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Duodenoscopy image of two pigment stones extracted from the common bile duct after endoscopic sphincterotomy.

Pancreatic sphincterotomy is a procedure performed during endoscopic retrograde cholangiopancreatography (ERCP) to incise the pancreatic sphincter muscle at the major or minor duodenal papilla.[1]

Pancreatic sphincterotomy is used for the management of sphincter of Oddi dysfunction (the valve controlling bile and pancreatic juice does not work properly), pancreas divisum (pancreatic juice drains through a smaller opening), and chronic pancreatitis. [2][3] It is generally avoided in individuals with bleeding disorders (blood does not clot normally), severe heart or lung disease, and active pancreatitis.[4]

The current standard practice utilizes two techniques: pull-type sphincterotomy (the standard wire-guided method) and needle-knife sphincterotomy (often guided by a pancreatic stent).[1] Common complications include pancreatitis, bleeding, and perforation.[1] Recovery is quick with mild chest and abdominal pain that resolves over time.[5][6]

The development of pancreatic sphincterotomy began in 1887 with the description of the sphincter of Oddi and evolved from open surgery in the early 20th century to the modern endoscopic approach developed in the 1970s.[7][8][9]

Indications

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Sphincter of Oddi Dysfunction (SOD)

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Sphincter of Oddi dysfunction (SOD) occurs predominantly in females.[10] It may impair the outflow of pancreatic juice, leading to recurrent pancreatitis or chronic stomach pain.[11] Pancreatic sphincterotomy is often performed for patients with type II SOD, characterized by abnormal pressure readings, or in those who do not improve after biliary sphincterotomy (bile duct sphincter excision).[2] SOD affects both the biliary and pancreatic parts of the sphincter complex, but pancreatic sphincterotomy only treats the pancreatic part and is reserved for pancreatic duct dysfunction.[2]

Pancreas Divisum

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In pancreas divisum, the majority of pancreatic juice drains through the smaller minor papilla instead of the larger major papilla.[12] Pancreatic sphincterotomy is achieved through endoscopic minor papillotomy to alleviate outflow obstruction at the minor papilla. This procedure is primarily considered for those with recurrent acute pancreatitis. The benefit appears greatest for this group, whereas outcomes are less favorable for patients with chronic pancreatitis.[2]

Chronic Pancreatitis with Ductal Obstruction or Hypertension

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Patients with chronic pancreatitis may have long-term stomach pain resulting from pancreatic duct stenosis (narrowing) or calculi (stones), leading to elevated pressure within the pancreatic duct. Procedures that relieve pressure in the pancreatic duct, such as endoscopic sphincterotomy, can alleviate symptoms in some patients with chronic pancreatitis.[2] Additionally, sphincter of Oddi incision can prevent repeated episodes of pancreatitis caused by obstructed drainage of pancreatic juice.[13]

Supplementary to Endoscopic Management of Pancreatic Duct Stones or Strictures

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A pancreatic sphincterotomy can be performed to facilitate therapeutic procedures within the pancreatic duct, such as stone extraction, widening narrowed areas (strictures) with a balloon, and placement of pancreatic duct stents (small tubes). The treatment improves drainage and makes it easier to insert instruments by opening the duct wider.[3] Additional indications include stent placement before surgery for mucinous ductal ectasia (a cyst-like growth in the duct) and stenting in the treatment of pancreatic fistula (an abnormal connection that leaks pancreatic fluid).[1]

Contraindications

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Pancreatic duct sphincterotomy carries significant risks. Contraindications include:

Coagulopathy and Bleeding Disorders

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Uncorrected coagulopathy (blood fails to clot properly) is a contraindication. The American Society for Gastrointestinal Endoscopy (ASGE) classifies therapeutic sphincterotomy as a high-bleeding risk procedure.[14] Bleeding risk increases significantly when the international normalized ratio (INR, a measure of blood clotting time) exceeds 1.5 or the platelet count falls below 50,000/μL.[4]

