Multimedia article. Sphincterotome stricturoplasty for long ampullary stenoses and benign biliary strictures (with video).
BACKGROUND
Long ampullary stenoses and fibrotic distal biliary strictures are not infrequently encountered during endoscopic retrograde cholangiopancreatography (ERCP). Instead of balloon dilation and stenting, we propose that these strictures can be managed with sphincterotome stricturoplasty (SS) during the initial ERCP.


OBJECTIVE
To report our clinical experience with SS for benign distal biliary strictures.


METHODS
Review on prospectively collected data.


METHODS
All (consecutive) patients who underwent ERCP and SS performed by the authors in a 12-month period. Long ampullary stenosis and/or distal biliary stricture is defined as significant narrowing of CBD from the level of duodenal wall into the common bile duct (CBD) after initial sphincterotomy. The upstream CBD is dilated. Despite adequate ES, contrast drainage is poor due to the downstream stricture. SS was performed using the same sphincterotome in slightly bowed position under endoscopic and fluoroscopic guidance. The cutting wire was placed parallel to the superior border within the stricture and incising the stenosis. In cases of relatively long strictures, during initial SS the majority of the cutting wire was inside the biliary opening. This differs from ES, where about one-third to one-half of the length of cutting wire is outside the ampulla.


METHODS
Clinical data, hospital course, procedure-related complication rates, and outcomes were prospectively collected in a database.


RESULTS
During the study period, 308 ERCPs were performed. Benign and short (≤15 mm in length) distal biliary strictures were observed in 25 patients. Mean ± SD stricture length was 7.4 ± 3.0 mm. The presumed etiologies for these strictures were choledocholithiasis (n = 22) and postsphincterotomy stenosis (n = 3). There was no perforation, post-ERCP pancreatitis, postsphincterotomy bleeding, or cholangitis. To date, none of these patients who had SS have needed follow-up ERCP.


CONCLUSIONS
Single-operator experience, limited follow-up period.


CONCLUSIONS
Compared with balloon stricturoplasty ± biliary stenting, SS is a simple and cost-effective alternative option in managing long ampullary stenosis and/or distal fibrotic biliary stricture during the initial ERCP.
Tang
Shou-Jiang
SJ
Division of Gastroenterology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA. sjtang2000@yahoo.com
Singh
Sundeep
S
Singh
Shailender
S
D000328:Adult; D014670:Ampulla of Vater / Q000473:pathology / Q000601:surgery*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000191:economics / Q000379:methods*; D002763:Cholecystectomy; D042883:Choledocholithiasis / Q000150:complications / Q000601:surgery; D003135:Common Bile Duct / Q000473:pathology / Q000601:surgery*; D003251:Constriction, Pathologic / Q000601:surgery; D003287:Contrast Media; D003362:Cost-Benefit Analysis; D005260:Female; D005355:Fibrosis; D005471:Fluoroscopy; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology / Q000473:pathology / Q000601:surgery*; D015641:Radiography, Interventional; D012189:Retrospective Studies; D016717:Sphincterotomy, Endoscopic / Q000295:instrumentation / Q000379:methods
D003287:Contrast Media