Standard biliary sphincterotomy technique: The cutting edge
- Priya Jamidar, MD, FACG, FASGE
Priya Jamidar, MD, FACG, FASGE
- Professor of Medicine
- Yale School of Medicine
Approximately 150,000 patients undergo endoscopic biliary sphincterotomy every year in the United States. Biliary sphincterotomy refers to the cutting of the biliary sphincter and is typically carried out during endoscopic retrograde cholangiopancreatography (ERCP). The principal indications for sphincterotomy include removal of common bile duct stones, treatment of papillary stenosis, and facilitation of endotherapy (ie, stent placement, tissue sampling, and stricture dilation).
Sphincterotomy is a technically complex procedure that is performed under visual and fluoroscopic guidance. Deep cannulation of the bile duct is followed by electrocautery to incise the sphincter of Oddi. This topic review will focus on the technique of endoscopic biliary sphincterotomy. Its clinical applications and complications are discussed separately. (See "Endoscopic retrograde cholangiopancreatography: Indications, patient preparation, and complications".)
Sphincterotomes (also known as papillotomes) are available with a number of different configurations, which can be broadly categorized as pull, push, and needle-knife. Several modifications are available within each category that are designed for specific clinical settings or anatomic variations. This topic review will focus on the most commonly used sphincterotome (the Erlangen or pull-type version), which consists of a wire-loop partially enclosed in a Teflon catheter. The wire exits the catheter about 3 cm before its distal end and reenters the catheter about 3 mm from its tip. The portion of the catheter distal to the reentry point is referred to as the "nose." When the wire is tightened, the tip of the catheter is bowed so that the exposed wire is brought away from the catheter. There are also sphincterotomes available that can rotate (Autotome Rx, Boston Scientific, Natick, MA) and may facilitate better sphincterotome and cutting wire orientation.
Nose length — Pull-type sphincterotomes are available with long and short noses. Compared with the long-nosed devices, the short-nosed devices are more responsive to bowing, provide more control during sphincterotomy, and often do not require deep cannulation before the cutting wire exits the endoscope. However, they are more likely to become inadvertently dislodged from the bile duct. With the widespread (nearly universal) use of multilumen sphincterotomes and over the wire sphincterotomies, the long-nose devices are now rarely used.
Diathermy wire — Another variable distinguishing sphincterotomes is the length of the exposed wire, which ranges from 15 to 40 mm. Devices with longer wires follow the natural curve of the endoscope and elevator, and are more likely to enter the papilla in the correct orientation. However, the longer length of wire may not always be an advantage since the ideal transfer of energy occurs when a short segment of cutting wire is applied to sphincter tissue. The most commonly used cutting wires are 25 and 30 mm long. To limit contact of the cutting wire with the endoscope channel, one sphincterotome has insulation covering the proximal one-half (CleverCut, Olympus).
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