Litiasis masiva de la vía biliar intra y extra hepática. Reporte de 2 casos / Massive intra- and extra-hepatic bile duct lithiasis. Report of 2 cases

Resumen La presencia conjunta y masiva de cálculos biliares de la vía biliar, tanto intra como extra hepática, es una rara entidad dentro de la población occidental. A continuación, se presentan 2 casos, los cuales debutan con cuadro clínico de dolor en hipocondrio derecho y con datos clínicos y de laboratorio de obstrucción de la vía biliar, y que mediante estudio de colangio resonancia, se evidencian múltiples litos endoluminales de la vía biliar de manera global, además se muestra del tratamiento de uno de los casos mediante CPRE con evacuación exitosa de los cálculos biliares.

Abstract The joint and massive presence of gallstones from the bile duct, both intra and extra hepatic, is a rare entity within the western population. Two cases are presented below, which debuted with a clinical picture of pain in the right hypo chondrium and with a clinical picture of pain in the right hypochondrium and with clinical and laboratory data of bile duct obstruction, and that by means of a resonance cholangiography study, multiple endoluminal stones of the bile duct are evidenced. Overall, it also shows the treatment of one of the cases by ERCP with successful evacuation of the gallstones.

Peroral cholangioscopy for the evaluation of bile duct stricture in hepatocellular carcinoma on a preoperative examination / Journal of Rural Medicine

Objective: Bile duct tumor thrombosis in hepatocellular carcinoma (HCC) is a relatively rare event with a poor prognosis. Furthermore, bile duct tumor thrombus in HCC may be misdiagnosed when only imaging modalities are used. The efficiency of peroral cholangioscopy (POCS) in evaluating bile duct lesions has been reported.Patients: We present three cases of HCC with bile duct strictures in which POCS was performed as a preoperative evaluation.Results: In these three cases, diagnosing whether the lesion was a bile duct tumor thrombus on CT and endoscopic retrograde cholangiopancreatography was difficult. We performed POCS in three cases and were able to diagnose the presence of bile duct tumor thrombus of HCC, including differentiation from extrinsic compression of the bile duct.Conclusion: POCS for HCC with bile duct features is useful for the preoperative diagnosis of bile duct tumor thrombus, especially in cases where the surgical procedure depends on the presence of bile duct tumor thrombus.

Tratamiento endoscópico de las estenosis poscolescistectomía de la vía biliar / Endoscopic treatment of postcholecystectomy bile duct stenosis

Introducción: La estenosis de la vía biliar es una afección poco frecuente, pero con serias repercusiones en la morbilidad de los pacientes. La gran mayoría ocurre después de la cirugía hepatobiliar: la colecistectomía es la más común de estas cirugías. El reconocimiento temprano y el enfoque multidisciplinario adecuado es la piedra angular para lograr obtener resultados finales óptimos. Objetivo: Describir el tratamiento endoscópico de los pacientes con estenosis poscolescistectomía atendidos en el Instituto de Gastroenterología (Cuba). Métodos: Se realizó un estudio retrospectivo descriptivo de los pacientes con diagnóstico de estenosis biliar poscolescitectomía. Se determinaron variables sociodemográficas, clínicas y endoscópicas de interés. Resultados: Se estudiaron 16 pacientes. Predominaron las mujeres menores de 50 años. El 75 % de los pacientes tenían antecedente de colecistectomía laparoscópica. Las estenosis biliares tipo I y III, según la clasificación de Bismuth, fueron las más usuales. El tratamiento endoscópico mediante colangiografía retrógrada endoscópica (CPRE) con colocación de múltiples prótesis plásticas fue la conducta terapéutica más empleada. Conclusiones: En las estenosis poscolescitectomía los procedimientos endoscópicos se han convertido en el tratamiento de elección, como un procedimiento menos invasivo, con baja morbilidad y mortalidad, con evidentes resultados comparables a los logrados con procedimientos quirúrgicos no endoscópicos(AU)

