Early and primary needle knife fistulotomy in endoscopic retrograde cholangiopancreatography (ERCP): should this be used more often?

Objective Needle knife fistulotomy (NKF) has traditionally been employed as a second-line technique for biliary access. There is emerging evidence in favour of its early use and as a primary cannulating technique. The aim of this study was to analyse the outcomes of a decade’s worth of experience in early and primary NKF. We present the largest UK single centre, single-operator experience on the use of early and primary NKF in endoscopic retrograde cholangiopancreatography (ERCP). Methods All patients at a tertiary centre who had either primary NKF or early NKF between January 2013 and December 2023 were selected for analysis. The main outcomes of successful biliary cannulation, papilla morphology and complications were analysed. Results A total of 329 cases of early or primary NKF were identified. The successful cannulation rate was 88.5% on the index procedure and 92.7% following repeat attempt. PEP rate was 2.4%, bleeding 0.3% and perforation 0.3%. Haraldsson type 3 papillae were best suited for NKF with 95.6% biliary cannulation rate (p=0.01) and 1.8% pancreatitis (p=0.86). NKF in ERCP for choledocholithiasis had higher rates of biliary cannulation at 93.9% (p<0.001) and lower rates of pancreatitis at 0.9% (p=0.01) compared with other indications. Primary NKF had a 93.5% biliary cannulation rate with no complications. Conclusion Early and primary NKF is safe and effective, especially when used on patients with favourable characteristics. These characteristics include Haraldsson type 3 papillae and stone disease.