Wide disparities in attitudes and practices regarding Type II sphincter of Oddi dysfunction: a survey of expert U.S. endoscopists

Background: Sphincter of Oddi manometry (SOM) is recommended in the evaluation of suspected Type II sphincter of Oddi dysfunction (SOD2), though its utility is uncertain. Little is known about the practice of expert endoscopists in the United States regarding SOD2.

Methods: An anonymous electronic survey was distributed to 128 expert biliary endoscopists identified from U.S. advanced endoscopy training programs.

Results: The response rate was 46.1 % (59/128). Only 55.6 % received training in SOM, and 49.2 % currently perform SOM. For biliary SOD2, 33.3 % routinely obtain SOM, 33.3 % perform empiric sphincterotomy, and 26.3 % perform single session endoscopic ultrasound/endoscopic retrograde cholangiopancreatography (EUS/ERCP). In contrast, an equal number (35.1 %) favor SOM or single session EUS/ERCP for suspected acute idiopathic recurrent pancreatitis, while 19.3 % would perform empiric sphincterotomy. Those who perform SOM believe it to be important in predicting response to treatment compared with those who do not (71.8 % vs 23.1 %, P = 0.01). Yet only 51.7 % of this group performs SOM for suspected SOD2. Most (78.6 %) believe that < 50 % of patients report improvement in symptoms after sphincterotomy. Common reasons for not obtaining SOM included unreliable results (50 %), and procedure-related risks (39.3 %). Most (59.3 %) believe SOD2 is at least in part a functional disorder; only 3.7 % felt SOD is a legitimate disorder of the sphincter of Oddi.

Conclusions: Our survey of U.S. expert endoscopists suggests that SOM is not routinely performed for SOD2 and concerns regarding its associated risks and validity persist. Most endoscopists believe SOD2 is at least in part a functional disorder that will not respond to sphincterotomy in the majority of cases.

• References

• 1 Behar J, Corazziari E, Guelrud M et al. Functional gallbladder and sphincter of oddi disorders. Gastroenterology 2006; 130: 1498-1509
• 2 Thatcher BS, Sivak MV, Tedesco FJ et al. Endoscopic sphincterotomy for suspected dysfunction of the sphincter of Oddi. Gastrointest Endosc 1987; 33: 91-95
• 3 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: 2101-2109
• 4 Toouli J, Roberts-Thomson IC, Kellow J et al. Manometry based randomised trial of endoscopic sphincterotomy for sphincter of Oddi dysfunction. Gut 2000; 46: 98-102
• 5 Geenen JE, Hogan WJ, Dodds WJ et al. The efficacy of endoscopic sphincterotomy after cholecystectomy in patients with sphincter-of-Oddi dysfunction. NEJM 1989; 320: 82-87
• 6 Sherman S, Lehman G, Jamindar P et al. Efficacy of endoscopic sphincterotomy and surgical sphincteroplasty for patients with sphincter of Oddi dysfunction (SOD): randomized, controlled study. Gastrointest Endosc 1994; 40: P125
• 7 Guelrud M, Mendoza S, Rossiter G et al. Sphincter of Oddi manometry in healthy volunteers. Dig Dis Sci 1990; 35: 38-46
• 8 Maldonado ME, Brady PG, Mamel JJ et al. Incidence of pancreatitis in patients undergoing sphincter of Oddi manometry (SOM). Am J Gastroenterol 1999; 94: 387-390
• 9 Smithline A, Hawes R, Lehman G. Sphincter of Oddi manometry: interobserver variability. Gastrointest Endosc 1993; 39: 486-491
• 10 Coyle WJ, Pineau BC, Tarnasky PR et al. Evaluation of unexplained acute and acute recurrent pancreatitis using endoscopic retrograde cholangiopancreatography, sphincter of Oddi manometry and endoscopic ultrasound. Endoscopy 2002; 34: 617-623
• 11 Arguedas MR, Linder JD, Wilcox CM. Suspected sphincter of Oddi dysfunction type II: empirical biliary sphincterotomy or manometry-guided therapy?. Endoscopy 2004; 36: 174-178
• 12 Khashab MA, Watkins JL, McHenry L et al. Frequency of sphincter of Oddi dysfunction in patients with previously normal sphincter of Oddi manometry studies. Endoscopy 2010; 42: 369-374
• 13 Petersen BT. An evidence-based review of sphincter of Oddi dysfunction: part I, presentations with “objective” biliary findings (types I and II). Gastrointest Endosc 2004; 59: 525-534
• 14 Sheehan SJ, Lee JH, Wells CK et al. Serum amylase, pancreatic stents, and pancreatitis after sphincter of Oddi manometry. Gastrointest Endosc 2005; 62: 260-265
• 15 Tarnasky PR, Palesch YY, Cunningham JT et al. Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction. Gastroenterology 1998; 115: 1518-1524
• 16 Singh P, Gurudu SR, Davidoff S et al. Sphincter of Oddi manometry does not predispose to post-ERCP acute pancreatitis. Gastrointest Endosc 2004; 59: 499-505