Papillotomy and functional disorders of the sphincter of Oddi

The term "functional" as applied to disorders of the sphincter of Oddi is indefinite since it encompasses a spectrum of disorders from histopathologic fibrosis of the sphincter to sphincteric dysfunction without evident pathologic transformation. Although there are several approaches to the diagnosis of sphincter of Oddi dysfunction, the diagnosis still depends on the exclusion of other causes of obstruction. Reports of surgical sphincteroplasty in patients with this diagnosis suggest that the outcome is unpredictable. Operative mortality ranges from 0.6% to 6.0% and morbidity from 3.3% to 18%. Operative sphincteroplasty appears to have no adverse sequelae long-term, although there are few reports of extended follow-up. In our experience, about 10% of patients undergoing endoscopic sphincterotomy for calculi have recurrent biliary problems during extended follow-up, but most problems were not formidable. In large series of patients undergoing endoscopic sphincterotomy, papillary stenosis is the indication for the procedure in about 5% of cases. With this indication, immediate complications occur with greater frequency compared to endoscopic sphincterotomy for choledocholithiasis. The validity of every proposed test for sphincter dysfunction and/or stenosis has been challenged, and the diagnosis must still be considered imprecise. This fundamental problem makes it difficult to interpret the results of endoscopic sphincterotomy. It also necessitates a cautious approach to management of this disorder by endoscopic sphincterotomy. Other methods of sphincter manipulation such as endoscopic balloon dilation have not been studied extensively. Although endoscopic sphincterotomy has been performed in a few patients with idiopathic recurrent pancreatitis, the procedure must be considered experimental in this group of patients.