Systematic Biliary Sphincterotomy

Manley C Uy, Virgilio P Banez, Ma Lourdes O Daez,
Peter P Sy, Wendell Z Espinosa, Marilyn C Talingdan-Te
Section of Gastroenterology, Department of Medicine,
Philippine General Hospital, University of the Philippines. Manila, Philippines
Many thanks to Drs. Shrode and Kahaleh for their
comments [1] on our paper “Early ERCP in acute
gallstone pancreatitis without cholangitis: A meta-
analysis” [2]. They have raised an argument for biliary
sphincterotomy which deserves further comment.
Drs. Shrode and Kahaleh [1] noted correctly that two
out of the three mortalities in the early ERCP group of
the Oria study [3] were not reported to be directly due
to ERCP. However, it is worthwhile to take into
consideration that one mortality was attributed to
progressive respiratory failure despite early ERCP and
sphincterotomy. Taking note that the incidence of
severe and mild pancreatitis and other demographic
and clinical characteristics were grossly the same in
both groups, only one patient died in the early
conservative group. Furthermore, both groups had the
same number of patients undergoing surgery (45 early
ERCP vs. 47 early conservative, respectively) but
nobody in the early conservative group died from
biliary surgery as compared to the mortality in the early
ERCP group which was attributed to elective biliary
surgery. it was interesting that there was the absence of
mortality in the early conservative group despite more
complicated surgeries due to the larger number of
patients necessitating transcystic ductal stone clearance
and/or laparoscopic/open choledochotomy for main
bile duct stones (one in the early ERCP vs. 19 in the
early conservative management group). The large
number of early conservative management patients
with positive intraoperative cholangiography (40%),
meaning persistent common bile duct stone, also raises
doubts as to the need for early ERCP with
sphincterotomy [3]. As to the study of Folsch et al. [4],
although Drs. Shrode and Kahaleh [1] correctly noted
that 22 patients in the early conservative management
group required ERCP and that four patients died from
cholecystitis and/or jaundice, they failed to note that
there were fewer patients who died from respiratory
and renal failure than in the early ERCP group. The
two aforementioned organ failures are both possible
complications of acute pancreatitis. This was in a
background of the same demographic characteristics
(including severity of pancreatitis) [4]. Also, the fact
that multiple conservatively managed patients
eventually need ERCP with sphincterotomy is not the
issue; it is the timing of the intervention and not just
the need for it.
Drs. Shrode and Kahaleh [1] were also correct in
saying that both studies failed to note mortalities
according to whether or not sphincterotomy was
carried out. However, Oria et al. [3] did have
information regarding morbidities in the setting of
sphincterotomy. Though there was no significant
differences between the two groups in the incidence of
organ failure on admission and of new or persisting
organ failures, all five patients in the early ERCP group
who developed new organ failures and four out of the
five patients who had persistent organ failures had
morbidiries [3]. In the study of Folsch et al. [4],
papillotomy in the early ERCP group resulted in 2
episodes of bleeding. There were no complications of
papillotomy in the early conservative management
group [4]. If sphincterotomy was really needed and
helpful, there should have been better numbers in the
sphincterotomy group. As it is, the data is in favor of
early conservative management despite the fact that
there were more patients in the early ERCP group of
both studies undergoing sphincterotomy (74.5% in the
Oria study [3] and 46% in the Folsch study [4]).
Biliary sphincterotomy, even in the absence of
pancreatitis, is not without risks. It can result in
Received September 15th, 2009
Key words
Cholangitis; Gallstones; Pancreatitis, Acute
Necrotizing; Sphincterotomy, Endoscopic
Correspondence Manley C Uy

Page 2
JOP. J Pancreas (Online) 2009 Nov 5; 10(6):703-704.
JOP. Journal of the Pancreas - - Vol. 10, No. 6 - November 2009. [ISSN 1590-8577]
bleeding, perforation, cholangitis and pancreatitis itself
[5]. Admittedly, endoscopic expertise plays a major
role in the outcome, but only a minority of
endoscopists achieve an adequate volume of cases to
become experts, and referral to specialized centers is
usually not feasible [3, 6]. Therefore, we could not just
recommend that all cases of gallstone pancreatitis
(suspected or confirmed) undergo biliary
sphincterotomy. We reiterate our suggestion that more
evidence is needed from adequately powered
randomized placebo-controlled multicenter studies
using patients diagnosed with a standardized definition
of gallstone acute pancreatitis plus confirmed
choledocholithiasis but without obstructive jaundice
and/or acute cholangitis presenting within a clearly
defined period after onset of the disease. In the
meantime, it might be prudent not to carry out early
ERCP with or without endoscopic sphincterotomy in
patients with gallstone acute pancreatitis unless there is
at least a slight suspicion of cholangitis or persistent
ampullary obstruction [2].
Potential conflict of interest None known
Shrode CW, Kahaleh M. Early ERCP in acute gallstone
pancreatitis without cholangitis: a need for systematic biliary
sphincterotomy! JOP. J Pancreas (Online) 2009; 10:701-2. [PMID
Uy MC, Daez ML, Sy PP, Banez VP, Espinosa WZ, Talingdan-
Te MC. Early ERCP in acute gallstone pancreatitis without
cholangitis: a meta-analysis. JOP. J Pancreas (Online) 2009; 10:299-
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J, editors. Advanced Digestive Endoscopy:ERCP.
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