Is there a Need for Dual Sphincterotomy in Patients with Chronic Pancreatitis?

Kim et al. raise the interesting question of whether biliary sphincterotomy is mandatory to prevent patients from developing acute cholangitis due to edema after endoscopic pancreatic sphincterotomy (EPS) alone, in patients with chronic pancreatitis.

To address the first point about EPS technique: biliary sphincterotomy was not generally performed in our series. The biliary sphincter was cut previously or in the same session in only seven of the 171 patients (4.1 %), to facilitate management of accompanying biliary complications (e. g., stent placement for biliary stricture and bile duct stone removal). No episodes of acute cholangitis related to EPS were observed during the follow-up period [1].

Kim et al. also raise the question of whether there is a need for dual sphincterotomy in general, or in patients with a special risk profile. The need for biliary sphincterotomy before pancreatic sphincterotomy, in order to maintain biliary drainage, is still a matter of controversy [2]. In a study by Kozarek et al., 3.6 % (of 56 patients) suffered from acute cholangitis after EPS [3]. Another study of 76 patients with chronic pancreatitis reported acute cholangitis in three patients after EPS [4], but surprisingly, all of the patients undergoing EPS at the major papilla (n = 62) received a biliary sphincterotomy at the same session.

The first (and to our knowledge only) prospective randomized study on dual sphincterotomy in chronic pancreatitis versus EPS alone was published by Kim et al. [5]. They conclude that biliary sphincterotomy following EPS is not mandatory in general and should be limited to patients with elevated alkaline phosphatase (AP) levels and a dilated common bile duct (CBD). Fifty-six percent (five of nine) patients with at least a twofold elevation of AP and a CBD diameter greater than 12 mm had acute cholangitis after EPS alone - a rate that seems unusually high.

Several reports on EPS in patients with chronic pancreatitis have not mentioned acute cholangitis as a clinical problem. It should be recognized that these studies did not focus on the risk factors described by Kim et al. [5]. However, distal common bile duct strictures have been reported to occur in 2.7 - 45.6 % of patients with chronic pancreatitis in general [2], and therefore several patients in these series may have had the potential risk factors.

In a study by Elton et al. [6], none of 134 patients with EPS had acute cholangitis, while only 16 of the 134 (12 %) did not receive biliary drainage after EPS. Smits et al. reported on 51 patients with EPS and pancreatic stent placement for chronic pancreatitis [7]. EPS (without biliary sphincterotomy) was performed in 31 of these patients, and no episodes of cholangitis were reported. In another study of 93 patients with chronic pancreatitis, EPS was carried out using the Erlangen-type sphincterotome [8]. Biliary sphincterotomy was not routinely performed either before or after EPS, and again there were no cases of acute cholangitis. These data are comparable with those of the previous largest study on EPS in chronic pancreatitis, including 118 patients [9]. The number of biliary ESTs is not stated in detail in this report, but at least 65.3 % of the study cohort did not undergo biliary sphincterotomy. Even in this large series, no episodes of acute cholangitis were clinically evident. In our study, EPS was performed in 171 patients with chronic pancreatitis, and again, no cases of acute cholangitis were observed [1].

In our opinion, dual sphincterotomy should not be generally recommended for patients with chronic pancreatitis. The potential benefits of dual sphincterotomy have to be weighed up against the well-known risks of biliary sphincterotomy [10]. Possible criteria for selecting patients for dual sphincterotomy (e. g., elevated AP, dilated CBD) [2] need to be clarified by larger randomized controlled trials, as most of the recently published series have not reported any problems with acute cholangitis after EPS alone.

As is known from the literature, patients may develop acute cholangitis even after dual sphincterotomy [4]. Further studies should therefore address two questions: Firstly, are there additional risk factors for acute cholangitis after EPS (e. g., the volume of contrast media injected into the bile duct)? And secondly, if there are clear risk factors, is biliary sphincterotomy sufficient for patients who are at risk, or do they need nasobiliary drainage to prevent them from developing cholangitis?

References

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