Endoscopic Sphincterotomy

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Endoscopic Sphincterotomy

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Endoscopic biliary sphincterotomy was first reported in 1974. Approximately 150,000 patients undergo endoscopic biliary sphincterotomy in the United States each year. Sphincterotomy is a complex procedure that incorporates the use of endoscopic as well as fluoroscopic guidance. The technique involves deep cannulation of the bile duct followed by severance of the sphincter of Oddi with the electrocautery. This topic focuses on preparation for, as well as the technique involved in, endoscopic biliary sphincterotomy.

The primary indications for endoscopic sphincterotomy include the following:

Endoscopic sphincterotomy has been used in conjunction with endoscopic balloon dilatation in the treatment of choledocholithiasis. [1]

Endoscopic sphincterotomy has been employed in the treatment of postcholecystectomy abdominal pain potentially attributable to type III (without elevated biochemical markers or CBD dilation) sphincter of Oddi dysfunction. However, the EPISOD (Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction) study, which assessed 103 such patients with little or no objective evidence of biliary obstruction, found endoscopic sphincterotomy to be no better than sham treatments in this setting. [2]

Contraindications for endoscopic sphincterotomy include the following:

Park et al carried out a meta-analysis aimed at assessing the relative efficacy of various endoscopic techniques for removal of CBD stones, including endoscopic sphincterotomy, endoscopic papillary balloon dilatation (EPBD), and endoscopic sphincterotomy with balloon dilatation (ESBD). [3] ​ They noted the following:

Ho S, Rayzan D, Fox A, Kalogeropoulos G, Mackay S, Hassen S, et al. Endoscopic sphincterotomy with sphincteroplasty for the management of choledocholithiasis: a single-centre experience. ANZ J Surg. 2017 Sep. 87 (9):695-699. [Medline].

Cotton PB, Pauls Q, Keith J, Thornhill A, Drossman D, Williams A, et al. The EPISOD study: long-term outcomes. Gastrointest Endosc. 2018 Jan. 87 (1):205-210. [Medline].

Park CH, Jung JH, Nam E, Kim EH, Kim MG, Kim JH, et al. Comparative efficacy of various endoscopic techniques for the treatment of common bile duct stones: a network meta-analysis. Gastrointest Endosc. 2018 Jan. 87 (1):43-57.e10. [Medline].

Johlin FC, Tucker RD, Ferguson S. The effect of guidewires during electrosurgical sphincterotomy. Gastrointest Endosc. 1992 Sep-Oct. 38 (5):536-40. [Medline].

O’Brien JW, Chen SL, Connolly R, Libby ED. Current induction in a fiberglass guidewire compared to conventional wires during simulated papillotomy. Gastrointest Endosc. 1997 Jun. 45 (6):493-7. [Medline].

Sherman S, Uzer MF, Lehman GA. Wire-guided sphincterotomy. Am J Gastroenterol. 1994 Dec. 89 (12):2125-9. [Medline].

Elta GH, Barnett JL, Wille RT, Brown KA, Chey WD, Scheiman JM. Pure cut electrocautery current for sphincterotomy causes less post-procedure pancreatitis than blended current. Gastrointest Endosc. 1998 Feb. 47 (2):149-53. [Medline].

Haag R, Cuschieri A. Recent advances in high-frequency electrosurgery: development of automated systems. J R Coll Surg Edinb. 1993 Dec. 38 (6):354-64. [Medline].

Kohler A, Maier M, Benz C, Martin WR, Farin G, Riemann JF. A new HF current generator with automatically controlled system (Endocut mode) for endoscopic sphincterotomy–preliminary experience. Endoscopy. 1998 May. 30 (4):351-5. [Medline].

Norton ID, Petersen BT, Bosco J, Nelson DB, Meier PB, Baron TH, et al. A randomized trial of endoscopic biliary sphincterotomy using pure-cut versus combined cut and coagulation waveforms. Clin Gastroenterol Hepatol. 2005 Oct. 3 (10):1029-33. [Medline].

