Complications of Endoscopic Biliary Sphincterotomy
Martin L. Freeman, M.D., Douglas B. Nelson, M.D., Stuart Sherman, M.D., Gregory B. Haber, M.D., Mary E. Herman, R.N., Paul J. Dorsher, M.D., Joseph P. Moore, M.D., M. Brian Fennerty, M.D., Michael E. Ryan, M.D., Michael J. Shaw, M.D., Jeffrey D. Lande, M.S., and Alfred M. Pheley, Ph.D.
Background Endoscopic sphincterotomy is commonly used to removebile-duct stones and to treat other problems. We prospectivelyinvestigated risk factors for complications of this procedureand their outcomes.
Methods We studied complications that occurred within 30 daysof endoscopic biliary sphincterotomy in consecutive patientstreated at 17 institutions in the United States and Canada from1992 through 1994.
Results Of 2347 patients, 229 (9.8 percent) had a complication,including pancreatitis in 127 (5.4 percent) and hemorrhage in48 (2.0 percent). There were 55 deaths from all causes within30 days; death was directly or indirectly related to the procedurein 10 cases. Of five significant risk factors for complicationsidentified in a multivariate analysis, two were characteristicsof the patients (suspected dysfunction of the sphincter of Oddias an indication for the procedure and the presence of cirrhosis)and three were related to the endoscopic technique (difficultyin cannulating the bile duct, achievement of access to the bileduct by "precut" sphincterotomy, and use of a combined percutaneous–endoscopicprocedure). The overall risk of complications was not relatedto the patient's age, the number of coexisting illnesses, orthe diameter of the bile duct. The rate of complications washighest when the indication for the procedure was suspecteddysfunction of the sphincter of Oddi (21.7 percent) and lowestwhen the indication was removal of bile-duct stones within 30days of laparoscopic cholecystectomy (4.9 percent). As comparedwith those who performed fewer procedures, endoscopists whoperformed more than one sphincterotomy per week had lower ratesof complications (8.4 percent vs. 11.1 percent, P = 0.03).
Conclusions The rate of complications after endoscopic biliarysphincterotomy can vary widely in different circumstances andis primarily related to the indication for the procedure andto endoscopic technique, rather than to the age or general medicalcondition of the patient.
Source Information
From the Hennepin County Medical Center, Minneapolis (M.L.F., J.D.L., A.M.P.); the Minneapolis Veterans Affairs Medical Center, Minneapolis (D.B.N.); Indiana University Medical Center, Indianapolis (S.S.); Wellesley Hospital, Toronto (G.B.H.); the University of Minnesota Hospital and Clinic, Minneapolis (M.E.H.); St. Cloud Clinic of Internal Medicine, St. Cloud, Minn. (P.J.D.); Duluth Clinic, Duluth, Minn. (J.P.M.); the University of Arizona, Tucson (M.B.F.); the Marshfield Clinic, Marshfield, Wis. (M.E.R.); and Park Nicollet Clinic, Minneapolis (M.J.S.). Other contributing authors were Robert D. Mackie, M.D., Digestive Health Care, Minneapolis; Joanne C. Imperial, M.D., California Pacific Medical Center, San Francisco; Stephen E. Silvis, M.D., Minneapolis Veterans Affairs Medical Center, Minneapolis; Paul P. Kortan, M.D., Wellesley Hospital, Toronto; William B. Silverman, M.D., University of Pittsburgh, Pittsburgh; John T. Cunningham, M.D., Medical University of South Carolina, Charleston; James A. DiSario, M.D., University of Utah Medical Center, Salt Lake City; Priya A. Jamidar, M.D., University of California at Los Angeles, Los Angeles; Paul N. Yakshe, M.D., University of Minnesota Hospital and Clinic, Minneapolis; and George M. Logan, M.D., St. Paul–Ramsey Medical Center, St. Paul, Minn. Institutions and endoscopists participating in the study are listed in the Appendix.
Address reprint requests to Dr. Freeman at the Department of Medicine, Hennepin County Medical Center, 701 Park Ave., Minneapolis, MN 55415.
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