Introduction: Bile duct stenosis is an infrequent condition, but it seriously affects patient morbidity. The vast majority of cases occur after hepatobiliary surgery, cholecystectomy being the most common of such surgeries. Early recognition and an appropriate multidisciplinary approach are the cornerstones to achieve optimal final results. Objective: Describe the endoscopic treatment of patients with postcholecystectomy stenosis cared for at the Institute of Gastroenterology in Cuba. Methods: A retrospective descriptive study was conducted of the patients diagnosed with postcholecystectomy bile duct stenosis. Determination was made of sociodemographic, clinical and endoscopic variables of interest. Results: A total 16 patients were studied. There was a predominance of women aged under 50 years. 75% of the patients had a history of laparoscopic cholecystectomy. The most common bile duct stenoses were types I and III by Bismuth's classification. The most frequent therapeutic management was endoscopic treatment by endoscopic retrograde cholangiography (ERCP) with placement of multiple plastic prostheses. Conclusions: Endoscopic procedures have become the treatment of choice in postcholecystectomy stenosis. They are less invasive, their morbidity and mortality are low, and their results are comparable to those of non-endoscopic surgical procedures(AU)

Tratamiento endoscópico de las estenosis poscolescistectomía de la vía biliar / Endoscopic treatment of postcholecystectomy bile duct stenosis

Introducción: La estenosis de la vía biliar es una afección poco frecuente, pero con serias repercusiones en la morbilidad de los pacientes. La gran mayoría ocurre después de la cirugía hepatobiliar: la colecistectomía es la más común de estas cirugías. El reconocimiento temprano y el enfoque multidisciplinario adecuado es la piedra angular para lograr obtener resultados finales óptimos. Objetivo: Describir el tratamiento endoscópico de los pacientes con estenosis poscolescistectomía atendidos en el Instituto de Gastroenterología (Cuba). Métodos: Se realizó un estudio retrospectivo descriptivo de los pacientes con diagnóstico de estenosis biliar poscolescitectomía. Se determinaron variables sociodemográficas, clínicas y endoscópicas de interés. Resultados: Se estudiaron 16 pacientes. Predominaron las mujeres menores de 50 años. El 75 por ciento de los pacientes tenían antecedente de colecistectomía laparoscópica. Las estenosis biliares tipo I y III, según la clasificación de Bismuth, fueron las más usuales. El tratamiento endoscópico mediante colangiografía retrógrada endoscópica (CPRE) con colocación de múltiples prótesis plásticas fue la conducta terapéutica más empleada. Conclusiones: En las estenosis poscolescitectomía los procedimientos endoscópicos se han convertido en el tratamiento de elección, como un procedimiento menos invasivo, con baja morbilidad y mortalidad, con evidentes resultados comparables a los logrados con procedimientos quirúrgicos no endoscópicos(AU)

Introduction: Bile duct stenosis is an infrequent condition, but it seriously affects patient morbidity. The vast majority of cases occur after hepatobiliary surgery, cholecystectomy being the most common of such surgeries. Early recognition and an appropriate multidisciplinary approach are the cornerstones to achieve optimal final results. Objective: Describe the endoscopic treatment of patients with postcholecystectomy stenosis cared for at the Institute of Gastroenterology in Cuba. Methods: A retrospective descriptive study was conducted of the patients diagnosed with postcholecystectomy bile duct stenosis. Determination was made of sociodemographic, clinical and endoscopic variables of interest. Results: A total 16 patients were studied. There was a predominance of women aged under 50 years. 75 percent of the patients had a history of laparoscopic cholecystectomy. The most common bile duct stenoses were types I and III by Bismuth's classification. The most frequent therapeutic management was endoscopic treatment by endoscopic retrograde cholangiography (ERCP) with placement of multiple plastic prostheses. Conclusions: Endoscopic procedures have become the treatment of choice in postcholecystectomy stenosis. They are less invasive, their morbidity and mortality are low, and their results are comparable to those of non-endoscopic surgical procedures(AU)

