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Management of Common Bile Duct Stones in Cirrhotic Patients with Coagulopathy: A Comparison of Supra-Papillary Puncture and Standard Cannulation Technique

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Abstract

Background and Study Aims

Bleeding is not uncommon following endoscopic sphincterotomy. Supra-papillary puncture (SPP) might be safer than standard cannulation (SC) techniques in patients with coagulopathy. The aim of the study was to compare the safety and effectiveness of SPP and SC.

Patient and Methods

This was a prospective case control intervention study. Decompensated cirrhotic patients with coagulopathy and choledocolithiasis underwent SC and SPP methods for biliary access.

Results

One hundred five patients (56 [53.3%] men, mean [SD] age 56 [15.8]) underwent ERCP. SC and SPP were performed in 63 and 42 patients, respectively. Biliary access was achieved in 56/63 (89%) and 40/42 (95%) of patients undergoing SC and SPP, respectively (P = 0.13; 95% CI [−0.16; 0.03]). Complications occurred in 10/63 (15.8%) patients undergoing SC and 5/42 (11.9%) SPP (P = 0.28; 95% CI [−0.17, 0.16]). Five (7.9%) and two (3.2%) episodes of post-sphincterotomy bleeding was seen in the SC and SPP groups, respectively (P = 0.36; 95% CI [−0.16, 0.05]). In contrast, three (4.8%) episodes of pancreatitis were seen in the SC and none in the SPP group (P = 0.05; 95% CI [0.001; 0.004]). A cost-effectiveness analysis demonstrated that SPP is an acceptable alternative at an ICER of US$ 5,974.92 per additional successful procedure.

Conclusion

SPP is a safe and effective technique for the management of common bile duct stones in decompensated cirrhotic patients. Conditional to the willingness-to-pay and to the local ERCP-related costs, SPP is also a cost-effective alternative to the SC methods. SPP is associated with a lower rate of complications but larger studies to validate these findings are necessary.

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Abbreviations

ERCP:

Endoscopic retrograde cholangiopancreatography

SC:

Standard cannulation

SPP:

Supra-pappilary puncture

NKS:

Needle knife sphincterotomy

PT-INR:

Prothrombin time-international normalized ratio

CBD:

Common bile duct

BS:

Biliary sphincterotomy

CI:

Confidence interval

SD:

Standard deviation

CT:

Computer tomography

ACER:

Average cost-effectiveness ratio

ICER:

Incremental cost-effectiveness ratio

WTP:

Willingness to pay

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Conflict of interest

Everson Artifon holds a patent for the Artifon Catheter (Scitech, Goiânia, Brasil). Drs Dayse Aparicio, Renato Baracat, Christiano M. Sakai, Ruel T. Garcia, Decio S Couto, Todd H Baron and Ms Vanessa Teich have no conflict of interest or financial ties to disclose. Dr Eduardo B. da Silveira is on the speakers’ bureau for Genentech, Inc. The conduct of this investigation and the preparation of the manuscript were not supported by any private or public grant. Dr Everson Artifon holds a patent for the Artifon Catheter (Scitech, Goiânia, Brasil) and Dr Eduardo da Silveira is on the speaker’s bureau for Genentech, Inc..

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Authors and Affiliations

  1. The Hospital Ana Costa, Santos, SP, Brazil

    Everson L. A. Artifon, Dayse Aparicio, Christiano M. Sakai & Decio S. Couto

  2. The Hospital Estadual de Sapopemba, University of São Paulo School of Medicine, São Paulo, Brazil

    Everson L. A. Artifon, Jonas Takada & Renato Baracat

  3. San Jose Gastroenterology (SJGI), San Jose, CA, USA

    Eduardo B. da Silveira & Ruel T. Garcia

  4. MedInsight, Rio de Janeiro, Brazil

    Vanessa Teich

  5. 800 High School Way, Mountain View, CA, 94041, USA

    Eduardo B. da Silveira

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  1. Everson L. A. Artifon
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Correspondence to Eduardo B. da Silveira.

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Artifon, E.L.A., da Silveira, E.B., Aparicio, D. et al. Management of Common Bile Duct Stones in Cirrhotic Patients with Coagulopathy: A Comparison of Supra-Papillary Puncture and Standard Cannulation Technique. Dig Dis Sci 56, 1904–1911 (2011). https://doi.org/10.1007/s10620-011-1593-2

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  • DOI: https://doi.org/10.1007/s10620-011-1593-2

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