Bile duct carcinoma arising in metaplastic biliary epithelium of the intestinal type: a case report

We report herein a case of distal bile duct carcinoma showing intestinal differentiation diagnosed 3 years after endoscopic sphincterotomy for choledocholithiasis. The diagnostic problem in this case was that the granular mucosa, which is a typical finding of superficial mucosal extension of bile duct carcinoma in general, was interpreted as hyperplasia accompanying metaplasia in cholangioscopic biopsy. Discrimination of superficial mucosal cancer extension from hyperplastic mucosa with metaplastic changes was impossible using cholangioscopic examination. In our case, reflux and stasis of the duodenal and pancreatic juice into the biliary tract might have occurred because of abnormal function of the papilla of Vater following endoscopic sphincterotomy. It might be suggested that endoscopic sphincterotomy contributed to the metaplastic changes in the bile duct mucosa in our case.     

Guidewire technique for endoscopic transpapillary procurement of bile duct biopsy specimens without endoscopic sphincterotomy

BACKGROUND: Endoscopic sphincterotomy may be required when endoscopic transpapillary bile duct biopsy specimens are needed for tissue diagnosis. However, endoscopic sphincterotomy has potential complications. A guidewire technique for obtaining transpapillary biopsy specimens without endoscopic sphincterotomy was evaluated. METHODS: A total of 13 patients (11 men, 2 women; mean age 67.5 years) with biliary stricture or obstruction underwent endoscopic retrograde cholangiography. A guidewire was then inserted across the stricture or obstruction and into an intrahepatic duct. Alongside the guidewire, the biopsy forceps (1.5 mm diameter) was introduced into the papillary orifice with the duodenoscope extremely close to the papilla. OBSERVATIONS: Tissue was obtained in 92.3% of the cases for histopathologic evaluation without difficulty or complication. The single failure occurred in a patient who had undergone a partial gastrectomy with Billroth I anastomosis. CONCLUSIONS: The guidewire technique for endoscopic transpapillary procurement of biopsy specimens of the bile duct obviates the need for endoscopic sphincterotomy.     

Ampullary hamartoma: endoscopic diagnosis and treatment

This study shows a patient who presented with intermittent biliary tract obstruction caused by ampullary hamartoma. Endoscopic retrograde cholangiopancreatography showed a large ulcerated papilla and dilated biliary ducts. Tissue diagnosis was established by a large particle biopsy obtained with a snare. The patient underwent a successful endoscopic sphincterotomy and has remained symptom free for 4 years.     

Endoscopic diagnosis and treatment of non-traumatic bilhemia. A case report

Biliovascular fistulas are abnormal communications with two types of clinical manifestations depending on type of flow in fistulous tract: 1) hemorrhage into biliary tract known as hemobilia, or 2) bile into bloodstream, known as bilhemia. Historically, this complication has been treated with surgery; however, technological progress at present allows treatment with intervention techniques without surgery being mandatory. In 1975, Clemens and Wittrin introduced the term bilhemia, a rare complication of hepatic damage producing excessively high levels of serum bilirubin and moderate rise of hepatic enzymes secondary to post-traumatic intrahepatic biliovenous fistula. Although this pathology is rare, it is considered dangerous; of 50 patients reported in the literature, 25 died due to this problem. The main purpose of treatment is to release tract obstruction by endoscopic sphincterotomy of Vater's papilla or, if the process is localized in proximal areas of biliary tract, through percutaneous biliary drainage or preferably nasobiliary drainage with continuous suction. This procedure can at least produce temporary relief and occasionally fistula closure. A longer effect can be achieved with biliary stent placement. We describe what is, to our knowledge, the first case of diagnosis and successful treatment of non-traumatic bilhemia with endoscopic sphincterotomy and nasobiliary catheter placement.     

