Freeman Martin L, Guda Nalini M
Division of Gastroenterology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, USA.
Curr Treat Options Gastroenterol. 2005 Apr;8(2):127-134. doi: 10.1007/s11938-005-0005-0.
Endoscopic sphincterotomy is performed on the biliary and pancreatic sphincters for a variety of indications such as removal of stones, as part of treatment of strictures, to facilitate placement of stents, for closure of ductal leaks, and other indications. Pancreatic sphincterotomy has been increasingly performed for the treatment of papillary stenosis, sphincter of Oddi dysfunction, and for chronic and acute recurrent pancreatitis. Efficacy is clear for more traditional indications, but is not as well defined for some of the latter indications. Minor papillotomy is most often performed for acute recurrent pancreatitis associated with pancreas divisum, sometimes for chronic pancreatitis, and for other indications. Equipment, techniques, and safety of sphincterotomy have improved significantly over the past decades. Success rates are substantially higher when a sphincterotomy is performed by high-volume endoscopists. However, complications such as pancreatitis, bleeding, and perforation can still occur in up to 10% of cases and may occasionally be severe. Patients with the least clear indication or chance of benefit from sphincterotomy, such as those with suspected sphincter of Oddi dysfunction or suspected but absent bile duct stones, are at highest risk of complications. Complications are less frequent, but fully not eliminated, with an experienced endoscopist or an expert in the field. Risk of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) with biliary and/or pancreatic sphincterotomy can be substantially reduced by placement of a small-caliber pancreatic stent. Major challenges include defining the settings in which sphincterotomy is most likely to be effective, selection of appropriate patients for therapeutic ERCP by utilization of alternative imaging techniques such as magnetic resonance cholangiopancreatography and endoscopic ultrasound, and dissemination of newer techniques into practice to ensure optimal safety and efficacy for sphincterotomy.
内镜括约肌切开术可用于胆管和胰管括约肌，适用于多种适应症，如结石取出、作为狭窄治疗的一部分、便于支架置入、闭合导管漏以及其他适应症。胰管括约肌切开术越来越多地用于治疗乳头狭窄、Oddi括约肌功能障碍以及慢性和急性复发性胰腺炎。对于更传统的适应症，疗效是明确的，但对于一些后者的适应症，疗效尚未明确界定。小乳头切开术最常用于与胰腺分裂相关的急性复发性胰腺炎，有时用于慢性胰腺炎以及其他适应症。在过去几十年中，括约肌切开术的设备、技术和安全性有了显著改善。由经验丰富的内镜医师进行括约肌切开术时，成功率会显著更高。然而，胰腺炎、出血和穿孔等并发症仍可能发生在高达10%的病例中，偶尔可能很严重。括约肌切开术适应症最不明确或受益机会最小的患者，如疑似Oddi括约肌功能障碍或疑似但无胆管结石的患者，并发症风险最高。由经验丰富的内镜医师或该领域专家操作时，并发症发生频率较低，但并未完全消除。通过放置小口径胰管支架，可大幅降低内镜逆行胰胆管造影（ERCP）联合胆管和/或胰管括约肌切开术后胰腺炎的风险。主要挑战包括确定括约肌切开术最可能有效的情况，通过利用磁共振胰胆管造影和内镜超声等替代成像技术选择合适的患者进行治疗性ERCP，以及将新技术推广应用以确保括约肌切开术的最佳安全性和疗效。
