Botulinum Toxin Injection after Biliary Sphincterotomy

We were intrigued by the paper by Gorelick et al. [1] concerning the innovative use of botulinum toxin injection after biliary sphincterotomy as a method for reducing the risk of postprocedural pancreatitis. A sham-controlled trial of 26 patients appeared to show a reduction in pancreatitis rates when botulinum toxin was administered; however, the results did not show statistical significance. More important, however, was that the overall pancreatitis rate was no less than 35 %; four of the patients (15 %) developed moderate pancreatitis, and one had a severe episode. These high figures are alarming and surely unacceptable.

We recommend strongly the use of temporary pancreatic duct stenting in patients undergoing endoscopic therapy for sphincter of Oddi dysfunction. Randomized studies have shown benefit [2] [3], which persists in routine practice. We use 3-Fr stents 10 - 12 cm long, with an external pigtail, but without any internal flaps. They are designed to pass spontaneously within a week or two, and we obtain an abdominal radiograph within 3 - 4 weeks to show that this has happened.

In the last year, we have performed sphincterotomies (biliary and/or pancreatic) after manometry in 220 patients with sphincter of Oddi dysfunction type III. Seventeen patients (8 %) developed pancreatitis; fourteen episodes were mild, two moderate, and one severe.

We are also interested in the use of Botox at the sphincter of Oddi. However, we always place a 3-Fr stent when injecting Botox, for fear of partial temporary occlusion of the pancreatic orifice by the injection material.

References

• 1 Gorelick A, Barnett J, Chey W. et al . Botulinum toxin injection after biliary sphincterotomy.  Endoscopy. 2004;  36 170-173
• 2 Fazel A, Quadri A, Catalano M F. et al . Does a pancreatic duct stent prevent post-ERCP pancreatitis? A prospective randomized study.  Gastrointest Endosc. 2003;  57 291-294
• 3 Tarnasky P R, Palesch Y, Cunningham J. et al . Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction.  Gastroenterology. 1998;  115 1518-1524