Routine biliary sphincterotomy may not be indispensable for endoscopic pancreatic sphincterotomy.
OBJECTIVE
It is generally accepted that biliary sphincterotomy is mandatory to avoid possible cholestasis and infection due to edema after pancreatic sphincterotomy. However, biliary sphincterotomy is an invasive procedure and the above claim on dual sphincterotomy has not been proven by a prospective randomized study. The aim of our study was to determine whether cholangitis develops more frequently when the patients have not undergone concomitant biliary sphincterotomy during the endoscopic pancreatic sphincterotomy.


METHODS
From January 1990 to November 1997, 60 patients (38 men, 22 women, age range 19-45 years) with non-alcoholic chronic calcifying pancreatitis were prospectively enrolled. The patients with jaundice (bilirubin > or = 3 mg/dl), cholangitis, or parenchymal liver disease were excluded. The patients were randomly subjected either to dual sphincterotomy (group I, n = 30) or to pancreatic sphincterotomy alone (group II, n = 30). Groups I and II were further classified as IA (or IIA) and IB (or IIB), according to the level of serum alkaline phosphatase (sALP) and the diameter of the common bile duct (CBD). Group IA (or IIA) was defined when abnormal in both sALP (> or = 2 times the upper limit of normal) and CBD diameter (> or = 12 mm), whereas group IB (or IIB) was defined when normal, or solely abnormal in sALP or CBD diameter.


RESULTS
As a complication after sphincterotomy, pancreatitis developed in one of eight patients (12.5%) in group IA, whereas cholangitis occurred in one of 22 (4.5%) and hemorrhage in one of 22 (4.5%) cases in group IB. By contrast, in group IIA, the cholangitis developed in 56% (five of nine patients), which was significantly more frequent than in any other groups (P < 0.05). Hemorrhage (one of 21, 4.8%) and pancreatitis (one of 21, 4.8%) occurred in group IIB.


CONCLUSIONS
Our results suggest that dual sphincterotomy may be indicated only in patients who have both dilated choledochus and elevated alkaline phosphatase in chronic pancreatitis. Routine biliary sphincterotomy may not be indispensable for pancreatic sphincterotomy.
Kim
M H
MH
Dept. of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. hjkim@www.amc.seoul.kr
Myung
S J
SJ
Kim
Y S
YS
Kim
H J
HJ
Seo
D W
DW
Nam
S W
SW
Ahn
J H
JH
Lee
S K
SK
Min
Y I
YI
D000328:Adult; D002761:Cholangitis / Q000453:epidemiology / Q000209:etiology*; D002908:Chronic Disease; D003131:Combined Modality Therapy; D003135:Common Bile Duct / Q000601:surgery*; D013505:Digestive System Surgical Procedures / Q000009:adverse effects* / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010195:Pancreatitis / Q000175:diagnosis / Q000601:surgery*; D011446:Prospective Studies; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects* / Q000379:methods; D016896:Treatment Outcome