Comparison of treatment outcomes between biliary plastic stent placements with and without endoscopic sphincterotomy for inoperable malignant common bile duct obstruction.

AIM: Considerable controversy surrounds the adoption of endoscopic sphincterotomy (ES) to facilitate the placement of 10F plastic stents (PS) and to reduce the risk of pancreatitis The aim of the study was to assess the possible advantages of ES before PS placement. METHODS: From 3/1996 to 6/2001, 172 consecutive patients, who underwent placement of a single 10F- polyethylene stent for inoperable malignant strictures of the common bile duct, were randomly assigned to 2 groups. In group A (96 patients), a ES was performed before PS placement In Group B, 96 patients had PS directly. Early complications (within 30 d) and late effects (from 30 d to stent replacement) were assessed. Patency interval was defined as the period between PS placement and obstruction or death. The success of stent replacement in the 2 groups was evaluated. RESULTS: Stent insertion was successful in 95.8%(92/96) of the pts in group A and in 93.7%(90/96) of the patients in group B (P>0.05). Early complications were more frequent in patients who underwent ES (6.5% vs 4.4%) but the data were not significant (P>0.05). In group A pancreatitis developed in two patients and bleeding in three; whereas pancreatitis occurred in 2 patients in group B. Complications were managed conservatively. No procedure related mortality occurred. All late complications were acute cholangitis due to stent occlusion. We performed a stent replacement in 87 patients that was successful in 84 cases without differences between groups. CONCLUSION: Sphincterotomy does not seem to be necessary for placement of 10F-PS in patients with malignant common bile duct obstruction.

Endoscopic sphincterotomy for stenosis of the sphincter of Oddi.

BACKGROUND: Sphincter of Oddi dysfunction (SOD) is one of the causes of postcholecytectomy syndrome and biliary pain. Endoscopic sphincterotomy (EST) is recommended in some cases for patients refractory to conservative treatment. By the Milwaukee classification, patients with biliary pain can be divided into three groups. Group I patients show all the objective signs suggestive of a disturbed bile outflow-i.e., elevated liver function tests, dilated common bile duct (CBD), and delayed contrast drainage during endoscopic retrograde cholangio pancreatography (ERCP). Group II patients have biliary-type pain along with one or two of the criteria from group I. Group III patients have only biliary pain, with no other abnormalities. This study confirms the effectiveness of EST for the relief of symptoms in group I patients (papillary stenosis). METHODS: Between 1989 and 1999, we treated eight patients clinically diagnosed as having group I papillary stenosis by EST. Their ages ranged from 52 to 73 years. In addition to biliary pain, all patients were found to have dilated CBD, elevated enzyme levels, and delayed contrast drainage at ERCP. None of the patients had CBD stones or other causes of obstruction. Sphincter of Oddi manometry was not performed. RESULTS: EST was successfully performed in eight patients. Each patient had a very large papilla. A false orifice was found in one patient. In five patients, endoscopic cannulation of the bile duct was very difficult. The use of a long, tapered catheter and guidewire papillotomy was necessary in four patients. A precut papillotomy was performed in one patient. All patients achieved resolution of their symptoms after EST. There were no complications. The average length of the follow-up period was 26 months. CONCLUSIONS: SOD is a real entity that continues to pose a diagnostic dilemma. EST is an effective and safe modality for the treatment of papillary stenosis (group I patients). SOD manometry is not necessary before EST in group I patients.

[Usefulness of continuous duodenal catheterization and drainage in the postoperative period after papillosphincteroplastic operations]. / Utilità del sondaggio duodenale continuato nel decorso post-operatorio degli interventi di papillosfinteroplastica.

The Authors claim the continuous emptying of the duodenum after papillosphincteroplastic useful in preventing APP. In order to prove it they present 27 running cases of sphicteroplastic so treated in which the postoperative amylasemy did not exceed the normal values.

[Sphincter of Oddi dysfunction--prolonged medical therapy or early endoscopic sphincter ablation]. / Oddi-sphincter-dyskinesis--elhúzódó gyógyszeres kezelés vagy korai endoszkópos papillotomia.