Hepatobiliary and pancreatic infections in AIDS: Part one

Infections of the liver and biliary tract are common during the course of AIDS. A variety of viral, bacterial, fungal, and other opportunistic infections can present with hepatobiliary involvement as either the primary site of infection or secondary to a disseminated process. Coinfection with hepatitis B and C are particularly common due to the shared means of transmission of these viruses with HIV. The typical presenting features of hepatobiliary infections are right upper quadrant (RUQ) pain and abnormal liver function tests. Initial evaluation should include an RUQ ultrasonogram, which will usually identify abnormalities in the biliary tract and may demonstrate some parenchymal abnormalities as well. A liver biopsy is necessary to determine the etiology of focal hepatic lesions or opportunistic infections within hepatic parenchyma when other less invasive tests are negative or inconclusive. Special stains and culture techniques are required to identify specific organisms in the biopsy specimen. HIV-related biliary disorders include acalculous cholecystitis, which is a potentially serious condition requiring prompt recognition and gallbladder decompression. AIDS-cholangiopathy is a form of cholangitis involving the intra- and/or extrahepatic biliary tree. Endoscopic retrograde cholangio-pancreatography (ERCP) is the test of choice, demonstrating the stricturing, dilatation, and beading of bile ducts seen in this condition. Endoscopic sphincterotomy of the papilla of Vater may provide symptomatic relief for patients with papillary stenosis. Opportunistic infections of the pancreas have been reported. Evaluation should include a computerized tomogram of the abdomen and possible pancreatic tissue aspiration or biopsy. Management of pancreatitis is supportive.     

Innovation of endoscopic management in difficult common bile duct stone in the era of laparoscopic surgery

Common bile duct(CBD) stone is a common biliary problem, which often requires endoscopic approach as the initial treatment option. Roughly, 7%-12% of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management. In general, there are three classifications of difficult CBD stone, which are based on the characteristics of the stone(larger than 15 mm, barrel or square-shaped stones, and hard consistency), accessibility to papilla related to anatomical variations, and other clinical conditions or comorbidities of the patients. Currently, endoscopic papillary large balloon dilation(EPLBD) of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts. If failed extraction is still encountered, mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered. Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available. To our knowledge, conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches. The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.     

A case report of papilla Vater carcinoma showing positive expression of thymidine phosphorylase

Recently, we experienced an interesting case of papilla Vater carcinoma. The patient was a 61-year-old woman, who was referred to our department from a private hospital with a chief complaint of high fever. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography revealed an anomalous arrangement of the pancreaticobiliary duct without a common channel and a tumor, which was detected on the papilla Vater and diagnosed as well-differentiated adenocarcinoma. Pylorus-preserving pancreaticoduodenectomy with lymph node dissection was performed. The immunohistochemical stain showed the strong expression of thymidine phosphorylase in the tumor tissue and also in the normal biliary tract, despite positive p53 cells being undetected in either tumor tissue or epithelium of biliary tract. These findings may suggest important indications to consider some mechanisms of carcinogenesis in the biliary tract.     

Is conventional sphincterotomy possible in patients with common bile duct stones impacted at the ampulla of Vater?

BACKGROUND: Needle knife precut papillotomy has been used to gain access or remove impacted common bile duct stones at the ampulla of Vater. However, precut papillotomy is a risky procedure with high complication rates and is presumably best dealt with by the expert. We attempted to find out the feasibility of performing conventional endoscopic sphincterotomy in patients with impacted stones at the ampulla. METHODS: All patients undergoing endoscopic retrograde cholangiopancreatography for stones impacted at the ampulla between the years 2000 and 2005 were enrolled in the study. All attempts were made to achieve biliary cannulation through the conventional route including use of the long route or guidewire to cannulate the papilla. Needle knife papillotomy was resorted to only if attempts to cannulate the papilla through the conventional route failed. The success and complications of the procedures were recorded. RESULTS: Thirty-two patients were enrolled. The impacted bile duct stone could be removed in all the patients. Conventional endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy were performed in 23 patients with impacted stones. The long route had to be employed in seven patients while guidewire cannulation of the papilla was needed in four patients. Needle knife papillotomy was needed in only nine patients. None of the patients in whom the conventional route was employed developed complications, whereas bleed requiring endoscopic management was observed in three (33%) of the nine patients in whom needle knife papillotomy was performed. CONCLUSIONS: Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy can be performed by the conventional route in the majority of patients with impacted stones at the ampulla. This approach appears to be safer than needle knife papillotomy. However, needle knife papillotomy may be required in patients in whom biliary access cannot be gained through the conventional approach.     