Usefulness of Endoscopic Transpapillary Tissue Sampling for Malignant Biliary Strictures and Predictive Factors of Diagnostic Accuracy

BACKGROUND/AIMS: It is sometimes difficult to distinguish between malignant and benign biliary strictures using imaging studies alone, and pathological diagnosis is necessary. The aim of this study was to determine the usefulness of endoscopic transpapillary tissue sampling and factors predictive of diagnostic accuracy. METHODS: From April 2008 to December 2014, 136 patients underwent endoscopic transpapillary tissue sampling for malignant biliary strictures. The cytological and histological findings were reported as negative, suspicious, or positive. Suspicious and positive findings were defined as pathologically positive. RESULTS: The sensitivity was 65.0% for forceps biopsy, 49.5% for brush cytology, 46.2% for bile aspiration cytology, and 21.9% for endoscopic nasobiliary drainage cytology. The combination of these procedures improved the sensitivity (72.8%). Endoscopic transpapillary tissue sampling was more sensitive for lesions of biliary origin (91.4%) than for extrabiliary lesions (66.3%). In surgical cases, the sensitivity for tumors with an infiltrative growth pattern (53.3%) was significantly lower than for a tumor with an expanding or intermediate growth pattern (87.5%). CONCLUSIONS: Combining procedures can improve diagnostic accuracy. It may be possible to predict the sensitivity of endoscopic transpapillary tissue sampling by evaluating the etiology and tumor growth pattern using preoperative imaging studies.

Endoscopic Management of Anastomotic Strictures after Liver Transplantation

Endoscopic treatment of biliary strictures involving plastic stent placement has been used widely. The use of self-expandable metal stents (SEMSs) has been described for anastomotic strictures following liver transplantation (LT). This review aimed to assess and compare the efficacy of plastic stents with SEMS in LT patients. Information was retrieved regarding technical success, stricture resolution, the number of endoscopic retrograde cholangiography procedures, follow-up, immediate, and late complications. Eight studies involving plastic stents had a stricture resolution rate of 84.5%, with the rates ranging from 63% to 100%. These rates are comparable with the stricture resolution rate of 75% determined from six studies that involved 236 patients who received metal stents and the rates ranged from 53% to 81%. The observed success rate for metal stents used to manage post-LT anastomotic biliary strictures was below the reported rate for multiple plastic stents. Hence, the currently available metal stents should not be offered for the management of post-LT anastomotic biliary strictures.

Intraductal Ultrasonography without Radiocontrast Cholangiogram in Patients with Extrahepatic Biliary Disease

BACKGROUND/AIMS: Intraductal ultrasonography (IDUS) has been performed as an adjunct to endoscopic retrograde cholangiography (ERC) during radiocontrast cholangiography (RC). Radiation exposure during RC poses a health risk to both patients and examiners. We evaluated the feasibility of IDUS without RC in various extrahepatic biliary diseases. METHODS: IDUS was performed with the insertion of an IDUS probe from the papilla of Vater to the confluent portion of the common hepatic duct without fluoroscopy. The technical success rate and procedure-related complications were evaluated retrospectively. RESULTS: Wire-guided IDUS without RC was performed in 105 patients. The mean age was 66.5 years, and 50 (47.6%) were male. The IDUS diagnoses included choledocholithiasis (73, 69.5%), benign biliary stricture (11, 10.5%), choledocholithiasis with biliary pancreatitis (9, 8.6%), bile duct cancer (5, 4.8%), pancreatic cancer (1, 0.9%), and others (6, 5.7%). After IDUS, 66 (62.8%) underwent stone removal, 19 (18.1%) underwent biliary drainage, and 7 (6.6%) underwent brush cytology and biopsy. No significant complications such as perforation or severe pancreatitis occurred. CONCLUSIONS: IDUS without RC was a feasible and safe approach in patients with various extrahepatic biliary diseases. We anticipate a potentially important role of IDUS in various ERC procedures because it lacks the hazards of RC.

