4669 Endoscopic biliary sphincterotomy in patients with post cholecystectomy pain and sphincter of oddi dysfunction: an effective and long lasting therapy.

Abstract

Persistent abdominal pain is present in 15-20% of post cholecystectomy patients. After excluding other causes, patients can be defined using the Milwaukee classification and sphincter of Oddi manometry (SOM). Currently, limited data is available in reference to the long -term impact of biliary sphincterotomy on the clinical course of patients with elevated sphincter of Oddi pressure (SOP). The aim of this study was to evaluate the long-term outcome of endoscopic biliary sphincterotomy in patients with SOD. Methods: All SOM performed for post cholecystectomy pain and suspected SOD were reviewed. Patients with pancreatitis were excluded.A total of 92 manometries were identified. A basal SOP greater than 40 was considered to be abnormal(SOD). All measurements were from the biliary sphincter. No attempt was made to measure the pancreatic sphincter pressure. Thirty three patients (36%) had SOD. All patients with SOD underwent biliary sphincterotomy. Patients were admitted overnight for observation. Further follow-up was obtained by telephone interview using a standard protocol which included 21 variables addressing pain resolution, narcotic use, the need for hospital admissions or ER visits, and any further intervention. Results: Complete telephone interview and follow-up was obtained in all 33 patients. The mean follow-up was 45 months (range 6- 134). Patients were classified using Milwaukee classification into 3 groups: type I (1 patient); type II (7 patients) and type III (25 patients). 15(45%) patients were pain free (Type I= 1 patient; Type II=2 patients; Type 3= 12 patients); 5 (15%) patients had mild pain that did not require narcotics (Type II= 2 patients); (Type 3= 3 patients). 9 (27%) of patients did not improve (Type II=2 patients; Type III :7 patients). Six patients underwent a second ERCP with SOM. Four patients had elevated pancreatic sphincter pressure and underwent pancreatic sphincterotomy. In 2 patients, residual biliary pressure was present, and underwent extension of the biliary sphincterotomy. Complications occurred in 4 patients (12%) all of which consisted of mild pancreatitis. Overall, 25 patients (75%) felt better after biliary sphincterotomy.Conclusions:1- Biliary sphincterotomy is safe an effective in the majority of patients with SOD. 2-Benefits appear to be long term.3- Routine measurement of pancreatic sphincter pressure is not needed initially in this group of patients.