SMALL SPHINCTEROTOMY COMBINED WITH ENDOSCOPIC PAPILLARY LARGE BALLOON DILATION IN PATIENTS WITH BILLROTH II GASTRECTOMY

Background: The difficulty in orienting a duodenoscope or sphincterotome in Billroth II gastrectomy patients with an afferent loop is well known to experienced biliary endoscopists. In patients who have large biliary stones, stone retrieval is technically difficult, particularly when a mechanical lithotriptor is required. To address this issue a new technique was developed to gain greater access to the common bile duct. Methods: This new technique, small endoscopic sphincterotomy combined with endoscopic papillary large balloon dilation (SES + EPLD), was carried out in eight cases with Billroth II reconstruction. First, endoscopic sphincterotomy (ES) with a small incision was performed with a capped forward‐viewing endoscope. Then, endoscopic papillary dilation was performed with a large balloon to slowly match the size of the bile duct. Stones were then retrieved from the biliary duct with a balloon and a basket. Results: Stone retrieval was successful in all cases. Dilating the papillary orifice with a large balloon made it possible to remove large stones smoothly without crushing them. After dilation with the large balloon, there were some instances of oozing, but no perforations near the papilla. Conclusions: SES + EPLD was effective for the retrieval of large biliary stones without the use of mechanical lithotripsy for B‐II reconstruction cases. This new method, incorporating a slow dilation of the papilla up to a large diameter, could provide a larger opening than a large ES. This method of stone retrieval is easy to perform and may be able to play a role in the treatment of large and multiple bile duct stones with B‐II gastrectomy.     

Relationship between intraduodenal peri-ampullary diverticulum and biliary disease in 178 patients undergoing ERCP

BACKGROUND:The presence of intraduodenal peri-ampullary diverticulum is often observed during upper digestive tract barium meal studies and endoscopic retrograde cholangiopancreatography(ERCP).A few papers in China and overseas reported that the diverticulum had something to do with the incidence of cholelithiasis. This study was undertaken to further test this notion and ascertain the relationship between intraduodenal peri- ampullary diverticulum and biliary disease,especially the formation of bile duct pigment stones. METHODS:A total of 178 patients who had undergone ERCP or endoscopic sphincterotomy(EST)were studied retrospectively.They were divided into 6 groups according to the category of biliary disease,and the incidence rates of intraduodenal peri-ampullary diverticulum were calculated. RESULTS:There were 44 patients with intraduodenal peri- ampullary diverticulum in 81 patients with primary bile duct pigment stones(54.32%),4 in 8 patients with bile duct stones and gallbladder stones(50%),7 in 33 patients with bile duct stones secondary to gallbladder stones(21.21%), 3 in 21 patients with inflammation and stricture of the end of the bile duct and papilla(14.29%),1 in 22 patients with carcinoma of the end of the bile duct and papilla(4.54%), and 5 in 13 patients with post-cholecystectomy syndrome or sphincter of Oddi dysfunction(38.46%). CONCLUSIONS:The incidence rate of intraduodenal peri- ampullary diverticulum in patients with primary bileduct pigment stones is higher than that in patients with bile duct stones secondary to gallbladder stones,patients with inflammation and stricture of the end of the bile duct and papilla,and patients with carcinoma of the end of the bile duct and papilla.These findings indicate that the anatomical abnormalities and malfunction of the sphincter of Oddi play an important role in the formation of bile duct pigment stones.     

Endoscopic management of biliary leaks. The answer for the future

Bile duct diseases and biliary leaks are not uncommon complications and their management is challenging. Majority of bile leaks occur secondary to trauma, major liver, gallbladder and biliary tract surgeries. Early recognition of bile leaks by imaging combined with a high clinical suspicion is required. Bile leaks can be managed either conservatively, or through percutaneous drainage, or endoscopically or by surgical intervention. The innovations in endoscopic techniques have expanded the horizons for managing patients with bile leaks irrespective of their etiology. Endoscopic interventions through biliary sphincterotomy alone, biliary stenting with or without sphincterotomy, and nasobiliary drainage with or without sphincterotomy, use of self expanding covered metal stents and the recent use of biodegradable stents have been very effective in the management of all kinds of biliary leaks. All endoscopic techniques are based on the principle that eliminating the rise in pressure inside the bile duct by promoting decompression in the form of stent placement/sphincterotomy promotes healing of bile leaks. Further future developments in endoscopic techniques are expected to improve their effectiveness in managing patients with bile leaks.     

