Endoscopic Sphincterotomy



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

May 29, 2020 | Posted by in GASTROENTEROLOGY | Comments Off on Endoscopic Sphincterotomy
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