Experiencia con el método laparoendoscópico rendez-vous para manejo en un solo tiempo delitiasis vesicular y coledocolitiasis / Experience with laparoendoscopic rendez-vous approach in a single time management of vesicular lithiasis and choledocholithiasis

Se describe la primera experiencia con la utilización del método laparoendoscópico rendez-vous en el manejo de pacientes con litiasis vesicular y alta sospecha de coledocolitiasis en el servicio de Cirugía I del Hospital Universitario de Caracas. Método: Se aplicó el método rendez-vous a 8 pacientes que ingresaron con los diagnósticos de litiasis vesicular y alta sospecha de coledocolitiasis de forma electiva. Resultados: Se realizó la colangiografía intraoperatoria en 7 de 8 pacientes, se confirmó la presencia de coledocolitiasis en cuatro pacientes (57%) y se logró la extracción exitosa de cálculos de la vía biliar en 3 (75%) a través de colangiografía retrógrada endoscópica selectiva sobre guía biliar previa-mente colocada por el cirujano vía transcística. No se reportaron casos de pancreatitis post procedimiento ni casos de litiasis residual en 3 meses de seguimiento. La media de estadía hospitalaria fue de 9,75 días (2 ­ 25 días) y de estadía postoperatoria 2,87 días (1 ­ 7 días). Conclusión: El método rendez-vous se presenta como alternativa terapéutica mínimamente invasiva segura y exitosa para el manejo de pacientes con alta sospecha de coledocolitiasis y litiasis vesicular, trayendo como beneficios la resolución en un tiempo anestésico de ambas patologías, la disminución de las complicaciones de la CPRE y una estancia hospitalaria corta(AU)

We describe the first experience using laparoendoscopic "ren-dez-vous" approach in the management of patients diagnosed with simultaneous cholecystolithiasis and choledocholithiasis at General Surgery Department of "Hospital Universitario de Caracas". Method: Eight patients diagnosed with simultaneous cholecystolithiasis and choledocholithiasis underwent elective laparoendoscopic "rendez-vous" approach. Results: Intraoperative cholangiography confirmed choledocholithiasis in four patients (57%), lithiasis were successfully extracted on three of them (75%) using intraoperative endoscopic retrograde cholangiography after transcystic insertion of a guide wire to reach Vater's papilla. No post endoscopic retrograde cholangiography pacreatitis or residual common ductal stones were reported after a 3 months follow. Mean hospital stay was 9.75 days (2-25 days), and mean post operatory stay was 2.87 days (1-7 days). Conclusion: Rendez-vous approach isa minimal invasive, safe and effective choice available to the management of patients diagnosed with simultaneous cholecystolithiasis and choledocholithiasis, which is performed in a single anesthesia, needs a short hospital stay and lowers ERC complications(AU)

Tumor de la confluencia hiliar hepática (Klatskin) / Hilar Cholangiocarcinoma (Klatskin tumor)

Se revisa el caso clínico de un paciente de 71 años que cursa con una lesión obstructiva del hilio hepático, la evolución clínica, los estudios imagenológicos y los paraclínicos sugieren un tumor de Klatskin, el cual fue manejado por derivación biliar percutánea aliviando la ictericia. En la presente revisión se consideran los factores etiopatogénicos de estos tumores, su nueva clasificación anatómica así como las diversas alternativas del estudio por imágenes, enfatizando en la clasificación de Bismuth-Corlette. Se confrontan las alternativas de paliación, como los diferentes tipos de stents endoscópicos o el abordaje percutáneo, la extensión del drenaje (uni o bilateral). Por último, se revisan los aspectos quirúrgicos y las posibilidades de quimio y radioterapia en estos tumores.