Is duodenal diverticulum a risk factor for sphincterotomy?

It is uncertain whether ERCP and associated procedures are more difficult when the papilla is inside or adjacent to a duodenal diverticulum. We have therefore reviewed the data from 2458 consecutive, prospectively reported ERCPs between November 1983 and March 1988. Three hundred and eight patients (12.5%) had periampullary diverticula and in 21 the papilla was located deep within the diverticulum of whom 227 had undergone endoscopic sphincterotomy (73.7%). Comparison was made with the 2150 patients without diverticula of whom 1223 (56.9%) had undergone sphincterotomy. The success rate of specific duct cannulation was 94.2% in the diverticulum group and 96.7% in those without diverticula (p less than 0.05). The overall success rate of endoscopic sphincterotomy was 95.2% in the diverticulum group, as compared with 98.0% in those without diverticula (p less than 0.05). The procedure related morbidity and mortality of sphincterotomy were 5.2%/0.9% and 4.0%/0.7% respectively (NS). If only those who had successful cholangiography were included there was no difference in sphincterotomy success between those with and without diverticula. The group of patients with papilla deep within diverticula had a slightly higher failure rate of pure endoscopic sphincterotomy (11.8% v 5.7%: NS) but did not have a higher complication rate. In the subgroup of patients with choledocholithiasis, duct clearance of stones was as successful after sphincterotomy in those with diverticula as in those without. Medium term complications (mean 26 months) occurred in 1.4% of patients with diverticula and in 0.7% of patients without diverticula. We conclude that diagnostic cholangiography is more difficult when the papilla is closely associated with a diverticulum but that if diagnostic cholangiography is obtained, sphincterotomy may be performed as successfully and as safely in those with or without diverticula.     

Periampullary Diverticula Causing Pancreaticobiliary Disease

Our purpose was to determine if the presence of duodenal diverticula predisposes to the development of pancreaticobiliary disease. Between May 1999 and February 2001, 381 patients were examined by endoscopic retrograde cholangiopancreaticography. Of these patients, 51 had periampullary diverticula. In 27 patients the papilla was located inside the diverticulum (Group I), in 19 patients it was located at the edge of the diverticulum (Group II), and 5 patients it was located at a distance closer than 3 cm to the diverticulum (Group III). Seventeen patients in group I and 11 patients in group II had had a previous cholecystectomy. The overall incidence of biliary system stone disease was 22.2% in group I, 36.8% in group II, and 100% in group III. All patients were treated with endoscopic sphincterotomy and three (two in group I and one in group II) developed biliary system disease (cholangitis or pancreatitis). We think that sphincterotomy should be applied regardless of the presence of stone if the papilla is located inside or at the edge of the diverticulum. If the papilla is located 3 cm or more far for diverticulum, it should be considered within the frame of general sphincterotomy indications in the absence of stone disease.     

Sphincter of oddi (pancreatic) hypertension and recurrent pancreatitis

Major papilla pancreatic sphincter dysfunction, a variant of sphincter of Oddi dysfunction, causes pancreatitis and pancreatic-type pain. The gold standard for diagnosis is sphincter of Oddi manometry, most commonly performed at endoscopic retrograde cholangiopancreatography (ERCP). Noninvasive testing, such as secretin-stimulated transabdominal or endoscopic ultrasound assessment of pancreatic duct diameter, is less reliable and has relatively low sensitivity. Two thirds of patients with biliary sphincter of Oddi dysfunction have elevated pancreatic basal sphincter pressure. To maximize the diagnostic yield of sphincter of Oddi dysfunction, both the biliary and pancreatic sphincter pressures should be measured. Patients with sphincter of Oddi dysfunction may respond to biliary sphincterotomy alone, but evaluation of their pancreatic sphincter is warranted if symptoms persist after biliary therapy alone. Whether both biliary and pancreatic sphincters should be treated at the first ERCP session is controversial. Biliary and pancreatic endoscopic sphincterotomies are associated with two-to fourfold increased incidence of pancreatitis following the procedure in patients with pancreatic sphincter hypertension. Prophylactic pancreatic duct stenting reduces the frequency and severity of complications by greater than 50%.     

Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone-induced acute cholangitis and pancreatitis

Urgent or emergency endoscopic retrograde cholangiopancreatography (ERCP) is indicated for gallstone-induced acute cholangitis and pancreatitis. The technique and optimal timing of ERCP depend on the disease state, its severity, anatomy, patient background, and the institutional situation. Endoscopic transpapillary biliary drainage within 24 h is recommended for moderate to severe acute cholangitis. The clinical outcomes of biliary drainage with nasobiliary drainage tube placement and plastic stent placement are comparable, and the choice is made on a case-by-case basis considering the advantages and disadvantages of each. The addition of endoscopic sphincterotomy (EST) is basically not necessary when performing drainage alone, but single-session stone removal following EST is acceptable in mild to moderate cholangitis cases without antithrombotic therapy or coagulopathy. For gallstone pancreatitis, early ERCP/EST are recommended in cases with impacted gallstones in the papilla. In some cases of gallstone pancreatitis, a gallstone impacted in the papilla has already spontaneously passed into the duodenum, and early ERCP/EST lacks efficacy in such cases, with unfavorable findings of cholangitis or cholestasis. If it is difficult to diagnose the presence of gallstones impacted in the papilla on imaging, endoscopic ultrasonography can be useful in determining the indication for ERCP.     

Endoscopic management of biliary complications after orthotopic liver transplantation

BACKGROUND: Biliary complications are a serious problem in patients after liver transplantation and often require reoperation. This study was conducted to summarize the endoscopic diagnosis and management of biliary complications after orthotopic liver transplantation (OLT). METHODS: From December 2000 to November 2003, twelve endoscopic retrograde cholangiopancreatographies(ERCPs) were performed in 7 patients after OLT at Digestive Endoscopic Center of Changhai Hospital in Shanghai, China. The therapeutic maneuvers included endoscopic sphincterotomy (EST), biliary stent placement, balloon and basket extraction, irrigation, and nasobiliary tube placement. A retrospective study was made to determine the types of biliary tract complications after OLT. The success of ERCP and therapeutic maneuvers was also evaluated. RESULTS: Biliary tract complications including biliary stricture, biliary leak, biliary sludge, and stump leak of the cyst duct were treated respectively by endoscopic sphincterotomy with sludge extraction, stricture dilation or endoscopic retrograde biliary drainage. Two of the 3 patients with proximal common bile duct stricture were successfully treated with ERCP and stent placement. Four patients with anastomotic stricture and/without bile leak were treated successfully by dilation and stent placement or endoscopic nosobiliary drainage. No severe ERCP-related complications occurred. CONCLUSIONS: ERCP is an effective and accurate approach for the diagnosis of biliary tract complications after OLT, and placement of a stent is a safe initial treatment for biliary complications after liver transplantation.     

Sump syndrome. Treatment by endoscopic biliary "rendez-vous" procedure]

Sump syndrome consists on an entity in which the distal portion of the biliary tree does not drainage by the major papilla, so food and bile are retained and infections could appear leading to cholangitis. The real incidence of the sump syndrome after side-to-side choledocoduodenostomy is unknown, but has been described less than 10%. Several procedures have been used to solve it but at present endoscopic sphincterotomy is of choice the treatment of this condition that is followed by a good outcome. When major papilla can not be negotiated, an endoscopic approach consisting in a biliary endoscopic procedure could be used, negotiating the biliary tree by the side-to-side choledocoduodenostomy in this case. We report a clinical case of a patient with a side-to-side choledocoduodenostomy because of choledocolithiasis who developed a sump syndome. He was treated by a biliary endoscopic procedure because a papillary stenosis did not allow a transpapillar access to the biliary tree.     

