Suprapapillary needleknife fistulotomy: a safe and effective method for accessing the biliary system.

BACKGROUND: Suprapapillary needleknife fistulotomy is performed when standard biliary cannulation methods have failed. However, its role is controversial, with conflicting reports on its use. This study aimed to determine the efficacy and safety of needleknife fistulotomy after failure of conventional cannulation techniques. METHODS: All patients who underwent needleknife fistulotomy were identified from a single tertiary referral center database prospectively maintained from 1997 to 2007. RESULTS: A total of 2,603 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) over the 10-year period. Fistulotomy was performed for 352 patients (13.5%), with 317 of these patients (90.1%) experiencing successful biliary cannulation. With the use of fistulotomy, the total cannulation success rate increased from 79.0 to 91.2% (P < 0.0001). Endoscopic management of choledocholithiasis and hepatobiliary malignancy increased from 48.9 to 55.1% (P < 0.001), and from 12.0 to 16.0% (P < 0.001) for all cases. The complication rate was significantly higher for the patients who underwent fistulotomy than for those who did not (4.8% vs. 2.1%; P < 0.001), which can be explained by a higher rate of mild bleeding in the fistulotomy group. However, no significant difference in pancreatitis or perforation between the two groups was observed. In addition, no fatalities occurred after fistulotomy. CONCLUSION: Suprapapillary needleknife fistulotomy is an effective method for accessing the biliary system after failed standard cannulation. Despite a higher rate of mild bleeding, fistulotomy was not associated with an increased risk of serious complications.

Reducing unnecessary outpatient attendances.

PURPOSE: The purpose of this paper is to explore unnecessary outpatient department attendances and to improve efficiency by actively pre-assessing patient charts and pre-specifying management plans before scheduled outpatient visits. DESIGN/METHODOLOGY/APPROACH: All charts were reviewed by a senior clinician two weeks before the clinic and a brief, written management plan made. FINDINGS: A significant reduction in clinic sizes by about 40 per cent can be expected. There was a non-significant increase in the ratio of new to review patients and no significant reduction in waiting lists. RESEARCH LIMITATIONS/IMPLICATIONS: Pre-assessing patient charts leads to cancelling unnecessary outpatient reviews, which can increase outpatient department effectiveness. ORIGINALITY/VALUE: Clinical efficiency is becoming increasingly important. This work describes a simple strategy to improve outpatient department productivity.

Comparison of polyethylene glycol vs sodium picosulphate vs sodium biphosphonate by efficacy in bowel cleansing and patients' tolerability: a randomised trial.

INTRODUCTION: Adequate bowel preparation is necessary for a complete colonoscopy. Polyethylene glycol-electrolyte oral solution (PEG-EOS), sodium picosulphate (SS) and sodium biphosphonate (SP) are the three most commonly used purgative agents. We aimed to determine their efficacy and tolerability compared to each other in a randomised study. METHODS: 313 patients were randomly assigned to receive either PEG-EOS, SS or SP. Patients completed a tolerability score pre-colonoscopy. A cleanliness score was used to document adequacy of bowel preparation. A separate group of patients completed taste scores for the three cathartic agents before and after addition of flavour. RESULTS: PEG-EOS was the worst-tolerated regimen but achieved the highest rates of right colonic cleansing and the lowest rate of incomplete colonoscopies. There were no statistical differences in the rates of rectosigmoid and mid-gut cleansing among the three agents. SS was by far the preferred purgative in the taste assessment study. Addition of flavour increased significantly taste scores for PEG-EOS. CONCLUSION: For adequate bowel cleansing PEG-EOS is the most effective but is the least tolerated and least preferred among patients. Addition of flavour increases significantly patients' acceptance of PEG-EOS.

Rapid biliary stent clogging: two case reports in a 12 year ERCP series.

Rapid biliary stent clogging is poorly documented in the literature. We present two case reports in a 12-year ERCP series and highlight the challenges involved.