This is a clinical case of a 71-year-old man with an obstructive lesion of the hepatic hilum, the clinical, imaging studies and the lab tests suggest a Klatskin tumor, which was managed by percutaneous biliary drainage to relieve the jaundice. In this review we consider the pathogenetic factors of these tumors, a new anatomic classification and the various alternative imaging studies, emphasizing the Bismuth-Corlette classification. Confront palliative alternatives, such as different types of endoscopic stents or percutaneous approach, drainage extension (uni or bilateral). Finally, we review the surgical aspects and possibilities of chemotherapy and radiotherapy in these tumors.

Biliary Stricture after Adult Right-Lobe Living-Donor Liver Transplantation with Duct-to-Duct Anastomosis: Long-Term Outcome and Its Related Factors after Endoscopic Treatment

BACKGROUND/AIMS: Biliary stricture is the most common and important complication after right-lobe living-donor liver transplantation (RL-LDLT) with duct-to-duct biliary anastomosis. This study evaluated the efficacy and long-term outcome of endoscopic treatment for biliary stricture after LDLT, with the aim of identifying the factors that influence the outcome. METHODS: Three hundred and thirty-nine adults received RL-LDLTs with duct-to-duct biliary anastomosis between January 2000 and May 2008 at Kangnam St. Mary's Hospital. Endoscopic retrograde cholangiography (ERC) was performed in 113 patients who had biliary stricture after LDLT. We evaluated the incidence of post-LDLT biliary stricture and the long-term outcome of endoscopic treatment for biliary stricture. The factors related to the outcome were analyzed. RESULTS: Biliary strictures developed in 121 (35.7%) patients, 95 (78.5%) of them within 1 year of surgery. The mean number of ERCs performed per patient was 3.2 (range, 1 to 11). The serum biochemical markers decreased significantly after ERC (p<0.001). Stent insertion or stricture dilatation during ERC was successful in 90 (79.6%) patients. After a median follow-up period of 33 months from the first successful treatment with ERC, 48 (42.5%) patients achieved treatment success and 12 (10.6%) patients remained under treatment. The factors related to the outcome of endoscopic treatment were nonanastomotic stricture and stenosis of the hepatic artery (p=0.016). CONCLUSIONS: Endoscopic treatment is efficacious and has an acceptable long-term outcome in the management of biliary strictures related to RL-LDLT with duct-to-duct biliary anastomosis. Nonanastomotic stricture and stenosis of the hepatic artery are correlated with a worse outcome of endoscopic treatment.

Usefulness of the Rendezvous Technique for Biliary Stricture after Adult Right-Lobe Living-Donor Liver Transplantation with Duct-To-Duct Anastomosis

BACKGROUND/AIMS: Replacement of a percutaneous transhepatic biliary drainage (PTBD) catheter with inside stents using endoscopic retrograde cholangiography is difficult in patients with angulated or twisted biliary anastomotic stricture after living donor liver transplantation (LDLT). We evaluated the usefulness and safety of the rendezvous technique for the management of biliary stricture after LDLT. METHODS: Twenty patients with PTBD because of biliary stricture after LDLT with duct-to-duct anastomosis underwent the placement of inside stents using the rendezvous technique. RESULTS: Inside stents were successfully placed in the 20 patients using the rendezvous technique. The median procedure time was 29.6 (range, 7.5-71.8) minutes. The number of inside stents placed was one in 12 patients and two in eight patients. One mild acute pancreatitis and one acute cholangitis occurred, which improved within a few days. Inside stent related sludge or stone was identified in 12 patients during follow-up. Thirteen patients achieved stent-free status for a median of 281 (range, 70-1,351) days after removal of the inside stents. CONCLUSIONS: The rendezvous technique is a useful and safe method for the replacement of PTBD catheter with inside stent in patients with biliary stricture after LDLT with duct-to-duct anastomosis. The rendezvous technique could be recommended to patients with angulated or twisted strictures.

