Sphincterotomy-associated biliary strictures: features and endoscopic management

Background: "Sphincterotomy stenosis" is a recognized late complication of endoscopic biliary sphincterotomy. The narrowing is limited to the biliary orifice and can be managed simply by repeat sphincterotomy, A similar but p oorly characterized post-sphincterotomy complication involves narrowing tha t extends from the biliary orifice for a variable distance along the bile d uct, beyond the duodenal wall,This lesion cannot be managed by repeating th e sphincterotomy. Mefhods: Six patients (3 men) are described with sphincterotomy associated biliary strictures, ail smooth and high grade, presenting at a median of 19 months (range 8 to 60 months) after sphincterotomy. Further sphincterotomy was not possible as an intra-duodenal segment of bile duct was no longer v isible, Endoscopic management consisted of serial incremental stent exchang e at 2- to 4-month intervals. The goal of therapy was to place two 11.5F st ents side-by-side. Results: Stricture resolution was documented by cholangiography in all pati ents. One patient with a stricture resistant to treatment required three 10 F stents side-by-side, and another underwent treatment to a maximum of adja cent 11.5F and 7F stents. Two 11.5F stents were eventually placed in the ot her four patients. Overall median duration of stent placement was 12.5 mont hs. At a median of 26.5 months of stent-free follow-up, all patients remain asymptomatic, Conclusion: Sphincterotomy-associated biliary strictures are a distinct lat e complication of biliary sphincterotomy. These recalcitrant lesions are no t amenable to repeat sphincterotomy; however, the results of this study sug gest that they may be managed successfully by serial placement of stents of incrementally increasing diameter.