On Balance, Benefit of Sphincterotomy for Biliary Stenting Appears to Outweigh the Risk

On Balance, Benefit of Sphincterotomy for Biliary Stenting Appears to Outweigh the Risk

Bret T. Petersen, MD, MASGE, reviewing Kato S, et al. Clin Gastroenterol Hepatol 2021 Aug 13.

Limited reports have suggested that endoscopic biliary sphincterotomy (ES) at the time of transpapillary biliary stent placement may reduce the risk of post-ERCP pancreatitis (PEP). These investigators performed a randomized controlled trial at 26 centers to assess the incidence of PEP within 2 days of plastic endoscopic biliary stent or drain placement among patients assigned to ES (n=185) versus those assigned to no ES (n=185) prior to stent placement. Other adverse events attributable to biliary stenting within 30 days were also identified. 

Overall, 43 patients (12%) experienced PEP, including 7 with a prior ES (3.9%; 5 mild, 2 severe) and 36 without prior ES (20.6%; 26 mild, 5 moderate, 5 severe) (P<.001; 95% confidence interval, 10.1%-23.3%). This result was well beyond the predetermined 6% margin of noninferiority. Rates of cholangitis, cholecystitis, perforation, and recurrent biliary obstruction were not different, but bleeding was more common with ES (8 of 181 cases, 1 severe) than without (1 of 175 cases) (P=.048).

Bret T. Petersen, MD, FASGE


In this randomized trial, performance of ES reduced the incidence of PEP when plastic biliary stenting was performed. It is unknown whether similar benefits accrue in patients receiving larger caliber self-expanding metal stents. Whether specific comorbidities or anatomic features might enable prophylactic intervention or exclusion of those destined for post-ES bleeding will be of interest.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.


Kato S, Kuwatani M, Onodera M, et al. Risk of pancreatitis following biliary stenting with/without endoscopic sphincterotomy: a randomized controlled trial. Clin Gastroenterol Hepatol 2021 Aug 13. (Epub ahead of print) (https://doi.org/10.1016/j.cgh.2021.08.016)

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