Is peripapillary choledochoduodenal fistula an indication for endoscopic sphincterotomy?

Background: Most patients with a peripapillary choledochoduodenal fistula u ndergo fistulotomy by endoscopic sphincterotomy for the treatment of bile d uct stones. However, whether sphincterotomy should be performed in patients with the fistula but without stones is controversial. Methods: Among 165 patients in whom a benign peripapillary choledochoduoden al fistula was diagnosed at ERCP, the clinical outcome was retrospectively analyzed and compared between those who underwent fistulotomy by endoscopic sphincterotomy (group 1) and those whose fistula was left untreated (group 2), All patients with hepatolithiasis, residual stones, biliary diversion, or transduodenal papilloplasty were excluded (32, leaving 133), Fistulas w ere divided into types I and II according to the location of the fistula (I keda classification). Results: Follow-up data collected during a median period of 124 months were available for 127 of 133 patients (95%), 76 in group 1 and 53 in group 2, Late complications were bile duct stone recurrence (17 patients), acute cho langitis (7 patients), and biliary carcinoma (2 patients). The incidence of stone recurrence was not significantly different between the 2 groups (p = 0.1). In group 2, 4 patients (8%) with an untreated type II fistula had 1 to 3 episodes of presumed reflux cholangitis, which resolved quickly with c onservative treatment. Conclusions: Endoscopic sphincterotomy is not always necessary for peripapi llary choledochoduodenal fistulas if bile duct stones are absent because re flux cholangitis is a relatively rare complication that can be easily manag ed.