Pancreatic Sphincterotomy

  • Stefano Francesco Crinò
  • Laura Bernardoni
  • Armando GabbrielliEmail author


Since 1985 pancreatic sphincterotomy was used with therapeutic purpose itself or as a “gateway” for pancreatic duct treatments. Indications include: treatment of chronic pancreatitis (e.g., papillary stenosis, before stent placement or stone removal), recurrent pancreatitis in pancreas divisum (with or without santorinicele), sphincter of Oddi dysfunction (type I or II), pancreatic fistula, diagnostic or therapeutic pancreatoscopy, and IPMN-associated recurrent pancreatitis (very selected cases).

The procedure can be performed both at the minor and at the major papilla, depending on ductal anatomy, and in the latter case can be associated with biliary sphincterotomy.

Pancreatic sphincterotomy is performed in a similar fashion to the biliary one, generally employing the same devices. Guidewired deep cannulation of the main pancreatic duct is mandatory before sphincterotomy.

The procedure is considered to be at risk for the development of post-ERCP pancreatitis; thus prophylactic measures should be always executed (e.g., pancreatic stent deployment).


Recurrent pancreatitis Chronic pancreatitis Sphincter of Oddi dysfunction Post-ERCP pancreatitis Minor papilla Pancreas divisum Intraductal papillary mucinous neoplasm Santorinicele 

Supplementary material

Video 15.1

(MOV 1722915 kb)

Video 15.2

(MOV 403009 kb)

Video 15.3

(MOV 475195 kb)