INTRODUCTION: Sphincter of Oddi dysfunction is a real challenge from both diagnostic and therapeutic point of view. PATIENTS AND METHODS: In the last two years the authors have performed ERCP and EST in 29 patients with positive evocative test results, who had important enzyme elevations and/or did not respond to prolonged medical treatment. RESULTS: Endoscopic findings were positive in 25/29 patients (86.2%): 8 adenoma of p. Vateri, 17 papillitis were identified, and in 4 cases the papilla was intact. Histopathology obtained in 12 patients supported the diagnosis. In 6 patients, who underwent a postpapillotomy evocative test, after an average of 10 months follow up the results have been converted from positive to negative response in all but two cases. The two patients continued to have abdominal symptoms with persistent positive provocation tests because of restenosis, were treated with repapillotomy. CONCLUSIONS: The Debray and Nardi tests are useful screening tests for hypertonic biliary or pancreatic dyskinesia. Structural endoscopic and histological findings are frequent already in the functional cases. Early sphincter ablation should be considered in failure of medical therapy for preventing the transformation of this functional disorder into an organic, potentially precancerous state.

Laparoscopic hepaticoplasty using gallbladder as a subcutaneous tunnel for hepatolithiasis.

AIM: To investigate the feasibility, efficacy and safety of laparoscopic hepaticoplasty using gallbladder as subcutaneous tunnel and sphincter-of-Oddi preservation for hepatolithiasis. METHODS: From January 2010 to July 2013, six patients with hepatolithiasis were treated at our institution. All the patients underwent laparoscopic surgery. The procedures included common hepatic duct exploration, stone clearance by fiberoptic choledochoscopy, hilar bile duct hepaticoplasty with preservation of the sphincter of Oddi, anastomosis between the hilar bile duct and neck of the gallbladder, and establishment of a subcutaneous tunnel with the gallbladder. Two patients underwent left lateral hepatectomy simultaneously. Clinical data including operation time, intraoperative blood loss, operative morbidity, hospital mortality, stone clearance, and recurrence rate were analyzed. RESULTS: All patients successfully completed laparoscopic surgery. The mean length of hospital stay was 4.5 ± 0.9 d (range: 3-6 d). The mean blood loss of the hepatectomy was 450 mL (range: 200-700 mL), and the blood loss of the other four was 137 ± 151 mL (range: 50-400 mL). The mean operative time was 318 ± 68 min (range: 236-450 min). The operative morbidity and hospital mortality were zero. The immediate stone clearance rate was 100%. All patients were followed up for an average of 17 mo (range: 7-36 mo). One of the six patients had abdominal mass with pain, and subcutaneous tunnel cholangiography showed severe gallbladder-biliary anastomotic stricture at 4 mo postoperatively. There was no stone recurrence and no cholangitis during follow-up. CONCLUSION: Laparoscopic hepaticoplasty using gallbladder with a subcutaneous tunnel and preserving the sphincter of Oddi is feasible, safe and effective for hepatholithiasis.

Endoscopic therapy for bile leak based on a new classification: results in 207 patients.

BACKGROUND: Bile leak is among the most common complications of cholecystectomy. Endoscopic therapy is empiric; a systematic approach to management of bile leak has not been established. METHODS: The severity of bile leak was classified by endoscopic retrograde cholangiography into low grade (leak identified only after intrahepatic opacification) or high grade (leak observed before intrahepatic opacification). Therapy was based on this distinction: biliary sphincterotomy alone for low-grade leaks and stent placement for high-grade leaks. The success of this strategy in consecutive patients treated between 1989 and 1999 was reviewed. RESULTS: A total of 207 patients (127 women, 80 men; median age 57 years) with bile leak were referred for endoscopic management; 134 had undergone laparoscopic, and 72 had open cholecystectomy. Patients presented at a median of 9 days (range 1-50 days) after surgery. Symptoms included pain (56%), jaundice (16%), fever (11%), and abdominal distension (7%). Persistent percutaneous drainage was present in 48%. Endoscopic retrograde cholangiography identified the leak site in 204 patients: cystic duct stump, 159 patients (78%); duct of Luschka, 26 (13%); other, 19 (9%). Of 104 patients with low-grade leaks, 75 had sphincterotomy alone; improvement occurred in 68 patients (91%). Subsequent treatment was required in 7 patients (6 stent, 1 surgery). Stents were placed in the remaining 29/104 patients for the following reasons: biliary stricture (11/29); coagulopathy, precluding sphincterotomy (8/29); severe sepsis (3/29); inadequate drainage after prior sphincterotomy (2/29); and unclear reasons (5/29). Of 100 patients with high-grade leaks, 97 had stent placement. Persistent leakage necessitated another stent insertion in 4 patients. Closure of the leak was documented by endoscopic retrograde cholangiography in all 97 patients. Three patients with leaks not amenable to endoscopic treatment were referred for surgery. Bile-duct stones were identified in 41 patients (28, low-grade group; 13, high-grade group) and were extracted in all cases. Overall, complications occurred in 3 patients (2 pancreatitis, 1 perforation) and were managed conservatively with no mortality. CONCLUSIONS: A simple, practical endoscopic classification system for bile leak after cholecystectomy is proposed. This classification has clinical relevance for selection of optimal endoscopic management.

