0016-5107/80/2601-0013$02.00/0GASTROINTESTINAL ENDOSCOPYCopyright © 1980 by the American Society for Gastrointestinal Endoscopy

Diathermy ERCP

An alternative method for endoscopic retrograde cholangiopancreatography (ERCP)in jaundiced patients

G. C. Caletti, MDGabriella Verucchi, MD

L. Bolondi, MDG. Labo, MD

Bologna, Italy

Standard ERCP was unsuccessful in 5 jaundiced patients. Thisproblem was surmounted in 4 of these patients by endoscopicallyinducing a small choledochoduodenal fistula through which a cath­eter could be inserted and diagnostic cholangiograms were obtained.In the fifth patient, the attempt to create a fistula was insufficient,and the contrast material infiltrated the duodenal wall with transientensuing fever. In subsequent observations, the induced fistulaspromptly healed. The method is offered as an alternative procedurewhen standard ERCP fails.

Endoscopic retrograde cholangiopancreatography (ERCP)has established itself as a routine clinical procedure in thediagnosis of disease in the biliary or pancreatic system.2.6.11

In difficult cases it provides an excellent diagnosticmethod not only for distinguishing between intrahepatic("medical") and extrahepatic ("surgical") jaundice but alsofor detecting the origin of the obstruction.

Because, even in experienced hands, the bile ducts areopacified in only 70% to 85% of procedures,2.6.7-9.11 somepatients may be referred to surgeons without a precisedelineation of the biliary tracts.

In our series of 399 ERCP examinations for biliary disease,10 cases of spontaneous choledochoduodenal fistula werefound near the papilla, at the end of the longitudinal foldof the duodenum on the intramural or on the extramuralportion of the common bile duct. These fistulas werecannulated for cholangiography as described by other au­thors. lO

On the basis of this experience, in order to accomplishERCP in cases of failure or of unsuccessful selective can­nulation, we decided to produce artificial choledocho­duodenal fistulas endoscopically at the lower end of theintramural portion of the common bile duct, 5 to 8 mmproximal to the papilla, where spontaneous choledocho­duodenal fistulas tend to occur.

Apart from our preliminary report3 describing our firstcase, performed with a side-viewing gastroscope (OlympusGFB2) and a thicker diathermic needle (Olympus KD-1L),we know of no previous investigation of this technique.

We can now describe our experience with this method in5 patients with obstructive jaundice and report the evolu­tion of the endoscopically induced fistulas.

METHODS The 5 patients included 3 men and 2 womenwhose ages ranged from 40 to 83 years. All were admittedwith jaundice of unknown origin. In 1 patient ERCP failedbecause the orifice of the papilla was too small to permitintroduction of the cannula; in another patient cannulationwas unsuccessful because the papilla was surrounded bya large intramural portion of the common bile duct andthe orifice was directed toward the lower part of theduodenum; and in the remaining 3 patients only the nor­mal pancreatic ducts were opacified.

A special probe made by us, similar to the diathermiccutter (needle-type, Olympus KD-1L) but of a smallercaliber, was passed through the biopsy channel of theduodenoscope (Olympus jFB3) (Figure 1A). When facingthe intramural portion of the common bile duct, 5 to 8 mmabove the papilla, a small fistula 1 to 1.5 mm in diameterwas created with the diathermic cutter (Figure 18). Chol­angiography was then performed through the small hole(Figure 1C).

RESULTS Cholangiography through the endoscopically in­duced choledochoduodenal fistula was accomplishedwithout complications in 4 patients. A precise diagnosis,confirmed by operation or by necropsy in 3, was obtained( Table I). In 1 patient (case 3) the diathermic cutter was

VOLUME 26, NO.1, 1980

From the Istituto di Clinica Medica e Gastroenterologia della Universita di Bologna,Bologna, Italy. Reprint requests: Dr. Giancarlo Caletti, I Clinica Medica dell' Universita,

Policlinico S. Orsola, Bologna, Italy.

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Figure 1. A, Olympus }F83with special diathermicneedle-type cutter catheter. B,Needle is inserted to inducefistula above the normal pa­pilla. C, The resulting riJdio­graph shows a cancer in thehead of the pancreas obstruct­ing the common bile duct; thepancreatic duct is normal.

evolution of the fistuladefinitive diagnosisstandard ERCPpatient age/sex

Table I.Data pertaining to 5 patients in whom cholangiography was obtained by means of endoscopically induced fistulas.

ERCP through endoscopic com plica-fistu la tions

83/F cannulation failed

2 40/M

3 62/M normal pancreaticduct opacified

4 81/M

5 71/F

cancer of the head of none confirmed at necropsy not seen after 15 daysthe pancreas

normal bile and pan- none hepatitis healing ulcer at 10 days;creatic ducts not seen after 60 days

failure fever, 5 choledocholithiasis at not seen after 8 daysdays operation

cancer at the porta he- none confirmed at necropsy not seen after 11 dayspatis

cancer of the head of none confirmed at opera- not seen after 7 daysthe pancreas tion

not pushed deeply enough to reach the common bile ductlumen, and the contrast medium was injected in the duo­denal submucosa. Fever subsided after 5 days of antibiotictherapy; common bile duct stones were found at lateroperation.

Careful exploration of the duodenum during operation(2 cases) or at necropsy (2 cases) showed no signs of theendoscopically induced fistulas. In case 2, endoscopy 10days later showed, at the site of the fistula, a very smallhealing ulcer. At endoscopy 2 months later, the ulcer washealed.

CONCLUSIONS The site of the fistula must be in theintramural portion of the common bile duct not more than5 to 8 mm above the papilla to prevent retroperitonealperforation. The penetration of the diathermic needle must

be deep enough to reach the common bile duct lumen soas to avoid leakage of the contrast medium in the duodenalsubmucosa. The fistula should be as small as possible toallow prompt healing of the duodenal mucosa.

We think that 2 or 3 attempts to reach the common ductlumen with the diathermic needle can be done with min­imal risk. In 5 cases we had 1 failure and only 1 minorcomplication, thus affirming the feasibility of the methodin difficult cases of jaundice, when visualization of the bileducts is essential and selective cannulation has been un­successful. In addition, the described technique permitsthe insertion, through the fistula, of a papillotomy knife inorder to perform an endoscopic lithotomy when endo­scopic papillosphincterostomy is unsuccessful, and for pre­operative internal bile drainage in cases of papillary can­cer.4 ,13

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