sphincterotomy and sphincteroplasty

History and definitions In 1681 Glisson described a sphincter at the end of the common bile duct, which allowed bile to flow intermittently into the duodenum.' Exactly 200 years later, Oddi portrayed the sphincteric mechanism in greater detail,2 but it was not until 1957 that Boyden unravelled the complexity ofthe anatomical sphincter surrounding the terminus of the common bile duct and pancreatic duct.3 Although the surrounding duodenal musculature cancompress the distal end ofboth ducts, there is a more important sphincter that acts independently. Boyden showed a submucosal muscular sheath which surrounds the intramural portion of both ducts, and the two ducts are separated by a thin veil of tissue, the septum. Clinical application of this knowledge began in 1956 when Doubilet and Mulholland published the results of biliary sphincterotomy for recurrent pancreatitis, which they thought resulted from reflux of bile into the pancreatic duct.4 Believing that outflow obstruction was more important than reflux, Bartlett and Nardil extended the operation by dividing the common septum between the terminal bile duct and pancreatic duct, thereby achieving a pancreatic sphincterotomy in addition. Subsequently, Moody and colleagues actually excised this common septum (transampullary septectomy or extended papilloplasty) in 92 patients with disabling post cholecystectomy pain, 85 of whom were found to have stenosis of the origin of the duct of Wirsung.67 We have recently undertaken a modified pancreatic sphincteroplasty in a small series of patients with pancreatic or papillary disease.8 The first endoscopic cannulation of the papillar of Vater by McCune in 1968 opened a new era in the diagnostic approach to pancreatobiliary disorders.9 Six years later this purely diagnostic technique was adapted to become a therapeutic modality by the introduction of endoscopic biliary sphincterotomy," followed by other treatment modalities including pancreatic sphincterotomy. 11 The term 'sphincterotomy' means division of the mucosa and underlying sphincter mechanism, a procedure that can now be achieved either endoscopically or by transduodenal surgery. 'Sphincteroplasty' indicates mucosa-to-mucosa suture, eitherduodenum to bile duct alone (biliary sphincteroplasty) or bile duct to pancreatic duct in addition (pancreatic sphincteroplasty). Both procedures produce permanent destruction of the sphincter mechanism. Sphincteroplasty offers the theoretical advantage of preventing restenosis, but at present it can only be achieved by an open operation of some technical complexity. This paper reviews the indications for division of the pancreatic sphincter, both at the major and minor papilla, and the endoscopic and surgical means by which this can be accomplished.