Effectiveness of endoscopic sphincterotomy in complicated hepatic hydatid disease

Background:The aim of this study was to evaluate the results of endoscopic sphincterotomy in patients with hepatic hydatid cysts that have ruptured into the biliary tract. Methods:Over a 10-year period, 25 patients (11 men, 14 women, mean age 60 years) underwent treatment; 13 with no prior surgery were treated for biliary obstruction. Postoperative treatment was undertaken in 12 cases because of persistent drainage (8), duct obstruction (3), and postoperative pancreatitis (1). Results:In patients who had not undergone previous surgery, cholangiographic findings were hydatid vesicles in the biliary tract (6), dilation of the biliary tract (3), biliary fistula (2), distal stenosis (1), and purulent bile content after sphincterotomy (1). In all of these cases, sphincterotomy resolved duct obstruction with no complications. All patients with persistent postoperative drainage had a fistula tract between the biliary duct and the cavity, which was resolved by endoscopic treatment in all 8. The 3 patients with postoperative biliary obstruction had hydatid vesicles in the biliary tract, one with a long stenosis resembling sclerosing cholangitis, whereas the patient with postoperative pancreatitis had a distal stenosis. Satisfactory results were obtained with endoscopic sphincterotomy, although 1 patient required a biliary prosthesis. Conclusion:Endoscopic sphincterotomy resolves biliary obstruction and postoperative fistulae in most patients with hepatic hydatid cysts that have ruptured into the biliary tract. In some cases, a biliary prosthesis may be required. (Gastrointest Endosc 1998;48:593-7.)     

A novel technique for endoscopic sphincterotomy when using a percutaneous transhepatic cholangioscope in patients with an endoscopically inaccessible papilla

BACKGROUND: Endoscopic sphincterotomy is difficult and sometimes impossible in patients who have undergone gastrectomy or partial gastrectomy with Billroth II reconstruction. For such patients, a novel technique was developed in which endoscopic sphincterotomy is performed via percutaneous transhepatic cholangioscopy. This report describes an initial experience with this technique. METHODS: After dilation of the percutaneous fistula, a cholangioscope with a push-type sphincterotome attached was inserted into the bile duct via the fistula and then through the papilla into the duodenum. The tip of the instrument then was retroverted to obtain a frontal view of the papilla. Then, a sphincterotomy incision was extended to the proximal, orad margin of the papillary eminence. OBSERVATIONS: Percutaneous transhepatic biliary drainage was performed in 3 patients with obstructive jaundice and bile duct stones. In all patients, percutaneous transhepatic cholangioscopic sphincterotomy was performed successfully, without procedure-related complication. Thereafter, all stones and stone fragments cleared from the duct by spontaneous migration. CONCLUSIONS: Endoscopic sphincterotomy via percutaneous transhepatic cholangioscopy potentially is an innovative technique for endoscopic sphincterotomy in patients with an endoscopically inaccessible papilla.     

Safety of extension of a previous endoscopic sphincterotomy: a prospective study

OBJECTIVES: Data in the literature regarding complication risks after the extension of a previous endoscopic biliary sphincterotomy (repeat endoscopic biliary sphincterotomy) are limited and controversial. To explore this issue, we prospectively studied complications after repeat sphincterotomy and compared them with those of biliary endoscopic sphincterotomy in consecutive patients with choledocholithiasis. METHODS: A total of 250 patients underwent endoscopic biliary sphincterotomy and 81 underwent extension of a previous one. All patients had choledocholithiasis and were enrolled using specific criteria, excluding parameters predisposing to increased postsphincterotomy complications. RESULTS: The overall complication rate was 2.46% in the repeat sphincterotomy and 8.4% in the sphincterotomy group (p > 0.05). Complications for the repeat sphincterotomy and initial sphincterotomy groups, respectively, were as follows: bleeding, 2.46% and 2.8%; pancreatitis, 0% and 4.8% (p < 0.05); cholangitis, 0% and 0.4%; perforation, 0% and 0.4%; and hyperamylasemia, 3.7% and 12.8% (p < 0.05). There were no deaths. Bleeding episodes in the former group occurred when repeat sphincterotomy was performed early after the primary one. CONCLUSIONS: Repeat sphincterotomy is a safe technique for the treatment of patients with choledocholithiasis and seems to be as safe as initial sphincterotomy. It is not associated with increased hemorrhage risk. There is a trend toward a higher risk of hemorrhage when repeat sphincterotomy is performed early. Repeat sphincterotomy is safer than the initial sphincterotomy with respect to pancreatic complications.