In a prospective study, patients with biliary-like pain were randomly assigned to endoscopic sphincterotomy or sham procedure. Manometry was done but was not used to de­termine therapy. The results of manometry were correlated with the clinical outcome (Table 3). After four years of follow-up, it was found that patients with SO stenosis treated by sphincterotomy were more likely to show improvement in symptoms than patients with sphincter stenosis who had the sham procedure. If the manometric diagnosis was SO dyski- nesia, significant differences were not observed. The results from this study led to the conclusion that patients with sig­nificant SO dysfunction as characterized by an elevated ba­sal pressure (SO stenosis) should be treated by division of the SO. Similar results were reported around that time, and, subsequently, other prospective nonrandomized trials have confirmed the benefit of sphincterotomy for pa­tients with an elevated basal pressure. As dis­cussed above, sphincterotomy for type 3 patients with an elevated basal pressure may not be associated with longlast- ing benefit.

TABLE 3 Endoscopic sphincterotomy (ES) and sphincter of Oddi (SO) dysfunction

In many patients with idiopathic recurrent pancreatitis, manometry reveals sphincter stenosis. Pancreatic duct stenosis may also be found in patients who have had a biliary sphincterotomy for the treatment of recurrent pancreatitis. Thus, endoscopic biliary sphincterotomy is often ineffective for recurrent pancreatitis, and treatment must include divi­sion of the pancreatic sphincter. This is achieved via a trans- duodenal approach at open operation with division of the septum between the bile duct and pancreatic duct, creating a wide opening for both ducts. Endoscopic division of the pan­creatic portion of the SO has been reported but is not rou­tinely undertaken because morbidity and long term outcome have not been evalutated. The results of total sphincter divi­sion in producing symptomatic relief in patients with recur­rent pancreatitis depend on the selection of patients. Approximately 70% of patients with an abnormally elevated basal pressure are improved by sphincteroplasty and pancre­atic septoplasty. Lack of improvement may relate to the fact that many of these patients have been treated for many years with a variety of analgesics, including opiates, and that some have developed dependance on medication.
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