How to manage an obstructive stone at the Sphincter of Oddi (ERCP - Endoscopic Retrograde Cholangiopancreatography)?

From the Guidelines

Managing an obstructive stone at the Sphincter of Oddi during ERCP typically involves endoscopic sphincterotomy followed by stone extraction, as this approach has been shown to be effective in clearing common bile duct stones in 80% to 95% of cases 1.

Key Considerations

• The procedure should be performed by experienced gastroenterologists or general surgeons in an interventional suite or operating room under general anesthesia.
• Prior to the procedure, administration of glucagon (0.5-1mg IV) or hyoscine butylbromide (Buscopan 20mg IV) can help relax the sphincter and facilitate the procedure.
• Endoscopic sphincterotomy is typically performed using a sphincterotome with electrocautery to cut the sphincter muscle, creating an opening for stone removal.
• Extraction can be accomplished using a balloon catheter (inflated to 8-15mm depending on duct and stone size) or a wire basket (Dormia or similar type).
• For difficult stones, mechanical lithotripsy may be necessary to fragment the stone before removal.
• If the stone is impacted, a temporary biliary stent (7-10Fr plastic stent) may be placed to establish drainage while planning definitive treatment.

Post-Procedure Care

• Patients should receive prophylactic antibiotics if there was biliary obstruction (typically a single dose of ciprofloxacin 400mg IV or similar) 1.
• Patients should be monitored for complications such as post-ERCP pancreatitis, which can be reduced by rectal indomethacin (100mg) administered immediately before or after the procedure 1.

Alternative Approaches

• Laparoscopic bile duct exploration (LBDE) is a viable alternative for patients with difficult stone disease, with high rates of duct clearance and favorable long-term results 1.
• Percutaneous stone extraction and open duct exploration may be necessary in some cases where less invasive options fail or are not possible 1.

From the Research

Management of Obstructive Stone at Sphincter of Oddi

To manage an obstructive stone at the Sphincter of Oddi, the following approaches can be considered:

• Endoscopic Retrograde Cholangiopancreatography (ERCP) is a commonly performed procedure to remove bile duct stones 2, 3, 4.
• Endoscopic sphincterotomy (ES) is a valuable therapeutic modality in choledocholithiasis with jaundice, dilated common bile duct, acute pancreatitis, or cholangitis 4.
• Endoscopic balloon dilation of the sphincter of Oddi has been compared with sphincterotomy for stone extraction, with studies suggesting that balloon dilation is associated with increased short-term morbidity rates and death due to pancreatitis 2, 3.
• Sphincterotomy for biliary sphincter of Oddi disorder and idiopathic acute recurrent pancreatitis has been shown to improve symptoms in approximately 60% of patients, although the contribution of a placebo response is unknown 5.

Considerations for ERCP and Sphincterotomy

When considering ERCP and sphincterotomy for the management of obstructive stone at the Sphincter of Oddi, the following points should be taken into account:

• ERCP should be avoided if there is a low likelihood of biliary stone or stricture, especially in women with recurrent pain, a normal bilirubin, and no other objective sign of biliary disease 4.
• Endoscopists performing ERCP should have appropriate training and expertise before performing advanced procedures 4.
• The risk of pancreatitis is higher with endoscopic balloon dilation compared to sphincterotomy 2, 3.
• Sphincterotomy may not mitigate future episodes of acute pancreatitis 5.

Alternative Approaches

Alternative approaches to ERCP and sphincterotomy include:

• Endoscopic balloon sphincter dilation (sphincteroplasty) 3.
• Hydrostatic balloon dilation in the bile duct and pancreas 6.
• Laparoscopic common bile duct exploration and postoperative ERCP are both safe and reliable in clearing common bile duct stones 4.