Acute Pancreatitis (Non-biliary)

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In patients with active acute pancreatitis that is not caused by biliary obstruction, ERCP (with pancreatic sphincterotomy) is typically avoided as the procedure could worsen pancreatic inflammation. However, if there are clear indicators of emergency, such as biliary blockage or infection, urgent ERCP is necessary.[4]

Severe Cardiopulmonary Disease

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ERCP often requires moderate to deep sedation or general anesthesia. Patients with severe heart and lung problems, such as decompensated heart failure, advanced lung disease, or a recent heart attack, are at higher risk of complications. In such patients, the risks and benefits must be carefully weighed before proceeding.[4]

Anatomical Limitations or Failed Cannulation

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Procedure feasibility may be limited by changes in the anatomy of the digestive tract (for example, prior gastric bypass surgery), significant duodenal stenosis (narrowing of the duodenum), or multiple failed cannulation attempts. In some circumstances, different techniques such as percutaneous (through the skin) or surgical interventions may be considered.[15]

Technique

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Major Papilla Sphincterotomy

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Pull-type sphincterotomy is the standard and most common technique for pancreatic sphincterotomy at the major duodenal papilla.[1] It involves deep wire-guided cannulation and advancement of a wire-guided pull-type sphincterotome (a catheter equipped with an electrosurgical cutting wire that bows under tension) into the pancreatic duct.[1] The correct placement of the device is confirmed by a contrast pancreatogram (an X-ray image of the pancreatic duct).[1][16] Cutting current from the electrosurgical generator is applied to incise the pancreatic sphincter to avoid pancreatic damage and stenosis (narrowing of the duct).[17] The cut typically ranges from 5 mm to 10 mm.[17] A pancreatic stent (tube) is often placed following the procedure to maintain ductal drainage and reduce the risk of obstruction from post-procedure edema (swelling).[1]

Needle-knife sphincterotomy serves as an alternative to the pull-type technique, typically performed when conventional cannulation fails.[17] It involves the positioning of a pancreatic stent and advancement of a needle-knife papillotome (a catheter with a protruding, retractable electrosurgical wire) to the part of pancreatic sphincter that sits directly above the stent. The incision is made along the longitudinal axis of the stent to "unroof" the part of the papilla inside the duodenum. The cut is the same as in pull-type sphincterotomy, ranging from 5 mm to 10 mm.[1]

Pre-cut Pancreatic Sphincterotomy

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Pre-cut pancreatic sphincterotomy uses a needle-knife to enter the pancreatic duct when standard wire-guided cannulation is unfeasible, such as in the presence of an impacted stone blocking the duct.[1][18] There are several options for this technique, among which the free-hand needle-knife method is most commonly used.[1][16] Once the pancreatic duct blockage is relieved and cannulation is achieved, conventional pancreatic sphincterotomy (pull-type or needle-knife) is performed.[1][16]

Minor Papilla Sphincterotomy

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Minor papilla sphincterotomy is indicated for patients with symptomatic pancreatic divisum who need pressure relief in the duct or who cannot undergo endoscopic treatment via the major papilla.[1][19] As with major papilla sphincterotomy, two techniques are available for minor papilla sphincterotomy: the pull-type and needle-knife methods.[1]

Pull-type sphincterotomy uses a pull-type papillotome passed over a soft-tipped hydrophilic guidewire after cannulation into the dorsal pancreatic duct. The incision wire is positioned in parallel with the duct to remove the raised mucosal tissue of the minor papilla using pure or mixed electrosurgical current from the generator.[1]

Needle-knife sphincterotomy of the minor papilla is analogous to that for the major papilla. After wire-guided cannulation, a small-caliber pancreatic stent is placed into the dorsal pancreatic duct along the guiding wire. Following positioning of the stent and removal of the guidewire, the part of the raised minor papillary tissue that sits above the stent is cut by a needle-knife. The covering of the minor papilla is removed using either pure or mixed electrosurgical current from the generator.[1]

