantly lower than that for group B in the initial ERCP (82.0% vs. 92.1%, <i>p</i> = 0.003). In group A, success rates for stone removal were 90.2%, 80%, and 29.4% for stone sizes &lt;10 mm, 10 mm–15 mm, and &gt;15 mm, respectively (<i>p</i> &lt; 0.001). In contrast, group B showed success rates of 99.2%, 81.5%, and 71.4% for the same stone size categories (<i>p</i> &lt; 0.001). Pancreatitis occurred in 3.7% of group A and 5.8% of group B patients (<i>p</i> = 0.340). Regression analysis revealed that NKF cannulation, stone size (&gt;10 mm), and having 4 or more stones were associated with lower stone removal success compared to standard cannulation in the initial ERCP (OR 0.34, <i>p</i> = 0.015; stone size 10–15 mm: OR 0.20, <i>p</i> &lt; 0.001; stone size &gt;15 mm: OR 0.05, <i>p</i> &lt; 0.001; 4 or more stones: OR 0.4, <i>p</i> = 0.040). <b><i>Conclusions:</i></b> The removal of common bile duct stones after NKF access, although safe and effective, is less successful than after a standard cannulation, especially at the baseline ERCP.