25 Years of Endoscopic Sphincterotomy in Erlangen: Assessment of the Experience in 3498 Patients

Abstract

Background and Study Aims: The aim of the study was to investigate the evolution of endoscopic sphincterotomy (EST) over a period of 25 years at its birthplace in Erlangen, Germany.

Patients and Methods: A total of 3498 consecutive ESTs between 1973 and the end of 1997 were reviewed with respect to indications, technology, success, complications, therapy of complications and mortality. In order to demonstrate changes in the course of time, the results have been compiled separately for four time periods (A - D).

Results: During the 25 years' practice of EST in Erlangen the frequency of ETSs has increased constantly and significant changes have been observed concerning the spectrum of indications: Bile duct stones (total 55.1 %) decreased continuously from 91.1 % (period A) to 35.7 % (period D). In contrast, the proportion of ESTs applied for malignant obstruction (total 22.1 %) rose successively from 1.1 % (period A) to more than 25 % (periods B - D). Chronic pancreatitis as an indication for EST was established in period B (1.0 %) and accounted for 20.2 % of all procedures in period D (total 8.0 %). Several new indications (summarized as “others”) increased from 1.8 % in period A to 11.9 % in period D (total 6.7 %) whereas biliary pancreatitis and scarred papillary stenosis remained constantly below 5 %. Whereas the “Erlangen sphincterotome” was the only sphincterotome used in period A, it was almost completely replaced by guide-wire sphincterotomes in period D. With the introduction of the needle knife the precut technique became popular and was used with increasing frequencies: period B 31.9 %, period C 34.1 %, period D 41.9 %. The success rate in total was 95.2 %. For each time period the highest success rate of EST was obtained for bile duct stones (96 - 98 %), whereas EST appeared to be more difficult in case of malignant obstruction (93.3 %) or chronic pancreatitis (90.2 %), but for both indications growing experience resulted in an increase in the success rates (85.7 % to 94.9 % and 90.9 % to 94.0 %, respectively). Complications occurred in 7.9 % of cases. The complication rate declined significantly from 10.5 % in period A over 7.6 % in period B to 6.3 % in period C. Prospective data acquisition in period D revealed a significant increase in the detection of mild forms of acute pancreatitis, resulting in a slight increase of the complication rate (8.4 %). Needle-knife papillotomy did not significantly increase the complication rate. Whereas in period A 41 % of all complications were managed by surgery, this value dropped over 28 % (period B) and 7.5 % (period C) to ultimately 1.6 % in period D. The method-related mortality was nearly constant over the whole period of time (0.6 %).

Conclusions: Despite a continuous shift of indications and a changing mixture of learning endoscopists and EST experts over 25 years, the practice of EST at its birthplace in Erlangen has shown a constantly high success rate, a decreasing complication rate and an acceptable but mainly unchanged mortality rate. Currently, nearly all complications can be successfully managed nonoperatively.