Perini RF, Sadurski R, Cotton PB, Patel RS, Hawes RH, Cunningham JT. Post-sphincterotomy bleeding after the introduction of microprocessor-controlled electrosurgery: does the new technology make the difference?. Gastrointest Endosc. 2005 Jan. 61 (1):53-7. [Medline].

Kogure H, Tsujino T, Isayama H, Takahara N, Uchino R, Hamada T, et al. Short- and long-term outcomes of endoscopic papillary large balloon dilation with or without sphincterotomy for removal of large bile duct stones. Scand J Gastroenterol. 2014 Jan. 49 (1):121-8. [Medline].

Forbes A, Cotton PB. ERCP and sphincterotomy after Billroth II gastrectomy. Gut. 1984 Sep. 25 (9):971-4. [Medline]. [Full Text].

Al-Kawas FH, Geller AJ. A new approach to sphincterotomy in patients with Billroth II gastrectomy. Gastrointest Endosc. 1996 Mar. 43 (3):253-5. [Medline].

Liu F, Wang GY, Li ZS. Cap-assisted hemoclip application with forward-viewing endoscope for hemorrhage induced by endoscopic sphincterotomy: a prospective case series study. BMC Gastroenterol. 2015 Oct 15. 15 (1):135. [Medline].

Kumbhari V, Sinha A, Reddy A, Afghani E, Cotsalas D, Patel YA, et al. Algorithm for the management of ERCP-related perforations. Gastrointest Endosc. 2016 May. 83 (5):934-43. [Medline].

Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996 Sep 26. 335 (13):909-18. [Medline]. [Full Text].

Freeman ML. Adverse outcomes of ERCP. Gastrointest Endosc. 2002 Dec. 56 (6 Suppl):S273-82. [Medline].

Ikarashi S, Katanuma A, Kin T, Takahashi K, Yane K, Sano I, et al. Factors associated with delayed hemorrhage after endoscopic sphincterotomy: Japanese large single-center experience. J Gastroenterol. 2017 Dec. 52 (12):1258-1265. [Medline].

Langerth A, Sandblom G, Karlson BM. Long-term risk for acute pancreatitis, cholangitis, and malignancy more than 15 years after endoscopic sphincterotomy: a population-based study. Endoscopy. 2015 Dec. 47 (12):1132-6. [Medline].

Elmunzer BJ, Scheiman JM, Lehman GA, et al, U.S. Cooperative for Outcomes Research in Endoscopy (USCORE). A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med. 2012 Apr 12. 366 (15):1414-22. [Medline]. [Full Text].

[Guideline] Dumonceau JM, Andriulli A, Elmunzer BJ, Mariani A, Meister T, Deviere J, et al. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – updated June 2014. Endoscopy. 2014 Sep. 46 (9):799-815. [Medline]. [Full Text].

Priya A Jamidar, MD, FACG, FASGE Professor of Medicine, Director of Endoscopy, Associate Section Chief, Section of Digestive Diseases, Yale University School of Medicine

Disclosure: Received honoraria from Boston Scientific for speaking and teaching; Received honoraria from Olympus America for speaking and teaching.

Alejandro L Suarez, MD Clinical Instructor of Medicine, Fellow in Advanced Interventional Endoscopy (EUS & ERCP), Division of Gastroenterology, Yale University School of Medicine

Alejandro L Suarez, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Medical Student Association/Foundation, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Jason E Kinzel, MD Fellow in Gastroenterology, Department of Digestive Diseases, Yale-New Haven Hospital, Yale University School of Medicine

Jason E Kinzel, MD is a member of the following medical societies: American Medical Association, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Medscape Reference thanks Dawn Sears, MD, Associate Professor of Internal Medicine, Division of Gastroenterology and Hepatology, Scott and White Memorial Hospital; and Dan C Cohen, MD, Fellow in Gastroenterology, Scott and White Hospital, Texas A&M Health Science Center College of Medicine, for assistance with the video contribution to this article

Endoscopic Sphincterotomy

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