25 years of endoscopic sphincterotomy in Erlangen: Assessment of the experience in 3498 patients

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 ere 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.