Complications

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Early Complications

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Early complications usually appear within 72 hours following pancreatic sphincterotomy, with the majority manifesting within the first few hours.[1]

Post-procedural pancreatitis

Post-ERCP pancreatitis (PEP), inflammation of the pancreas, is the most concerning adverse event associated with pancreatic sphincterotomy. It is the least controllable complication, and may result in severe morbidity or mortality.[1]

PEP affects approximately 10 to 12 percent of individuals who undergo the procedure. Patients with the pancreatic type of sphincter of Oddi dysfunction (SOD) have a higher rate of PEP than those with chronic pancreatitis.[20]

For patients with SOD, placing a pancreatic stent during needle-knife sphincterotomy can lower the risk of PEP. This decision is made individually, weighing the likelihood of early pancreatitis against the chance of late complications.[1]

Treatment for PEP follows the same principles as that for acute pancreatitis.[5] Most patients improve with pain medications and intravenous fluid therapy.[5] Early assessment of disease severity helps identify patients at risk of developing severe PEP, allowing them to receive advanced life support, thereby improving prognosis.[5]

Bleeding

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Bleeding occurs in approximately 1 to 2 percent of pancreatic sphincterotomy procedures. About half of these cases are immediate bleeding, occurring during or within minutes to hours after the procedure, while the other half are delayed bleeding, occurring from hours to several days later.[21]

Risk factors include bleeding disorders, restarting blood-thinning medications (anticoagulants) within three days after the procedure, pre-existing bile duct infection, and lower endoscopist experience.[21]

Supportive non-invasive interventions are initially used, and endoscopic methods are applied if bleeding persists. For refractory bleeding (bleeding that does not stop by other treatments), angiographic embolization (a procedure that blocks the bleeding vessel using a catheter) or surgery is considered.[21]

Perforation

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Perforation is rare, affecting 0.3 to 1.3 percent of patients, but it can be a serious complication.[22]

Perforations are often asymptomatic initially, while symptoms such as severe abdominal pain, subcutaneous emphysema (air-trapping under the skin), abdominal distension (a swollen belly), fever, diaphoresis (cold sweating), and vomiting may appear at later stages.[23]

Management depends on the perforation locations, type, extent of fluid leakage, and symptoms.[23]

  • Guidewire perforations are mild and can be treated with medication alone.[22]
  • Peri-ampullary perforations are more serious, with higher morbidity and mortality. They require prompt drainage of bile away from the perforation site. Delayed diagnosis and surgery are associated with poorer outcomes.[22]
  • Duodenal perforations are the least common and generally require surgery.[22]

Late Complications

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Late complications occur at least 3 months after the procedure. They include papillary stenosis (narrowing of the sphincterotomy site) and proximal ductal strictures (narrowing of the pancreatic duct near the pancreas).[1]

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Pancreatic stents, while effective at reducing post-ERCP pancreatitis,[1] are associated with their own complications,[1][24] including:

  • pancreatic ductal and parenchymal changes (changes in status of pancreatic duct and pancreatic tissue): often reversible upon stent removal[1]
  • stone formation[1]
  • infection[1] which may cause fever and abdominal pain
  • ductal perforation[1] (a hole in the wall of the pancreatic duct)
  • stent migration[1][24]
  • stent occlusion which may cause pain and/or pancreatitis[1][24]
  • duodenal erosion[1] (damage to duodenal wall)

Recovery

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Patients may experience mild chest or abdominal pain, which typically gets better over time.[5][6] Post-procedure care focuses on managing discomfort and monitoring for complications like pancreatitis or bleeding.[5] Warning signs that require medical attention include fever, black sticky stool, and vomiting blood, as well as swelling, redness, and soreness near the insertion site in the abdomen that lasts more than 48 hours.[6]