The application of 16-slice CT cholangiography with MPR technique in biliary obstruction / 重庆医科大学学报

Objective:evaluate the diagnostic use of 16-slice CT cholangiography with multiplanar reformation(MPR)for the assessment of patients with biliary obstruction.Methods:16-slice CT cholangiography with the MPR technique was performed in 60 patients who were thought to have biliary obstruction.No cholangiographic contrast agent was administered.MRCP in 24 patients,Endoscopic retrograde cholangiopancreatography(ERCP)in 16 patients,and 28 patients underwent biopsy or surgery.The findings on 16-slice CT cholangiography were compared with those of MRCP,ERCP,biopsy or surgery.the surgical-pathological result was regarded as gold standard.Results:The findings were as follows:choledocholithiasi(sn=34),malignant stricture(n=14),benign stricture(n=2),and cholelithiasi(sn=1).A small common bile duct stone in one patient could not be detected by 16-slice CT cholangiography.Two patients with initial diagnoses of small common bile duct stone by 16-slice CT cholangiography were disclosed to have malignant bile ductstricture by reference examination.The accuracy of 16-slice CT cholangiography for the diagnoses of bile duct stones and bile duct stricture were 91.1% and 88.9% respectively.Conclusion:16-slice CT cholangiography with the MPR technique is a fast and non-invasive technique with relatively high accuracy for the diagnoses of the causes of biliary obstruction.

Preoperatively Diagnosed Asymptomatic Early Extrahepatic Bile Duct Cancer / 대한소화기내시경학회지

Cholangiocarcinoma is usually diagnosed at the advanced stage because early symptoms and signs are relatively infrequent. The preoperative diagnosis of early extrahepatic bile duct cancer in common bile duct is uncommon. Also, an extrahepatic bile duct cancer arising from the lower portion of the common bile duct is usually papillary and rarely nodular or sclerosing. We decribe a case, preoperatively diagnosed as early extrahepatic bile duct cancer in lower portion of common bile duct, nodular type on endoscopic retrograde cholangiography. It was incidentally detected by the slight elevation of gamma-glutamyl transpeptidase without any symptoms. An endoscopic retrograde cholangiography showed abrupt narrowing of the intrapancreatic portion of the common bile duct with irregular and nodular filling defect. The lesion was confined to mucosa on the endoscopic ultrasonography. This patient was diagnosed as early extrahepatic bile duct cancer and underwent Whipple's operation. A histopathologic examination of resected specimen revealed to be moderately differentiated adenocarcinoma at stage 1 (T1N0Mo) in the extrahepatic bile duct.

Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected choledocholithiasis / 대한내과학회지

BACKGROUND: Endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiography (ERC) are accurate for the diagnosis of commom bile duct stone. But sometimes, endoscopic sphincterotomy is done unnecessarily in patients with suspected choledocholithiasis. Endoscopic ultrasonography is a promising procedure for the diagnosis of extrahepatic cholestasis due to noninvasiveness and accuracy. We compared the effectiveness of endoscopic ultrasonography with endoscopic retrograde cholangiography in detecting the extrahepatic choledocholithiasis. METHODS: sixty nine patients suspected choledocholithiasis were evaluated using endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiography (ERC). Endoscopic sphincterotomy with instrumental exploration was then done when EUS or ERCP image showed the stones. RESULTS: Choledocholithiasis was confirmed in 53 (76.8%) patients. Seven patients were false negative on ERC, of whom all were true positive on endoscopic ultrasonography. Six patients false negative on ERC had small stone (<5 mm in diameter) in dilated bileduct and one patients had impacted stone on the ampulla of Vater. CONCLUSION: EUS could be an accurate for the diagnosis of choledocholithiasis and may prevent inappropriate invasive exploration of the common bile duct.

