Endoscopic papillary balloon dilation for revision of a symptomatic post-sphincterotomy stricture

Abstract

Post-sphincterotomy stricture is among the more uncommon long-term complications of preceeding endoscopic retrograde cholangiopancreatography (ERCP) including endoscopic sphincterotomy.¹ Overall, its incidence is estimated at up to 5% in long-term follow-up, warranting revision ERCP. In lack of a standard revision procedure, endoscopic treatment warrants individualization according to patient- (anatomy-directed) and operator-related (experience, etc.) factors to appropriately choose for example, among re-do papillotomy, balloon dilation and/or temporary metal or multiple plastic stenting.^{2, 3} Specifically, re-do cutting translates into higher risks of bleeding and/or perforation, while stenting and/or dilation is associated with higher post-ERCP pancreatitis (PEP) risks, such that intensified PEP prophylaxis is indicated, as was the case in this 45-year-old female with a symptomatic post-sphincterotomy stricture.⁴ The distinct selection of the revision procedure has to be taken into account aspects of duodenal anatomy (qualifying or not for a safe re-do papillotomy), severity and length of stricture (implying candidacy for stent treatment) as well as individual and institutional experience. The current patient had undergone index ERCP 3 years earlier elsewhere including endoscopic papillotomy to allow for extraction of bile duct stones. The recent ERCP was indicated due to biliary type-pain and elevated cholestasis parameters in association with common bile duct (CBD) dilation on abdominal ultrasound. Duodenoscopy indicated an excentric and severely shrunken biliary orifice post-sphincterotomy without adequate safety plane for re-do papillotomy (no intraduodenal bile duct segment) (Figure 1). After deep-biliary cannulation, a cholangiogram was performed with CBD diameter up to 14 mm with reduced contrast media clearance. After insertion of a 35″ hydrophilic-tip guidewire, endoscopic papillary balloon dilation (EPBD) up to 10 mm was performed (Supplementary  Video). The post-interventional course was uncomplicated with complete pain and cholestasis resolution, which was maintained throughout the follow-up period of 1 year.

The author declares no conflict of interest.

Ethical approval was waived (clinical routine case); informed consent has been obtained.