  1. 1.
    Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996;335:909–18.PubMedGoogle Scholar
  2. 2.
    ASGE Standards of Practice Committee, Chandrasekhara V, Khashab MA, Muthusamy VR, et al. Adverse events associated with ERCP. Gastrointest Endosc. 2017;85(1):32–47.Google Scholar
  3. 3.
    Buxbaum J, Yan A, Yeh K, et al. Aggressive hydration with lactated Ringer’s solution reduces pancreatitis after endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol. 2014;12:303–307.e1.PubMedGoogle Scholar
  4. 4.
    Kozarek RA, Ball TJ, Patterson DJ, et al. Endoscopic pancreatic duct sphincterotomy: indications, technique, and analysis of results. Gastrointest Endosc. 1994;40:592–8.PubMedGoogle Scholar
  5. 5.
    Cremer M, Devière J, Delhaye M, et al. Stenting in severe chronic pancreatitis: results of medium-term follow-up in seventy-six patients. Endoscopy. 1991;23:171–6.PubMedGoogle Scholar
  6. 6.
    Kim MH, Myung SJ, Kim YS, et al. Routine biliary sphincterotomy may not be indispensable for endoscopic pancreatic sphincterotomy. Endoscopy. 1998;30:697–701.PubMedGoogle Scholar
  7. 7.
    Jakobs R, Reimann JF. Is there a need for dual sphincterotomy in patients with chronic pancreatitis? Endoscopy. 2003;35:250–1.Google Scholar
  8. 8.
    Testoni PA, Mariani A, Aabakken L, et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(7):657–83.PubMedGoogle Scholar
  9. 9.
    Akiho H, Sumida Y, Akahoshi K, et al. Safety advantage of endocut mode over endoscopic sphincterotomy for choledocholithiasis. World J Gastroenterol. 2006;12:2086–8.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Elta GH, Barnett JL, Wille RT, et al. Pure cut electrocautery current for sphincterotomy causes less post-procedure pancreatitis than blended current. Gastrointest Endosc. 1998;47:149–53.PubMedGoogle Scholar
  11. 11.
    Verma D, Kapadia A, Adler DG. Pure versus mixed electrosurgical current for endoscopic biliary sphincterotomy: a meta-analysis of adverse outcomes. Gastrointest Endosc. 2007;66:283–90.PubMedGoogle Scholar
  12. 12.
    Varadarajulu S, Wilcox CM. Randomized trial comparing needle-knife and pull-sphincterotome techniques for pancreatic sphincterotomy in high-risk patients. Gastrointest Endosc. 2006;64(5):716–22.PubMedGoogle Scholar
  13. 13.
    Elton E, Howell DA, Parsons WG, et al. Endoscopic pancreatic sphincterotomy: indications, outcome, and a safe stentless technique. Gastrointest Endosc. 1998;47:240–9.PubMedGoogle Scholar
  14. 14.
    Mazaki T, Mado K, Masuda H, et al. Prophylactic pancreatic stent placement and post-ERCP pancreatitis: an updated meta-analysis. J Gastroenterol. 2014;49:343–55.PubMedGoogle Scholar
  15. 15.
    Pahk A, Rigaux J, Poreddy V, et al. Prophylactic pancreatic stents: does size matter? A comparison of 4-Fr and 5-Fr stents in reference to post-ERCP pancreatitis and migration rate. Dig Dis Sci. 2011;56(10):3058–64.PubMedGoogle Scholar
  16. 16.
    Lawrence C, Cotton PB, Romagnuolo J, et al. Small prophylactic pancreatic duct stents: an assessment of spontaneous passage and stent-induced ductal abnormalities. Endoscopy. 2007;39:1082–5.PubMedGoogle Scholar
  17. 17.
    Rashdan A, Fogel EL, McHenry L Jr, et al. Improved stent characteristics for prophylaxis of post-ERCP pancreatitis. Clin Gastroenterol Hepatol. 2004;2(4):322–9.PubMedGoogle Scholar
  18. 18.
    Seetharam P, Rodrigues G. Sphincter of Oddi and its dysfunction. Saudi J Gastroenterol. 2008;14(1):1–6.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Devereaux BM, Sherman S, Lehman GA. Sphincter of Oddi (pancreatic) hypertension and recurrent pancreatitis. Curr Gastroenterol Rep. 2002;4:153–9.PubMedGoogle Scholar
  20. 20.
    Thatcher BS, Sivak MV, Tedesco FJ, et al. Endoscopic sphincterotomy for suspected dysfunction of the sphincter of Oddi. Gastrointest Endosc. 1987;33:91–5.PubMedGoogle Scholar
  21. 21.
    Cotton PB, Durkalski V, Romagnuolo J, et al. Effect of endoscopic sphincterotomy for suspected sphincter of Oddi dysfunction on pain-related disability following cholecystectomy: the EPISOD randomized clinical trial. JAMA. 2014;311:2101–9.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Pereira SP, Gillams A, Sgouros SN, et al. Prospective comparison of secretin-stimulated magnetic resonance cholangiopancreatography with manometry in the diagnosis of sphincter of Oddi dysfunction types II and III. Gut. 2007;56(6):809–13.PubMedGoogle Scholar
  23. 23.
    Mariani A, Arcidiacono PG, Curioni S, et al. Diagnostic yield of ERCP and secretin-enhanced MRCP and EUS in patients with acute recurrent pancreatitis of unknown aetiology. Dig Liver Dis. 2009;41(10):753–8.PubMedGoogle Scholar
  24. 24.