Biliary Tract & Pancreas; Effectiveness of Endoscopic Ultrasonography in Detecting the Extrahepatic Choledocholithiasis / 대한소화기내시경학회지

BACKGROUND/AIMS: Ultrasonography is the easiest, fastest procedure for the diagnosis of choledocholithiasis, but the diagnostic failure are mostly because of the intrapancreatic level of this condition and the absence of bile duct dillatation. Endoscopic ultrasonography is a promising procedure for the diagnosis of extrahepatic cholestasis due to noninvasiveness and accuracy in the digestive gas interposition. The aim of this study was to prospectively compare the diagnostic accuracy of endoscopie ultrasonography with abdominal ultrasonography and endoscopic retrograde cholangiography in 66 patients with suspected choledocholithiasis. METHODS: All of the patients had abdominal ultrasonography, endoscopic ultrasonography ~and endoscopie retrograde cholangiography within 72 hours and final diagnosis was determined by endoseopic retrograde cholangiography with sphincterotomy. RESULTS: (l) Choledocholithiasis was confirmed in 45 patients: Thirteen patients had nondilated common bile ducts and 20 patients had stones with diamerer < 1 cm. (2) Endoscopic ultrasonography was more sensitive(95.5%) than abdominal ultrasonography (44.4%: P<0.0001) and similar to endoscopic retrograde cholangiography (97.8%). Specificity was same as 100% in 3 diagnostic tools. (3) Endoscopic ultrasonography was superior to abdommal ultrasonography for the diagnosis of choledocholithiasis with nondilated common bile duct(100% vs 15.3%, P<0.0001) and with less than 1cm sized small stone(100% vs 10.0%, P<0.0001). Endoscopic ultrasonography results did not depend on stone diameter or common bile duct dilatation. CONCLUSIONS: Endoscopic ultrasonography could be an accurate and safe diagnostic tool for the diagnosis of choledocholithiasis and could be promising especially in the cases with difficult cannulation of bile duct and gal1 stone pancreatitis.

The Efficacy and Safety of Needle-Knife Papillotomy for Endoscopic Sphincterotomy and Cholangiography / 대한소화기내시경학회지

BACKGROUND: Conventional endoscopic sphincterotomy with papillotome(CES) is an established method of management for patients with biliary obstruction from various causes. However, an alternative treatment to CES must be considered when antecedent cholangiagraphy is unsuccessful or when cannulatian with the conventional papillotome fails. The needle-knife papillotomy(NKP) is one of the alternative methods to CES. Recently, it has been suggested that NKP can be used to achieve diagnostic cholangiography. But NKP is controversial because results from studies assessing its efficacy and safety are conflicting. The current study was undertaken to assess retrospectively the efficacy and safety of NKP and CES. METHODS: All enrolled patients(CES group 113, NKP group 105) underwent ERCP between September 1993 and August 1996 at Korea Univeisity Guro Hospital. NKP for cannulation was used only when biliary tract disease was suspected but deep canulation failed inspite of several attempts. The efficacy and safety of NKP and CES were evaluated according to the rate of success of performing purposes(removal of common bile duct stones, inser tion of endoscopic nasobiliary drainage or endoprosthesis, treatment of sphincter of Oddi dysfunction, and cannulation) and complications(bleeding, perforation, pancreatitis). RESULTS: 1. Overall success rates of performing purposes were 92.9% in CES group(removal of common bile duct stones 95.2%, insertion of endoscopic nasobiliary drainage or endoprosthesis 84.6%, treatment of sphincter of Oddi dysfunction 100%) and 80.0% in NKP group(removal of common bile duct stone 86.7%, insertion of endoscopic nasobiliary drainage or endoprosthesis 80.6%, treatment of SO dysfunction 100%, cannulation 70.6%). The success rate of CES was significantly higher than that of NKP(p=0.04). 2. The morbidity rate of NKP was 10.5%(8 bleeding cases, 1 perforation case, 2 pancreatitis cases) but was not significantly different from that of rate for CES 8.0%(9 bleeding dases). 19 patients with complications recovered uneventfully with conservative treatment. Only 1 patient(ampullary carcinoma) undertwent operation due to severe bleeding after NKP. There was no procedure-related mortality in both groups. CONCLUSION: NKP is an effective endoscopic tool allowing successful endoscopic sphincterotomy when conventional technique fails. And, in carefully selelected cases, NKP is a useful aid for a successful diagnostic cholangiograph.