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Are complications of endoscopic sphincterotomy age related?

EDITOR,—Deans et al (Gut 1997;41:545–8) have supported the use of endoscopic sphincterotomy for bile duct stones in young people in preference to laparoscopic bile duct exploration. They do this because sphincterotomy causes no more complications in young than in old people. Any comparison between the two methods must also take into account the complications, particularly pancreatitis, that occurred in the remaining two-thirds of the patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) without sphincterotomy. Laparoscopic duct exploration is still a relatively new technique. Rhodes et al reported 129 explorations with one case of postoperative pancreatitis. We have had no pancreatitis in 53 explorations. Until larger series are reported judgement is impossible. For the treatment of bile duct stones a comparison of therapeutic success and the manoeuvres required to achieve it are required on an intention-to-treat basis. The consequences of sphincterotomy and reflux in the very long term are not known. Most bile duct stones are predominantly composed of pigment, thought to be caused by reflux through an incompetent sphincter. They are seen in about 10% of patients after sphincterotomy but these data include only small numbers of young patients with long term follow up. Data for the events of 20–30 years after sphincterotomy are not available, yet a quarter of the patients in the study of Deans et al might be expected to live this length of time. Apart from stone formation, long term duodenobiliary reflux may have other adverse eVects. Kurumado et al reported dysplastic change in rat mucosa after formation of biliary enteric fistulae. Biliary malignancy is seen in anomalous pancreatico-biliary junctions, postulated to be caused by unusual reflux. The application of these reports to the eVect of sphincterotomy needs to be cautious but they act as a warning that sphincterotomy might not be entirely benign in the long term. Laparoscopic bile duct exploration oVers the possibility of safe choledocholithotomy without sphincter destruction and it merits further study.