Biliary endoscopic sphincterotomy
Biliary endoscopic sphincterotomy | |
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ICD-9-CM | 51.85 |
Biliary endoscopic sphincterotomy is a procedure where the
This procedure was developed in both Germany and Japan and was first published in each nation in 1974.
Medical Uses
Therapeutic
Extraction of choledocholithiasis and/or intrahepatic stones: choledocholithiasis is the presence of gallstones within the common bile duct. They can be either primary (formed within the duct) or secondary (entering the duct from the gallbladder). Biliary endoscopic sphincterotomy allows for opening of the sphincter of Oddi, allowing stones to be removed.[4]
Treatment of benign biliary/papillary strictures: diseases such as
Treatment of sphincter of Oddi dysfunction: this is a diagnosis of exclusion which encompasses a broad spectrum of hepatobiliary disorders including spasms, strictures, or inappropriate relaxation. Sphincterotomy appears to be safe and effective for the treatment of sphincter of Oddi dysfunction.[6]
Treatment of bile leaks: leakage of bile into the abdominal cavity is a complication of
Others:
- Palliation of malignant biliary strictures
- Gallbladder drainage
- Biliary parasite removal
- Sump syndrome
- Choledochocele
Diagnostic
- Biopsy
- Cholangioscope
Contraindications
Bleeding/coagulopathy:
Procedure
Equipment
Sphincterotomes: a sphincterotome (also called a papillotome) is a
Pull-type: pull-type sphincterotomes consist of a steel cutting wire within a
Push-type: push-type sphincterotomes have a similar design to pull-type, but instead tightening the wire pushes it out to form a bow oriented downwards. This is useful for patients with Billroth II anatomy.[1]
Needle-knife: a needle-knife sphincterotome has a retractable cutting wire of 3 to 5 mm with a Teflon sheath. They are most often used for a pre-cut sphincterotomy when standard methods of cannulation fail.[1]
Technique
Standard sphincterotomy: the sphincterotome is inserted into the bile duct. A
Pre-cut sphincterotomy: pre-cut biliary endoscopic sphincterotomy refers to the techniques used to cut the papillary mucosa and biliary sphincter in order to expose the underlying bile duct and gain access to it when standard cannulation fails.[1]
Transpancreatic biliary sphincterotomy (septotomy): when the guidewire is unintentionally inserted into the
Needle knife papillotomy: a needle knife sphincterotome is placed en face to the biliary papilla. An incision is then made stepwise, starting at the upper margin of the papillary orifice and extending towards the biliary sphincter, creating an incision to allow the bile duct to be cannulated.[1]
Needle knife fistulotomy: a needle knife fistulotomy has two different technique which are used. For the first technique an incision is made a few millimeters above the opening to the duct and then extended upwards. The other option is to make an incision in the roof of the papilla and then extend it either up or down without cutting the papillary orifice itself.[1] The rate of pancreatitis after ERCP was significantly lower after fistulotomy, compared to other precut techniques.[1]
Modifications for anatomic variations
Periampullary diverticulum: periampullary diverticulum makes the procedure more difficult because it becomes harder to assess the incision.[10] Needle-knife fistulotomy or pancreatic stent placement followed by precut sphincterotomy are two of several techniques that have been used to account for the increased difficulty.[11]
Surgically altered anatomy (Billroth II): if a patient has undergone a partial gastrectomy with Billroth II anastomosis, the papilla may appear to be upside down from the perspective of the endoscope compared to normal. Cannulation may need to be performed in a reverse position with the bile duct oriented downwards.[1]
Risks
The reported overall incidence of complications associated with ERCP and biliary endoscopic sphincterotomy has ranged from 3 to 12 percent.[12]
Pancreatitis: biliary endoscopic sphincterotomy is not an independent risk factor for pancreatitis after ERCP.[1]
Bleeding: immediate bleeding occurs during or immediately after biliary endoscopic sphincterotomy. It is seen in up to 30% of patients and self-limiting most of the time. Delayed bleeding occurs from a few hours up to 2 wk after the procedure.[13]
Perforation: the incidence of sphincterotomy related perforation, also named Type 2 duodenal perforation, is between 0% and 1.8%.[12]
Cholangitis/sepsis: the incidence of cholangitis after biliary endoscopic sphincterotomy is between 1% and 3%.[1]
Late complications: long-term complication vs of biliary endoscopic sphincterotomy include recurrent common bile duct stone, cholecystitis, cholangitis,
Alternatives
Balloon Dilation: balloon dilation is an alternative often used in patients with a coagulation disorder or if their anatomy makes a traditional sphincterotomy more difficult. Balloon dilation is associated with fewer long term complications owing to preservations of sphincter function.[14]