Endoscopic Sphincterotomy Technique

Updated: Feb 01, 2022
  • Author: Priya A Jamidar, MD, FACG, FASGE; Chief Editor: Kurt E Roberts, MD  more...
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Incision of Sphincter of Oddi

Endoscopic sphincterotomy (see the video below) is typically performed with the endoscope in the short position. Bowing the sphincterotome is usually necessary, which allows the wire to be forced upward toward the roof of the papilla. Using the elevator and the up-down deflecting knobs may facilitate the latter bowing technique. Sometimes, performing sphincterotomy in the long position is preferred; in this case, less bowing is required.

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.

The location of the sphincterotomy should be between the 11 o'clock and 1 o’clock positions. Deep cannulation is then facilitated. Once deep cannulation is achieved, the endoscopist can withdraw the sphincterotome tailored to the desired incision length. Generally speaking, approximately one half to two thirds of the wire should be visible in the duodenum.

One potential complication during the procedure is a retroperitoneal perforation that results from an uncontrolled "zipper-cut." This complication can be avoided by ensuring that enough wire is withdrawn from the papilla.

The incision length should be based on the following:

  • Indication
  • Duct size
  • Surrounding anatomy

The incision should be directed along the longitudinal axis of the intramural segment of the common bile duct (CBD). The incision should never be continued beyond the junction of the intramural segment of the CBD and the duodenal wall. This junction is located by identifying where the superior margin of the bulging impression of the intramural bile duct meets the duodenal wall. The sphincterotomy size can be assessed by using a 75% bowed sphincterotome or an inflated stone balloon. [19]

The authors perform the first third of the sphincterotomy with the generator in the cut setting, the middle third with blended current, and the final third with coagulation current. The rationale for this approach is as follows. The risk of causing pancreatitis may be highest during the initial portion of the sphincterotomy, whereas the risk of causing bleeding may be highest near the apex of the sphincterotomy (because of the proximity of the pancreatic orifice and the blood vessels, respectively).

The cut setting is used initially to cut rapidly (and presumably with minimal thermal injury) away from the pancreatic orifice. Blended current is used for the middle portion of the cut because at this point, the risks of pancreatitis and bleeding may be lowest. The sphincterotomy is completed with coagulation current because at this point, the risk of bleeding is highest.

The above recommendations are based on the authors' experience. Many experts perform the entire sphincterotomy using only the blended current setting.

Special cases

Billroth II

In this case, the papilla is upside down. This location requires the catheter to be oriented in the 6 o’clock position to cannulate the bile duct. Two techniques are used in patients who have undergone Billroth II anastomoses. The first calls for stenting of the bile duct and then using a needle-knife to cut over the stent. The incision is carried along the stent toward the junction of the intramural segment and the duodenal wall, which translates to the 6 o’clock position. [20]

The second technique involves a reverse sphincterotome. These sphincterotomes are designed so that the diathermy wire is oriented in the 6 o’clock position. The authors prefer the free-hand technique as described above because in practice, the reverse sphincterotomes often do not orient correctly.

Finally, in difficult cannulations, a needle-knife fistulotomy can be created with subsequent antegrade passage of a wire across the ampulla. [21]

Periampullary diverticulum

In cases of a periampullary diverticulum, sphincterotomy may be more difficult. The incision can usually be continued to the edge of the diverticulum; however, the size of the sphincterotomy may have to be limited because it is difficult to visualize the incision in these cases.



Potential complications of endoscopic sphincterotomy include the following:

  • Bleeding [22]
  • Infection [23]
  • Perforation [24]
  • Pancreatitis

The overall complication rate of ERCP varies according to patient- and procedure-related factors, but in general, it is in the range of 5-10%. In particular, within 30 days of biliary sphincterotomy, ERCP carries a 2% risk of hemorrhage and up to a 5.4% risk of acute pancreatitis. [25, 26]

A large study from Japan found that hemodialysis, heparin replacement, and early hemorrhage were risk factors for delayed hemorrhage after endoscopic sphincterotomy. [27]  Placement of a covered self-expandable metallic stent may decrease the extent of bleeding after ensdoscopic sphincterotomy and reduce rebleeding. [28]

Over the long term, patients who have undergone endoscopic sphincterotomy appear to be at higher risk for acute pancreatitis and cholangitis than those who have not, but they are not at significantly higher risk for pancreaticobiliary malignancy. [29]

Overall, awareness of these patient- and procedure-related factors is essential for avoiding or minimizing complications. With regard to the risk of bleeding, the recommendation is to avoid endoscopic sphincterotomy in patients with uncorrected severe coagulopathies, especially those receiving antithrombotic agents in whom delay of intervention is not feasible. For example, in emergency ERCP (eg, for septic shock secondary to cholangitis), placement of a biliary stent alone is the preferred alternative.

Rectal indomethacin is a widely available, inexpensive, and relatively safe nonsteroidal anti-inflammatory drug (NSAID) that can significantly reduce the risk of post-ERCP pancreatitis. [30] Guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) advocated routine use of rectal indomethacin or diclofenac in all patients undergoing ERCP. [31] In the United States, the current practice is to administer indomethacin to high-risk patients, including those undergoing procedures with high procedure-related risk (eg, biliary sphincterotomy).