[Effectiveness of sympathoadrenergic blocking in prevention of postoperative acute pancreatitis]. / Eficienta blocajului simpatoadrenergic în profilaxia pancreatitei acute postoperatorii.

The role of the vascular factor (namely hypoperfusion) in the onset of pancreatic necrosis is a well-established fact. In the present study an analysis is made of the efficiency of drug blocking of alpha and beta adreno-receptors in the prophylaxis of acute postoperative pancreatitis, following surgery of the Oddi sphincter. Compared with a control group of 301 papillo-sphincterotomies performed in a previous period the application of adrenergic blocking in 127 patients in whom interventions were performed on the Oddi sphincter led to a significant reduction in both morbidity and mortality through acute postoperative pancreatitis, from 5 to 2,3%, and from 1,3 to 0,7% respectively.

[Argon laser endoscopy therapy in refractory bleeding post sphynterotomy: report of two cases]. / Tratamiento endoscopico con argon plasma en sangrado refractario post esfinterotomia: reporte de dos casos.

We report two cases of successfully endoscopy therapy with argon plasma in upper gastrointestinal bleeding secondary a complication of endoscopic sphynterotomy, who fails to previous injectotherapy attempts. The bleeding control was complete and without complications.

Incomplete response to endoscopic sphincterotomy in patients with sphincter of Oddi dysfunction: evidence for a chronic pain disorder.

OBJECTIVES: The efficacy of endoscopic treatment of sphincter of Oddi dysfunction (SOD) with endoscopic sphincterotomy (ES) remains controversial. Although some studies have shown a positive impact on patient symptoms after treatment, these reports have been largely qualitative and evaluated on short-term response. The aim of our study was to quantitatively measure the long-term outcomes of endoscopic therapy in patients with SOD. METHODS: Thirty-three patients with suspected SOD underwent selective sphincter of Oddi manometry (SOM) of the biliary and/or pancreatic sphincter. Each patient completed a telephone-based survey measuring symptomatic pain before and after SOM +/- ES. The questioner was blinded to the results of SOM. The patients with normal SOM or SOD but who did not undergo ES served as controls. RESULTS: Of these 33 patients (27 women, mean age 48.7 yr, range 13-74), 19 (57.5%) were found to have SOD (12 biliary, six pancreatic, one both). The average follow-up was 18.1 months (range 7-34). Of the patients with SOD, 17 (89%) underwent ES. At follow-up of the 19 patients undergoing ES, five were taking narcotics for persistent pain, two were taking antidepressants, and 15 identified the endoscopic therapy as the reason for their relief. Of the 14 controls, seven were taking narcotics, seven were taking antidepressants, and two identified the endoscopy as the reason for their relief; some patients were taking both antidepressants and narcotics. CONCLUSIONS: Patients found to have SOD who undergo ES are more likely to be improved on long-term follow-up when compared with patients with suspected SOD but normal manometry without ES. However, almost uniformly, despite ES, patients continue to have pain, which is consistent with most chronic pain disorders and which suggests a multifactorial cause for the pain.

[Infiltrating injection in the management of post-papillotomy hemorrhages]. / Unterspritzung zur Behandlung der Papillotomie-Blutung.

Treatment was required in nine cases (1.7%) of haemorrhage after endoscopic sphincterotomy performed in 508 patients during 1981/82. Infiltrations with adrenalin (1: 10 000) and 1% polidocanol solution resulted in immediate arrest of haemorrhages in all cases. The endoscopic intervention could thus be completed successfully without further delay. The haemostatic effect was, without exception, permanent. There were no specific complications or late reactions.