History

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Theoretical Foundations

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In 1887, the sphincter of Oddi was first described by Ruggero Oddi as a muscle structure that controls the passage of bile and pancreatic juice into the duodenum.[7]

In the early 20th century, the American pathologist Eugene Opie suggested the "common channel hypothesis," which proposed that bile reflux into the pancreatic duct may cause pancreatitis. This theory established an early molecular framework relating sphincter failure to pancreatic inflammation.[25]

Development of Surgical Sphincterotomy (1919)

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The first surgical sphincterotomy is often credited to Canadian surgeon Edward W. Archibald in 1919, based on his experimental investigations of sphincter pressure and its association with pancreatitis.[8] Surgical transduodenal sphincterotomy was later studied as a therapy for recurrent pancreatitis and ductal blockage.[8]

Mid-20th Century Clinical Experience

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In 1956, Henry Doubilet and John H. Mulholland presented the findings of an eight-year study on transduodenal sphincterotomy. They studied hundreds of patients with recurrent pancreatitis. The study revealed alleviation of pain and reduction in repeated attacks, indicating the role of sphincterotomy in specific obstructive conditions.[13]

By the mid-twentieth century, sphincterotomy had become a standard surgical procedure for recurrent pancreatitis caused by ductal blockage. However, due to the high risk of complications, the treatment was recommended only for carefully selected patients.[26]

Transition to the Endoscopic Era (1970s Onward)

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The development of ERCP in the late 1960s and 1970s revolutionized the management of biliary and pancreatic diseases. Endoscopic sphincterotomy gradually replaced open surgical approaches for many indications.[9]

Endoscopic pancreatic sphincterotomy employs electrocautery to incise the sphincter under fluoroscopic guidance.[27] While less invasive than surgery, it carries a notable risk of complications. Overall ERCP-related complication rates range from 3 to 12 percent, with post-ERCP pancreatitis representing the most common adverse event.[28]

