When is sphincterotomy recommended?

Indications for Sphincterotomy

Sphincterotomy is primarily recommended for patients with detrusor sphincter dyssynergia and elevated storage pressures, particularly in spinal cord injury patients, to lower the risk of renal damage and recurrent bladder infections. 1

Types of Sphincterotomy

Biliary Sphincterotomy

Biliary sphincterotomy is indicated in the following clinical scenarios:

1. Common Bile Duct Stones (CBDS)

   • For extraction of confirmed bile duct stones 1
   • In patients with acute gallstone pancreatitis with cholangitis, jaundice, or dilated common bile duct 1
   • For patients with predicted or actual severe pancreatitis of gallstone etiology, ideally within 72 hours of pain onset 1

2. Biliary Obstruction

   • In patients with cholangitis requiring urgent biliary decompression 1, 2
   • When biliary drainage is needed but sphincterotomy cannot be safely completed, a limited sphincterotomy supplemented by endoscopic papillary balloon dilation (EPBD) is recommended 1

3. Gallstone Pancreatitis Prevention

   • For patients unable to undergo cholecystectomy, to reduce risk of recurrent pancreatitis 1

Urologic Sphincterotomy

Sphincterotomy in urologic settings is indicated for:

1. Neurogenic Lower Urinary Tract Dysfunction (NLUTD)

   • For patients with detrusor sphincter dyssynergia and elevated storage pressures 1
   • Particularly effective in spinal cord injury patients 1
   • To lower risk of renal damage and recurrent bladder infections 1

2. Anorectal Conditions

   • For low fistulas not involving sphincter muscle during abscess drainage 1
   • For obvious fistulas involving sphincter muscle, placement of a loose draining seton is preferred over sphincterotomy 1

Pre-Procedure Considerations

Coagulation Status

• Complete blood count (CBC) and INR/PT should be performed prior to biliary sphincterotomy 1
• Coagulopathy should be corrected before performing sphincterotomy 1
• If coagulopathy cannot be corrected, consider alternative procedures with lower bleeding risk, such as endoscopic stenting 1

Anticoagulant Management

• For elective sphincterotomy, discontinue oral anticoagulation 2-5 days before procedure (depending on the anticoagulant and patient's renal function) 1
• For patients on warfarin for high-risk conditions, bridging therapy may be required 1
• For patients on clopidogrel for high-risk cardiac conditions, cardiology consultation is recommended before discontinuation 1

Post-Procedure Evaluation

For Urologic Sphincterotomy

• Urodynamic studies (UDS) should be performed following sphincterotomy to assess outcomes 1
• UDS helps document the reduction in intravesical storage pressures 1

For Biliary Sphincterotomy

• In patients with gallstone pancreatitis who undergo sphincterotomy, subsequent laparoscopic cholecystectomy should still be considered 1
• Annual follow-up with focused history, physical exam, symptom assessment, basic metabolic panel, and urinary tract imaging for patients with lower urinary tract reconstruction 1

Complications and Risk Factors

Biliary Sphincterotomy Complications

• Post-ERCP pancreatitis (5.4%) 3
• Hemorrhage (2.0%) 3
• Higher complication rates associated with:
  • Suspected sphincter of Oddi dysfunction (21.7%) 3
  • Cirrhosis 3
  • Difficult bile duct cannulation 3
  • "Precut" sphincterotomy technique 3
  • Combined percutaneous-endoscopic procedures 3

Risk Reduction

• Use of mixed current rather than pure cut current for sphincterotomy to decrease risk of bleeding 4
• Rectal administration of diclofenac or indomethacin (100 mg) at the time of ERCP to reduce post-ERCP pancreatitis risk 1
• Higher procedure volume (>1 sphincterotomy per week) is associated with lower complication rates 3

Special Considerations

Altered Anatomy

• In patients with Billroth II gastrectomy or Roux-en-Y gastric bypass, sphincterotomy presents technical challenges 1
• For Billroth II patients, side-viewing duodenoscope is first choice, with forward-viewing endoscope as second option 4
• Patients with Roux-en-Y gastric bypass and CBDS should be referred to centers with advanced endoscopic and surgical capabilities 1

Small Papilla or Difficult Cannulation

• When biliary cannulation is difficult and repeated unintentional pancreatic duct access occurs, pancreatic guidewire-assisted biliary cannulation is recommended 4
• For small papilla that is difficult to cannulate, transpancreatic biliary sphincterotomy should be considered if unintentional guidewire insertion into pancreatic duct occurs 4

By understanding these indications and considerations, clinicians can appropriately select patients who would benefit from sphincterotomy while minimizing potential complications.