Is the Complication Rate the Same for Index Versus Repeat Biliary Sphincterotomy?

Abstract

Introduction: Much has been written about the complication rate related to biliary sphincterotomy. These reports have primarily included only patients undergoing initial biliary sphincterotomy. There are limited data regarding the outcome in patients undergoing repeat biliary sphincterotomy. Patients and Methods: From 1/2000 to 9/2003, 1210 ERCP were performed for indications of biliary disease. Of these, 842 pts underwent biliary sphincterotomy. There were 299 men, 543 women, mean age 58 years. Of these, 372 (44.2 %) were repeat procedures performed for recurrence or incomplete treatment of biliary disease requiring biliary sphincterotomy. Of these, 75 were men and 297 were women, mean age 53 years. Indications for sphincterotomy included: choledocholithiasis in 477, biliary pancreatitis in 42, bile duct stricture in 231, ampullary adenoma in 7, polycystic liver disease in 2 and bile leak in 43 and sphincter of Oddi dysfunction in 40. Of the 372 patients with recurrent or incomplete treatment of biliary disease, indications included: choledocholithiasis in 229, biliary pancreatitis in 6, bile duct stricture in 92, bile leak in 17, SOD in 28. Of the repeat procedures, 287of the index biliary sphincterotomies were performed at another institution. All procedures performed at our institution were done using 30 mm cutting wire sphincterotomes with a 5 mm tip. Sphincterotomies were performed with a cut-to- coagulation ration of 2 to 1. All procedures were performed by experienced biliary endoscopists. Results: Of the 470 pts with index biliary sphincterotomy, complications included acute pancreatitis in 26 pts (5.5%), perforation in 5 (1%), bleeding in 8 (1.7%), aspiration pneumonia in 1 (0.01%). Of the patients with repeat biliary sphincterotomy, complications included: acute pancreatitis in 3 (1%), perforation in 29 (8%), and bleeding in 19 (5%). There was no mortality in either group. Conclusions: 1.The complication rate after biliary sphincterotomy differs between index and repeat procedures; 2.The incidence of perforation and bleeding is significantly increased after repeat sphincterotomy; 3. Acute pancreatitis is significantly decreased as a complication after repeat biliary sphincterotomy; 4. Technical modifications are needed to decrease (hopefully abolish) these complications; 5. A prospective multicenter study with a larger number of patients is warranted.