Endoscopic Sphincterotomy

Updated: Mar 20, 2018
  • Author: Priya A Jamidar, MD, FACG, FASGE; Chief Editor: Kurt E Roberts, MD  more...
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Overview

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.

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Indications

The primary indications for endoscopic sphincterotomy include the following:

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

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]

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Contraindications

Contraindications for endoscopic sphincterotomy include the following:

  • 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
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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). [3] ​ 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
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