Biliary sphincterotomy: less benign than once thought?

Twenty-five years ago, Classen and Kawai, working independently, reported the first use of endoscopic sphincterotomy. Since that time, thousands of patients have undergone this procedure. The immediate risks of sphincterotomy, including pancreatitis, bleeding, perforation, and infection, are well documented. However, the long-term complications of ablating the sphincter of Oddi are poorly understood. It is becoming clear that exposing the biliary tree to duodenal contents is far from benign. Recently reported long-term complications of sphincterotomy include stone formation, cholecystitis, sphincterotomy site stenosis (with recurring cholangitis), and, possibly, an increased risk of cholangiocarcinoma. Balloon dilation of the duodenal papilla (balloon sphincterplasty) has been shown to carry unacceptable risk of serious and even fatal pancreatitis. Medical dilation of the papilla is rarely helpful. Consequently, endoscopists must reevaluate their use of endoscopic sphincterotomy in light of long-term complications in the data.