Background

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.

Indications

The primary indications for endoscopic sphincterotomy include the following:

Extraction of common bile duct (CBD) stones ^[1]
Treatment of papillary stenosis or type I (elevated liver biochemical markers with concomitant dilated CBD) or type II sphincter of Oddi dysfunction ^[2]
Facilitation of endotherapy (eg, stent placement, ^[3]tissue sampling, and stricture dilation)

Endoscopic sphincterotomy has been used in conjunction with endoscopic balloon dilatation in the treatment of choledocholithiasis.^{[4, 5]}Guidelines addressing the use of this procedure in this setting have been published by the European Society of Gastrointestinal Endoscopy^[6](ESGE) and the American Society of Gastrointestinal Endoscopy^[7](ASGE).

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.^[8]

Contraindications

Contraindications for endoscopic sphincterotomy include the following:

Recent myocardial infarction
Severe cardiopulmonary disease
Recent attack of acute pancreatitis (unless there is concomitant cholangitis or persistent biliary obstruction)
Contrast dye exposure causing anaphylaxis
Uncorrected severe coagulopathy, thrombocytopenia, or both

Outcomes

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).^[9] They noted the following:

ESBD was more efficacious in stone removal during the first endoscopic session
Pancreatitis tended to be less common with endoscopic sphincterotomy and ESBD than with EPBD, though the difference was not statistically significant
The risk of bleeding was higher with endoscopic sphincterotomy and ESBD than with EPBD

Periprocedure

[Guideline] Ryozawa S, Itoi T, Katanuma A, Okabe Y, Kato H, Horaguchi J, et al. Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy. Dig Endosc. 2018 Mar. 30 (2):149-173. [QxMD MEDLINE Link]. [Full Text].
Ren LK, Cai ZY, Ran X, Yang NH, Li XZ, Liu H, et al. Evaluating the efficacy of endoscopic sphincterotomy on biliary-type sphincter of Oddi dysfunction: A retrospective clinical trial. World J Clin Cases. 2021 Nov 16. 9 (32):9835-9846. [QxMD MEDLINE Link]. [Full Text].
Kato S, Kuwatani M, Onodera M, Kudo T, Sano I, Katanuma A, et al. Risk of Pancreatitis Following Biliary Stenting With/Without Endoscopic Sphincterotomy: A Randomized Controlled Trial. Clin Gastroenterol Hepatol. 2021 Aug 13. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Haseeb A, Freeman ML. Endoscopic Papillary Large Balloon Dilation Versus Endoscopic Sphincterotomy for Treatment of Bile Duct Stones. Curr Treat Options Gastroenterol. 2019 Jun. 17 (2):221-230. [QxMD MEDLINE Link].
[Guideline] Manes G, Paspatis G, Aabakken L, Anderloni A, Arvanitakis M, Ah-Soune P, et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2019 May. 51 (5):472-491. [QxMD MEDLINE Link].
[Guideline] ASGE Standards of Practice Committee., Buxbaum JL, Abbas Fehmi SM, Sultan S, Fishman DS, Qumseya BJ, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc. 2019 Jun. 89 (6):1075-1105.e15. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Johlin FC, Tucker RD, Ferguson S. The effect of guidewires during electrosurgical sphincterotomy. Gastrointest Endosc. 1992 Sep-Oct. 38 (5):536-40. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Sherman S, Uzer MF, Lehman GA. Wire-guided sphincterotomy. Am J Gastroenterol. 1994 Dec. 89 (12):2125-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Hedjoudje A, Cheurfa C, Farha J, Jaïs B, Aubert A, Lorenzo D, et al. Safety of different electrocautery modes for endoscopic sphincterotomy: a Bayesian network meta-analysis. Ther Adv Gastrointest Endosc. 2021 Jan-Dec. 14:26317745211062983. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Forbes A, Cotton PB. ERCP and sphincterotomy after Billroth II gastrectomy. Gut. 1984 Sep. 25 (9):971-4. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Wu CK, Hsu CN, Cho WR, Yang SC, Liu AC, Tai WC, et al. Increased Risk of Pyogenic Liver Abscess after Endoscopic Sphincterotomy for Treatment of Choledocholithiasis. Infect Drug Resist. 2021. 14:2121-2131. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
Freeman ML. Adverse outcomes of ERCP. Gastrointest Endosc. 2002 Dec. 56 (6 Suppl):S273-82. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Inoue T, Ibusuki M, Kitano R, Kobayashi Y, Ohashi T, Nakade Y, et al. Early Covered Self-Expandable Metal Stent Placement Is Effective for Massive Post-endoscopic Sphincterotomy Bleeding. Dig Dis Sci. 2020 Nov. 65 (11):3324-3331. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Dumonceau JM, Kapral C, Aabakken L, Papanikolaou IS, Tringali A, Vanbiervliet G, et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020 Feb. 52 (2):127-149. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

This video, captured via endoscopic retrograde cholangiopancreatography, shows sphincterotomy being performed. Sphincter of Oddi is being cut with electrocautery applied to biliary cannulation catheter. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.

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Author

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.

Coauthor(s)

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.

Specialty Editor Board

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.

Chief Editor

Kurt E Roberts, MD Associate Professor, Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Yale University School of Medicine; Chair, Department of Surgery, Saint Francis Hospital, Trinity Health of New England Medical Group

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 Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

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.

Acknowledgements

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

Background

Indications

Contraindications

Outcomes

References

Tables

Contributor Information and Disclosures

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