References

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  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Buscaglia, Jonathan M (2007). "Pancreatic sphincterotomy: Technique, indications, and complications". World Journal of Gastroenterology. 13 (30): 4064. doi:10.3748/wjg.v13.i30.4064. ISSN 1007-9327. PMC 4205306. PMID 17696223.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  2. 1 2 3 4 5 Bakman, Yan; Freeman, Martin L. (September 2012). "Update on biliary and pancreatic sphincterotomy:". Current Opinion in Gastroenterology. 28 (5): 420–426. doi:10.1097/MOG.0b013e32835672f3. ISSN 0267-1379.
  3. 1 2 Shaukat, Aasma; Wang, Amy; Acosta, Ruben D.; Bruining, David H.; Chandrasekhara, Vinay; Chathadi, Krishnavel V.; Eloubeidi, Mohamad A.; Fanelli, Robert D.; Faulx, Ashley L.; Fonkalsrud, Lisa; Gurudu, Suryakanth R.; Kelsey, Loralee R.; Khashab, Mouen A.; Kothari, Shivangi; Lightdale, Jenifer R. (August 2015). "The role of endoscopy in dyspepsia". Gastrointestinal Endoscopy. 82 (2): 227–232. doi:10.1016/j.gie.2015.04.003. ISSN 0016-5107.
  4. 1 2 3 4 Mukherjee, Dr. Jayanta. "Endoscopic Retrograde Cholangiopancreatography (ERCP): Indications, Patient Preparation and Complications - Walter Bushnell Healthcare Foundation". wbhf.walterbushnell.com. Retrieved 2026-03-24.
  5. 1 2 3 4 5 6 Cahyadi, Oscar; Tehami, Nadeem; de-Madaria, Enrique; Siau, Keith (2022-09-12). "Post-ERCP Pancreatitis: Prevention, Diagnosis and Management". Medicina (Kaunas). 58 (9): 1261. doi:10.3390/medicina58091261. ISSN 1648-9144. PMC 9502657. PMID 36143938.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  6. 1 2 3 "ERCP Advice on Discharge - Bedfordshire Hospitals NHS Trust". Bedfordshire Hospitals NHS Trust. Archived from the original on 2025-06-16. Retrieved 2026-04-09.
  7. 1 2 Ono, Keiichi; Hada, Ryukichi (July 1988). "Ruggero oddi to commemorate the centennial of his original article—"Di una speciale disposizione a sfintere allo sbocco del coledoco"". The Japanese Journal of Surgery. 18 (4): 373–375. doi:10.1007/BF02471459. ISSN 0047-1909.
  8. 1 2 3 Navarro, Salvador (November 2017). "The art of pancreatic surgery. Past, present and future. The history of pancreatic surgery". Gastroenterología y Hepatología (English Edition). 40 (9): 648.e1–648.e11. doi:10.1016/j.gastre.2017.10.010.
  9. 1 2 Meseeha, Marcelle; Goosenberg, Eric; Attia, Maximos (2026), "Endoscopic Retrograde Cholangiopancreatography", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 29630212, retrieved 2026-03-24
  10. ↑ Crittenden, Jordan P.; Dattilo, Jeffery B. (2026), "Sphincter of Oddi Dysfunction", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 32491794, retrieved 2026-03-24
  11. ↑ Delhaye, M; Matos, C; Arvanitakis, M; Devière, J (2008). "Pancreatic ductal system obstruction and acute recurrent pancreatitis". World Journal of Gastroenterology. 14 (7): 1027. doi:10.3748/wjg.14.1027. ISSN 1007-9327. PMC 2689404. PMID 18286683.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  12. ↑ Gutta, Aditya; Fogel, Evan; Sherman, Stuart (2019-11-02). "Identification and management of pancreas divisum". Expert Review of Gastroenterology & Hepatology. 13 (11): 1089–1105. doi:10.1080/17474124.2019.1685871. ISSN 1747-4124. PMC 6872911. PMID 31663403.
  13. 1 2 Doubilet, Henry (1956-02-18). "EIGHT-YEAR STUDY OF PANCREATITIS AND SPHINCTEROTOMY". Journal of the American Medical Association. 160 (7): 521. doi:10.1001/jama.1956.02960420001001. ISSN 0002-9955.
  14. ↑ Acosta, Ruben D.; Abraham, Neena S.; Chandrasekhara, Vinay; Chathadi, Krishnavel V.; Early, Dayna S.; Eloubeidi, Mohamad A.; Evans, John A.; Faulx, Ashley L.; Fisher, Deborah A.; Fonkalsrud, Lisa; Hwang, Joo Ha; Khashab, Mouen A.; Lightdale, Jenifer R.; Muthusamy, V. Raman; Pasha, Shabana F. (January 2016). "The management of antithrombotic agents for patients undergoing GI endoscopy". Gastrointestinal Endoscopy. 83 (1): 3–16. doi:10.1016/j.gie.2015.09.035.
