494 GASTROINTESTINAL ENDOSCOPY VOLUME 52, NO. 4, 2000 Narrowing of the biliary orifice after previous endoscopic biliary sphincterotomy (EBS) has been referred to as “sphincterotomy stenosis” and is a rec- ognized late and uncommon complication of this procedure. 1,2 Whether it is due to previously inade- quate electrosurgical division of the sphincter mus- cle or a fibrotic reaction at the site of the incision is unclear. The narrowing is usually limited to the bil- iary orifice and can be managed simply by repeating EBS, thus enlarging the orifice. 2,3 A clear distinction has not been drawn between this entity and a similar obstructive post-sphincter- otomy lesion that is not amenable to further EBS. In the latter the narrowing extends for a variable dis- Sphincterotomy-associated biliary strictures: features and endoscopic management Michael J. Bourke, MBBS, FRACP, Adam B. Elfant, MD, Ralph Alhalel, MD, David Scheider, MD, Paul Kortan, MD, Gregory B. Haber, MD Toronto, Ontario, Canada 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 poorly characterized post-sphincterotomy complication involves narrowing that extends from the biliary orifice for a variable distance along the bile duct, beyond the duodenal wall.This lesion cannot be managed by repeating the sphincterotomy. Methods: Six patients (3 men) are described with sphincterotomy associated biliary strictures, all smooth and high grade, presenting at a median of 19 months (range 8 to 60 months) after sphinc- terotomy. Further sphincterotomy was not possible as an intra-duodenal segment of bile duct was no longer visible. Endoscopic management consisted of serial incremental stent exchange at 2- to 4-month intervals. The goal of therapy was to place two 11.5F stents side-by-side. Results: Stricture resolution was documented by cholangiography in all patients. One patient with a stricture resistant to treatment required three 10F stents side-by-side, and another underwent treatment to a maximum of adjacent 11.5F and 7F stents.Two 11.5F stents were eventually placed in the other four patients. Overall median duration of stent placement was 12.5 months. At a medi- an of 26.5 months of stent-free follow-up, all patients remain asymptomatic. Conclusion: Sphincterotomy-associated biliary strictures are a distinct late complication of biliary sphincterotomy.These recalcitrant lesions are not amenable to repeat sphincterotomy; however, the results of this study suggest that they may be managed successfully by serial placement of stents of incrementally increasing diameter. (Gastrointest Endosc 2000;52:494-9). tance along the bile duct beyond the duodenal wall. An intraduodenal or intramural biliary segment is no longer present and consequently further EBS is not a therapeutic option. Our terminology for this lesion is a sphincterotomy-associated biliary stric- ture (SABS) and this is a report of six patients who were referred to us for management. PATIENTS AND METHODS Six patients were referred between March 1993 and July 1994 (Table 1). All patients had undergone cholecys- tectomy before (range 2 months to 20 years) or soon after initial EBS. All presented with either acute cholangitis characterized by right upper quadrant pain, fever and jaundice, or recurrent biliary colic and intermittent icterus. Cholestatic liver function test results were noted in all patients at presentation with serum bilirubin being ele- vated at 26 to 90 mmol/L (normal < 17). Four patients had undergone abdominal US, and bile duct dilatation was reported in these four with dimensions ranging between 10 and 15 mm. Three patients were referred by endos- copists who had attempted ERCP but failed to cannulate the common bile duct (two patients) or achieve stent placement (one patient). Endoscopic and radiologic features Retraction of the papilla was a conspicuous feature and was present in four patients. In all cases, neither a resid- Received October 20, 1999. For revision February 28, 2000. Accepted June 1, 2000. From the Centre for Therapeutic Endoscopy and Endoscopic Oncology, The Wellesley Hospital, University of Toronto, Toronto, Ontario, Canada. Presented in part at the annual meeting of the American Society for Gastrointestinal Endoscopy, May 16-17, 1995, San Diego, California. Reprint requests: Michael Bourke, MBBS, FRACP, Suite 111, 151- 155 Hawkesbury Rd., Westmead, Sydney NSW 2145, Australia. Copyright © 2000 by the American Society for Gastrointestinal Endoscopy 0016-5107/2000/$12.00 + 0 37/1/108970 doi:10.1067/mge.2000.108970