Repeat endoscopic biliary sphincterotomy: indications and complications

ABSTRACT

Endoscopic biliary sphincterotomy [EBS] carries a substantial risk of recurrent choledocholithiasis but retreatment with endoscopic retrograde cholangiopancreatography [ERCP] and repeat EBS is safe and feasible. However, long term results of repeat ERCP and EBS and risk factors for late complications are largely unknown. The aim of this study was to investigate indications and early complications after repeat EBS compared to patients with initial EBS, as well as the long term outcome of repeat ERCP with or without EBS for recurrent bile duct stones. Risk factors predicting late choledochal complications will be identified. Two groups of patients were included. The first group included 28 patients underwent repeat ERCP combined with EBS in 24 for post-EBS recurrent choledocholithiasis. The second group included 25 patients with symptoms of biliary obstruction and underwent ERCP and initial EBS. Early complications were compared for both groups. Patients in group I were followed for long term outcomes of repeat ERCP and EBS were assessed by multivariate analysis. Complete stone clearance was achieved in all patients in both groups. 16 patients in group 1 had no visible evidence of prior sphincterotomy. Early complications occurred in 3 patients in group I and 4 patients in group II. During a follow up period of 0.9 - 2.3 years [mean 1.4 yrs.] for patients in group I, 8 of them [28.5%] developed late complications including stone recurrence [5 patients], acute acalculous cholangitis [2 patients], and acute cholecystitis [1 patient]. There were no deaths attributable to biliary disease. Multivariate analysis identified three independent risk factors for choledochal complications interval between initial EBS and repeat ERCP and EBS bile duct diameter >/= 15 mm., and periampullary diverticulum. Choledochal complications were successfully treated with repeat ERCP with or without EBS in 4 patients. Repeat EBS is a safe and effective procedure to manage recurrent biliary and pancreatic complications after initial EBS. The commonest early indications in our study included bleeding at the time of initial EBS, small length of EBS and failure to continue the procedure due to cholangitis, and multiple stones with variable sizes with inability to clear the bile ducts through the initial EBS. Late indications were mainly due to suspected recurrent bile duct stones as indicated by upper right quadrant abdominal pain with elevation of cholestatic enzymes or jaundice, cholangitis, and bile duct lithiasis and dilation proved by ultrasonography. Tight stenosis of biliary orifice which is one of the indications of repeat EBS was not found in our patients. Early complications of repeat EBS are less than initial one. However late choledochal complications after repeat EBS are relatively frequent but are endoscopically manageable. Careful follow up is necessary, particularly for patients with dilated bile ducts, periampullary diverticulum, or early recurrence. Repeat ERCP with or without EBS is a reasonable treatment even for recurrent choledocholithiasis after initial EBS