  15. ↑ Testoni, Pier; Mariani, Alberto; Aabakken, Lars; Arvanitakis, Marianna; Bories, Erwan; Costamagna, Guido; Devière, Jacques; Dinis-Ribeiro, Mario; Dumonceau, Jean-Marc; Giovannini, Marc; Gyokeres, Tibor; Hafner, Michael; Halttunen, Jorma; Hassan, Cesare; Lopes, Luis (2016-06-14). "Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline". Endoscopy. 48 (07): 657–683. doi:10.1055/s-0042-108641. ISSN 0013-726X.
  16. 1 2 3 Freeman, Martin L.; Guda, Nalini M. (January 2005). "ERCP cannulation: a review of reported techniques". Gastrointestinal Endoscopy. 61 (1): 112–125. doi:10.1016/S0016-5107(04)02463-0.
  17. 1 2 3 Delhaye, Myriam; Matos, Celso; Devière, Jacques (2003-10-01). "Endoscopic management of chronic pancreatitis". Gastrointestinal Endoscopy Clinics of North America. Therapeutic ERCP: State of the Art. 13 (4): 717–742. doi:10.1016/S1052-5157(03)00070-9. ISSN 1052-5157.
  18. ↑ "Techniques of Selective Cannulation and Sphincterotomy". Endoscopy. 35 (8): 19–23. August 2003. doi:10.1055/s-2003-41532. ISSN 0013-726X.
  19. ↑ Vila, Jj; Kutz, M (October 2013). "Sphincterotomy of the Minor Papilla". Video Journal and Encyclopedia of GI Endoscopy. 1 (2): 588–592. doi:10.1016/S2212-0971(13)70252-8.
  20. ↑ Ross, Andrew S.; Kozarek, Richard A. (November 2010). "Therapeutic pancreatic endoscopy". Digestive and Liver Disease. 42 (11): 749–756. doi:10.1016/j.dld.2010.05.003. ISSN 1590-8658.
  21. 1 2 3 Ghoz, Hassan M.; Abu Dayyeh, Barham K. (October 2014). "Hemorrhagic complications following endoscopic retrograde cholangiopancreatography". Techniques in Gastrointestinal Endoscopy. 16 (4): 175–182. doi:10.1016/j.tgie.2014.07.002.
  22. 1 2 3 4 Wu, Hao M.; Dixon, Elijah; May, Gary R.; Sutherland, Francis R. (October 2006). "Management of perforation after endoscopic retrograde cholangiopancreatography (ERCP): a population-based review". HPB. 8 (5): 393–399. doi:10.1080/13651820600700617. PMC 2020744. PMID 18333093.
  23. 1 2 Cho, Kwang Bum (2014). "The Management of Endoscopic Retrograde Cholangiopancreatography-Related Duodenal Perforation". Clinical Endoscopy. 47 (4): 341. doi:10.5946/ce.2014.47.4.341. ISSN 2234-2400. PMC 4130890. PMID 25133122.
  24. 1 2 3 Monino, Laurent; Deprez, Pierre H. (2022), "Complications of Pancreatic Stents", Gastrointestinal and Pancreatico-Biliary Diseases: Advanced Diagnostic and Therapeutic Endoscopy, Springer, Cham, pp. 1703–1718, doi:10.1007/978-3-030-56993-8_99, ISBN 978-3-030-56993-8, retrieved 2026-03-25{{citation}}: CS1 maint: work parameter with ISBN (link)
  25. ↑ Navarro, Salvador (February 2018). "Revisión histórica de algunos conocimientos sobre pancreatitis aguda". Gastroenterología y Hepatología (in Spanish). 41 (2): 143.e1–143.e10. doi:10.1016/j.gastrohep.2017.11.004.
  26. ↑ Anderson, Timothy M.; Pitt, Henry A.; Longmire, William P. (April 1985). "Experience with Sphincteroplasty and Sphincterotomy in Pancreatobiliary Surgery:". Annals of Surgery. 201 (4): 399–406. doi:10.1097/00000658-198504000-00001. ISSN 0003-4932. PMC 1250725. PMID 3977443.
  27. ↑ Meseeha, Marcelle; Goosenberg, Eric; Attia, Maximos (2026), "Endoscopic Retrograde Cholangiopancreatography", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 29630212, retrieved 2026-03-25
  28. ↑ Chandrasekhara, Vinay; Khashab, Mouen A.; Muthusamy, V. Raman; Acosta, Ruben D.; Agrawal, Deepak; Bruining, David H.; Eloubeidi, Mohamad A.; Fanelli, Robert D.; Faulx, Ashley L.; Gurudu, Suryakanth R.; Kothari, Shivangi; Lightdale, Jenifer R.; Qumseya, Bashar J.; Shaukat, Aasma; Wang, Amy (January 2017). "Adverse events associated with ERCP". Gastrointestinal Endoscopy. 85 (1): 32–47. doi:10.1016/j.gie.2016.06.051.
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