    Watson RR, Klapman J, Komanduri S, et al. Wide disparities in attitudes and practices regarding Type II sphincter of Oddi dysfunction: a survey of expert U.S. endoscopists. Endosc Int Open. 2016;4(9):E941–6.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Park SH, Watkins JL, Fogel EL, et al. Long-term outcome of endoscopic dual pancreatobiliary sphincterotomy in patients with manometry-documented sphincter of Oddi dysfunction and normal pancreatogram. Gastrointest Endosc. 2003;57(4):483–91.PubMedGoogle Scholar
  26. 26.
    Bernardoni L, Crinò SF, De Conti G, et al. Preliminary experience with pancreatic sphincterotomy as treatment for intraductal papillary mucinous neoplasm-associated recurrent pancreatitis. Endosc Int Open. 2017;5(11):E1144–50.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Rieder B, Krampulz D, Adolf J, et al. Endoscopic pancreatic sphincterotomy and stenting for preoperative prophylaxis of pancreatic fistula after distal pancreatectomy. Gastrointest Endosc. 2010;72(3):536–42.PubMedGoogle Scholar
  28. 28.
    Goasguen N, Bourrier A, Ponsot P, et al. Endoscopic management of pancreatic fistula after distal pancreatectomy and enucleation. Am J Surg. 2009;197(6):715–20.PubMedGoogle Scholar
  29. 29.
    Shimura T, Suehiro T, Suzuki H, et al. Preoperative endoscopic pancreatic stenting for prophylaxis of pancreatic duct disruption during extirpation of a pancreatic head tumor. Am J Surg. 2007;194(4):553–5.PubMedGoogle Scholar
  30. 30.
    Esber E, Sherman S, Earle D, et al. Complications of major papilla pancreatic sphincterotomy: a review of 236 patients. Gastrointest Endosc. 1995;43:405A.Google Scholar
  31. 31.
    Dufault DL, Elmunzer BJ, Cotton PB, et al. Adverse events and reinterventions following pancreatic endoscopic sphincterotomy. Pancreas. 2018;47(7):880–3.PubMedGoogle Scholar
  32. 32.
    Lehman GA, Sherman S, Nisi R, et al. Pancreas divisum: results of minor papilla sphincterotomy. Gastrointest Endosc. 1993;39(1):1–8.PubMedGoogle Scholar
  33. 33.
    Maple JT, Keswani RN, Edmundowicz SA, et al. Wire-assisted access sphincterotomy of the minor papilla. Gastrointest Endosc. 2009;69(1):47–54.PubMedGoogle Scholar
  34. 34.
    Lans JI, Geenen JE, Johanson JF, et al. Endoscopic therapy in patients with pancreas divisum and acute pancreatitis: a prospective, randomized, controlled clinical trial. Gastrointest Endosc. 1992;38:430–4.PubMedGoogle Scholar
  35. 35.
    Mariani A, Di Leo M, Petrone MC, et al. Outcome of endotherapy for pancreas divisum in patients with acute recurrent pancreatitis. World J Gastroenterol. 2014;20(46):17468–75.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Crinò SF, Bernardoni L, Conti Bellocchi MC, et al. Efficacy of endoscopic minor papilla sphincterotomy for symptomatic santorinicele. Clin Gastroenterol Hepatol. 2017;15(2):303–6.PubMedGoogle Scholar
  37. 37.
    Brown NG, Howell DA, Brauer BC, et al. Minor papilla endotherapy in patients with ventral duct obstruction: identification and management. Gastrointest Endosc. 2017;85(2):365–70.PubMedGoogle Scholar
  38. 38.
    Park SH, de Bellis M, McHenry L, et al. Use of methylene blue to identify the minor papilla or its orifice in patients with pancreas divisum. Gastrointest Endosc. 2003;57:358–63.PubMedGoogle Scholar
  39. 39.
    Devereaux BM, Fein S, Purich E, et al. A new synthetic porcine secretin for facilitation of cannulation of the dorsal pancreatic duct at ERCP in patients with pancreas divisum: a multicenter, randomized, double-blind comparative study. Gastrointest Endosc. 2003;57:643–7.PubMedGoogle Scholar
  40. 40.
    Cai Q, Keilin S, Obideen K, et al. Intraduodenal hydrochloric acid infusion for facilitation of cannulation of the dorsal pancreatic duct at ERCP in patients with pancreas divisum: a preliminary study. Am J Gastroenterol. 2010;105:1450–1.PubMedGoogle Scholar
  41. 41.
    Dewitt J, McHenry L, Fogel E, et al. EUS-guided methylene blue pancreatography for minor papilla localization after unsuccessful ERCP. Gastrointest Endosc. 2004;59(1):133–6.PubMedGoogle Scholar
  42. 42.
    Benage D, McHenry R, Hawes RH, et al. Minor papilla cannulation and dorsal ductography in pancreas divisum. Gastrointest Endosc. 1990;36(6):553–7.PubMedGoogle Scholar
  43. 43.
    Bataille L, Deprez P. A new application for therapeutic EUS: main pancreatic duct drainage with a “pancreatic rendezvous technique”. Gastrointest Endosc. 2002;55(6):740–3.PubMedGoogle Scholar
  44. 44.
    Gerke H, Byrne MF, Stiffler HL, et al. Outcome of endoscopic minor papillotomy in patients with symptomatic pancreas divisum. JOP. 2004;5:122–31.PubMedGoogle Scholar
  45. 45.
    Attwell A, Borak G, Hawes R, et al. Endoscopic pancreatic sphincterotomy for pancreas divisum by using a needle-knife or standard pull-type technique: safety and reintervention rates. Gastrointest Endosc. 2006;64:705–11.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Stefano Francesco Crinò
    • 1
  • Laura Bernardoni
    • 1
  • Armando Gabbrielli
    • 1
    Email author
  1. 1.Gastroenterology and Digestive Endoscopy UnitThe Pancreas Institute, G.B. Rossi University HospitalVeronaItaly

Personalised recommendations