Endoscopic fistulotomy-' The suprapapillary punch ' : A method of access to the bile duct during ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is established as the method of choice to investigate the biliary tree when obstruction is suspected. On rare occasions, the papilla cannot be entered because of anatomical or pathological abnormalities. This report describes endoscopic fistulotomy or the suprapapillary punch that has been carried out at the Foothills Hospital in Calgary, Alberta, on 30 of 623 patients referred for ERCP for conditions causing obstruction of the common bile duct or suspected obstruction of the common bile duct. The following communication also describes the method of suprapapillary punch or endoscopic fistulotomy. Results have been excellent with only one complication, a minor attack of pancreatitis after the procedure. In summary, the 
suprapapillary punch or fistulotomy is a safe and useful method for entering the common bile duct when access by the usual method is impossible.

8(1):33,35.Endoscopic retrograde cholangiopancreatography (ERCP) is established as the method of choice to investigate the biliary tree when obstruction is suspected.On rare occasions, the papilla cannot be entered because of anatomi, cal or pathological abnormalities.This report describes endoscopic fistulotomy or the suprapapillary punch that has been carried out at the Foothills Hospital in Calgary, Alberta, on 30 of 623 patients referred for ERCP for conditions causing obstruction of the common bile duct or suspected obstruction of the common bile duct.The following communication also describes the method of suprapapillary punch or endoscopic fistulotomy.Results have been excellent with only one complication, a minor attack of pancreatitis after the procedure.In summary, the suprapapillary punch or fistulotomy is a safe and useful method for entering the common bile duct when access by the usual method is impossible.Kev Words: Endoscopic fistulotomy , Endoscopic 'f'etrogrcuk cholangiopancreatography (ERCP), SupraJXt.pillaryrunm Fistulotomie endoscopique -«Suprapapillotomie» : methode d'acces au canal biliaire durant la CPER RESUME: La cholangiopancreatographie endoscopique retrograde (CPER) s'est affirmee comme methode de choix pour examiner l'arbre biliaire lorsque l'on sou~onne une obstruction.Dans de rares cas, on ne peut acceder a la caroncule ~ cause d'anomalies anatomiques ou pathologiques.Ce rapport decrit une fisrulotomie endoscopique ou suprapapillotomie qui a ete effectuee au Foothills Hospital de Calgary, en Alberta, chez 30 des 623 patients adresses en consultation pour CPER a cause de problemes obstructifs averes OU sou~onnes du canal biliaire commun.La presentation suivante decrit egalement la methode de la suprapapillotomie ou fistulotomie endoscopique.Les resultats ont ete excellents, avec une seule complication, soit un episode mineur de pancreatite apres l'intervention.
En resume, la suprapapillotomie ou fistulotomie est une methode sure et efficace d'acceder au canal biliaire commun lorsque l'acces par la methode habituelle est impossible.angiopancreatography (ERCP) is well established as the investigation of choice in obstructive biliary disorders (1).Combined with endoscopic papillotomy, it is a powerful tool in the management of obstructing calculi, tumours and strictures of the bile duct.This report describes our experience with endoscopic fistulotomy, a method for gaining access to the bile duct that cannot be entered with the usual techniques of biliary cannulation through the ampulla of Yater.

Department of Medicine, The Unit1ersity of Calgary, Calgary Alberta
In 623 patients referred to the author's institution for ERCP for conditions causing obstruction of the common bile duce, it was impossible to enter the duct in the usual fashion in 30; they therefore underwent endoscopic fistu lotomy or what we have termed 'the suprapapi\lary punch'.All patients presented with typical symptoms of bile duct obstruction, including right upper quadrant pain, abnormal liver enzymes and a dilated common duct on ultrasonic examination.

PATIENTS AND METHODS
After the usual preli minaries, ERCP was performed in an effort to establish the cause of the obstruction and, if possible, to relieve it by papillotomy and related procedures.
Once cannulation was deemed impossible, the needle kn ife (Cook Can-Figure 1) The ampullais openedabotie the arif,ce ada) is punched 2 to 5 mm above the fimbriated end of the common bile duct, that is, the ampullary area or mass (Figure 1).Once bile is seen emanating through the little punched hole, a wireguided papillotome is pushed mto the common bile duct through this hole; alternatively, a catheter is pushed through the bile duct wall into the bile duct and x-rays are taken to confirm entry (Figure 2).If this is successful, a wire is left m the hole, a wire-guided papillotome is placed into the duct and a papillotomy is carried out to the transverse fold that delineates the intra-from the extramural duodenum (Figure 3 ).After chis scone extraction, a stent placement is easily achieved.If necessary, the incision can be extended downwards using a reverse papillotome to include the ampullary mass.
Entry in the duct was not possible via the ampulla, despite repeated attempts, in 30 patients.

RESULTS
In 24 of 30 cases, common duct stones were discovered.A papillotome was advanced over a wire passed through the cannula and a papillotomy was performed, with subsequent removal of the stones by either balloon or basket.
In one case, a short cancer of the 34 Figure 2) A cadieter is inserted through the opening ampulla was discovered.A small incision was made with the papillotome and a stent was placed with relief of the obstruction.Biopsies and brushings confirmed the diagnosis of ampullary carcinoma.
In two cases, no obvious pathology was detected to account for the symp• toms or the dilated bile duct, and the author assumes these were examples of papillary stenosis.Biopsies and brushings in these two cases were negative for malignancy.
In the remaining three cases, the punch failed to access the biliary system, and patients were referred for further investigation and treatment.
One complication occurred in this group of 30 patients; the patient with ampullary carcinoma developed pancreatitis after the procedure, which was short-lived, and he was referred for surgery to extirpate the malignancy.In 12 of the 24 successful cases, the area was reinspected after three to nine months.The fistula was patent in all cases reexammed and repeat cholangiography was normal.

DISCUSSION
Access to the bile duct is usually obtained through the ampulla of Yater via ERCP and, m practiced hands, presents no problem (2).However in 3 to Figure 3) A sr.andard papiUocomy is performed 5% of patients, failure to cannulate is reported (3).Precut papi llotomy has been advocated, but it is stated that the incidence of pancreatitis is significant (4).Combined radiological and endoscopic techniques are also advocated, and are relatively successful in some centres (5).
Endoscopic fisculotomy reportedly 1s another method of entry to the obstructed duct (6,7), with researchers stating that it should only be done if the dilated duct creates a bulge in the wall of the duodenum, a position with which we agree unreservedly.This technique should not be attempted if the above criterion is not present.

CONCLUSIONS
Endoscopic fistulotomy appears to be safe, and through the fistula that is created, procedures (such as papillotomy, scent placement and biopsies) can be carried out safety.In this group of 30 patients, only one complication occurred -mild pancreatitis -which resolved after simple medical management.
In conclusion, in patients in whom entry co the dilated bile duct is impossible with the usual array of techniques, endoscopic fistulotomy or the suprapapillary punch can be employed safely.