Transpapillary stenting of proximal biliary strictures: Does biliary sphincterotomy reduce the risk of postprocedure pancreatitis?

Background: Pancreatitis after biliary stenting is a rare complication. To reduce this risk, some endoscopists routinely perform biliary sphincterotomy before stenting, but the value of this practice is not established. Methods: The incidence of pancreatitis was reviewed in patients undergoing biliary stenting with and without a biliary sphincterotomy. Results: Postprocedure pancreatitis occurred in 4 of 83 (4.8%) patients treated with transpapillary biliary stents. Patients with proximal biliary strictures were at significantly increased risk for postprocedure pancreatitis (4 of 24) versus those with distal or no strictures (0 of 59) (p = 0.006). The four patients with pancreatitis after stenting had not undergone sphincterotomy. Of those treated conservatively, two cases were graded severe (one fatal), and one was mild. The other patient was markedly symptomatic from pancreatitis, but improved dramatically after treatment with a needle-knife sphincterotomy done within 24 hours of the original ERCP. Conclusion: The risk of pancreatitis following transpapillary biliary stenting is increased in patients with proximal biliary strictures. Such lesions (malignant or benign) may serve as a fulcrum, leading to medial deflection of the stent and compression of the pancreatic orifice. The hypothesis that sphincterotomy may decrease the risk of biliary stent- induced obstructive pancreatitis should be tested in patients with proximal biliary strictures.