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.

DESIGN: Review on prospectively collected data.

PATIENTS: 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.

MEASUREMENTS: 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.

LIMITATIONS: 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.