Endoscopic Sphincterotomy

Todd H. Baron, MD

Endoscopic sphincterotomy (ES) is often used as a primary therapeutic modality or a secondary tool to facilitate minimally invasive management of a variety of pancreaticobiliary disorders. When deep cannulation of the duct of interest fails, several different precut sphincterotomy techniques can be performed. In this chapter, the indications, techniques, and adverse events of endoscopic sphincterotomy will be discussed.

INDICATIONS AND CONTRAINDICATIONS

The indications and contraindications for ES are shown in Table 26.1 and can be subdivided into those that require selective biliary, pancreatic, or dual sphincterotomies, and/or to facilitate access in cases of difficult cannulation often referred to as “precut sphincterotomy.” Dual sphincterotomy (biliary and pancreatic) is sometimes utilized pre- or postendoscopic ampullectomy (papillectomy) with the intention of decreasing postampullectomy adverse events such as pancreatitis, cholangitis, and papillary stenosis or for improved diagnostic accuracy in detecting intraductal involvement.

Precut sphincterotomy refers to techniques utilized to gain access to the bile and pancreatic ducts when efforts at prior deep selective cannulation have failed. These techniques utilize electrosurgical energy to cut papillary tissue and expose underlining ducts to facilitate deep cannulation of the duct of interest. In patients with Billroth II anatomy, a needle knife sphincterotomy can be performed over a biliary stent since standard sphincterotomes orient in the opposite direction of the intended cut.

Patient Preparation

1. Informed consent
2. NPO per guidelines¹

3. Correction of coagulopathy

TABLE 26.1 Sphincterotomy Techniques

Technique	Indications	Contraindications
Biliary sphincterotomy	Choledocholithiasis Biliary leaks Sphincter of Oddi dysfunction Benign or malignant papillary stenosis Choledochocele Sump syndrome Biliary parasites Facilitate access for biliary interventions	Unstable or uncooperative patient Uncorrected coagulopathy Difficult anatomy precluding appropriate trajectory and visualization of the cut (e.g., intradiverticular papilla)
Pancreatic sphincterotomy/minor duct sphincterotomy	Sphincter of Oddi dysfunction (pancreatic type) Papillary stenosis/stricture Pancreatic divisum Facilitate further pancreatic duct interventions such as transpapillary drainage of pseudocysts, pancreatic duct fistula, and pancreatic duct obstruction	Low ERCP volume (relative <200 per year) Uncorrected coagulopathy New surgical anastomosis Difficult anatomy precluding appropriate trajectory and visualization of the cut
Precut sphincterotomy	Failure of standard cannulation Impacted gallstones in the ampulla Consider in Billroth II and altered anatomy Consider for minor duct sphincterotomy	Low ERCP volume (relative) Uncorrected coagulopathy Difficult anatomy precluding appropriate trajectory and visualization of the cut

4. Withholding of antithrombotics per guidelines, drug package inserts, and after discussion with healthcare providers (primary provider of patient’s antithrombotic agents)²
5. Management of cardiac pacemaker/defibrillator per guidelines³

Equipment Needed

1. Standard duodenoscope (native gastroduodenal anatomy)
2. Electrocautery pad
3. Electrosurgical generator (preferably controlled to allow precise control of the length of the cut and to eliminate “zipper cut”)
4. Standard sphincterotome of choice (many available)
5. Needle knife (many available)
6. Standard ERCP guidewires and catheters
7. Pancreatic stents for prevention of post-ERCP pancreatitis⁴
8. Rectal indomethacin for prevention of post-ERCP pancreatitis⁴
9. Secretin (ChiRhoStim) for minor papilla cannulation
10. Fully covered metal biliary stents
11. Coagulation devices for management of bleeding (bipolar probes, hemostatic forceps, clips)

TECHNIQUES⁵

Biliary and Pancreatic Sphincterotomy

1. Administration of rectal indomethacin 100 mg for prevention of post-ERCP pancreatitis.
2. Select electrosurgical current. A commonly used electrocautery option is the “Endo Cut” mode of the ERBE generator to allow precise control of the length of the cut and eliminate “zipper cuts,” while blending cut and coagulation currents. Pure cut can be considered for pancreatic sphincterotomy to reduce risk of stenosis but carries risk of uncontrolled cutting.
3. Deep cannulation of the duct of interest and passage of guidewire into the duct.
4. Withdraw sphincterotome toward the duodenum leaving the guidewire in place to allow about one-fourth to one-third of the cutting to be located inside the papilla.
5. Bow the tip of the sphincterotome to contact the roof of the papilla, making sure that no more that 5 mm of the cutting wire is inside the papilla (Fig. 26.1).

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