Bi-directional regulation of acupuncture on extrahepatic biliary system: An approach in guinea pigs.

Clinically, acupuncture affects the motility of the extrahepatic biliary tract, but the underlining mechanisms are still unknown. We applied manual acupuncture (MA) and electrical acupuncture (EA) separately at acupoints Tianshu (ST25), Qimen (LR14), Yanglingquan (GB34), and Yidan (CO11) in forty guinea pigs (4 groups) with or without atropinization under anesthesia while Sphincter of Oddi (SO) myoelectric activities and gallbladder pressure were monitored. In both MA and EA groups, stimulation at ST25 or LR14 significantly increased the frequency and amplitude of SO myoelectrical activities and simultaneously decreased the gallbladder pressure as compared to the pre-MA and pre-EA (P < 0.05). On the contrary, stimulation at GB34 or CO11 significantly decreased SO myoelectricity and increased the gallbladder pressure (P < 0.05). Pretreatment with atropine could abolish the effect of stimulation at acupoints ST25, GB34 and LR14 (P > 0.05), although significant myoelectricity increases were still inducible with MA or EA stimulation at CO11 (P < 0.05). In summary, acupuncture has bi-directional effects to gallbladder pressure and SO function, which probably due to autonomic reflex and somatovisceral interactions.

Impact of endoscopic papillary large-balloon dilation on sphincter of Oddi function: a prospective randomized study.

BACKGROUND AND AIMS: Endoscopic papillary balloon dilation (≤8 mm in diameter) preserves sphincter of Oddi (SO) function. However, it is still unknown whether papillary function is preserved after endoscopic papillary large-balloon dilation (EPLBD, ≥12 mm in diameter). We investigated SO function after EPLBD with or without endoscopic sphincterotomy (EST) by endoscopic manometry, up to 1 year after the procedure. METHODS: This was a prospective randomized study involving patients with bile duct stones ≥12 mm. Eighty-six patients who met the inclusion criteria were assigned randomly to either EPLBD alone or EST with EPLBD, and endoscopic manometric studies were performed. The primary outcome was comparison of the manometric data between the 2 groups and within each group both 1 week and 1 year after the procedure. RESULTS: One week after EPLBD alone and EST with EPLBD, the basal pressure of SO dropped from 30.4 (8.2) to 6.4 (8.4) mm Hg (P < .001) and 29.5 (18.9) to 2.9 (3.6) mm Hg (P < .001), respectively. SO function was not recovered at 1 year; the manometric measurements were similar to those taken at the 1-week time point in both groups. Similar outcomes were obtained in patients with EPLBD alone compared with those with EST and EPLBD, including the initial stone clearance rate (95.2% vs 97.7%, P = .612), the frequency of mechanical lithotripsy (21.4% vs 13.6%), and overall adverse events (11.9% vs 13.6%, P = 1.0) including the rate of pancreatitis after the procedure (7.1% vs 11.4%, P = .714). During an overall median follow-up of 17.8 months, the recurrence rate of bile duct stones was 16.7% in patients who underwent EPLBD alone and 15.9% in patients who underwent EST with EPLBD (P = .924). CONCLUSIONS: Both EPLBD alone and EST + EPLBD resulted in persistent and comparable loss of SO function after 1 year. EPLBD alone has similar efficacy and safety to those of EST with EPLBD with respect to removal of large stones.

Incidence and predictors of post-ERCP pancreatitis in patients with suspected sphincter of Oddi dysfunction undergoing biliary or dual sphincterotomy: results from the EPISOD prospective multicenter randomized sham-controlled study.

BACKGROUND AND STUDY AIM: Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) is a significant and potentially life-threatening adverse event and is common in patients with suspected sphincter of Oddi dysfunction (SOD). Here we aimed to identify predictors of the risk in this population. PATIENTS AND METHODS: The Evaluating Predictors and Interventions in SOD (EPISOD) study prospectively enrolled 214 post-cholecystectomy patients with SOD type III in seven US centers. Patients were randomized, using a 2:1 allocation, to sphincterotomy or sham procedure, irrespective of the results of sphincter of Oddi manometry. Patients in the sphincterotomy arm who had elevated pancreatic sphincter pressure were randomized to biliary only or to dual (biliary and pancreatic) sphincterotomy. All but one patient received prophylactic pancreatic stents, but none received pharmacological prophylaxis. Post ERCP pancreatitis (PEP) was defined as acute pancreatitis within the subsequent 7 days. Blinded research coordinators at each site called patients at 1 week post-procedure. RESULTS: PEP occurred in 26 patients, in 10.6 % (15/141) in the sphincterotomy arm and 15.1 % (11/73) in the sham arm; unadjusted relative risk 0.71 (95 % confidence interval [95 %CI] 0.34 - 1.46). PEP rate was not significantly different in patients who received sphincterotomy compared with those undergoing sham treatment. In addition, the proportion was not statistically different in those who received biliary sphincterotomy alone (12/94; 12.8 % [95 %CI 6.0 % - 19.5 %]) compared with dual sphincterotomy (3/47; 6.4 % [95 %CI 0.0 % - 13.4 %]). Multivariate analysis identified an interaction between duration of ERCP and sedation type (P < 0.02). CONCLUSION: The performance of biliary or dual sphincterotomy does not increase the risk of PEP in patients suspected of SOD. However, the high rate of PEP in patients with suspected SOD, despite pancreatic stenting in expert centers, is confirmed in this prospective study. The combined effect of duration of ERCP and sedation type on the development of PEP should be further explored.Clinicaltrials.gov registration: NCT00688662.

Unexplained common bile duct dilatation with normal serum liver enzymes: diagnostic yield of endoscopic ultrasound and follow-up of this condition.

BACKGROUND: There is scant literature about common bile duct (CBD) dilatation with normal liver function tests (LFTs). AIMS: The aims of this study were to assess the diagnostic yield of endoscopic ultrasound (EUS) in patients with CBD dilatation, normal LFTs, and prior inconclusive imaging tests, and to assess the natural history of these subjects. METHODS: We retrospectively reviewed our EUS database for patients referred for evaluation of CBD dilatation, normal LFTs, and prior inconclusive imaging. We excluded patients with a prior endoscopic retrograde cholangiopancreatography or a history of biliary obstruction, pancreatitis, or jaundice. Follow-up data were retrieved from medical records or by calling the general practitioners, referring specialists, patients, or their closest relatives. RESULTS: A total of 57 patients were enrolled. The mean CBD diameter was 12.5±3.6 mm. The majority of patients (50.8%) were asymptomatic. Abnormal EUS findings were recorded in 12 (21%) subjects: 6 patients had a periampullary diverticulum, 2 had ampullary adenoma, 2 had signs of chronic pancreatitis, 1 had a cancer of the pancreatic head, and 1 had a 7 mm CBD stone. Neither age, sex, prior cholecystectomy, clinical presentation, CBD diameter, nor a dilated main pancreatic duct were predictors of abnormal EUS findings. None of the patients complained of biliary symptoms or showed abnormal LFTs on long-term follow-up. CONCLUSIONS: CBD dilatation with normal liver chemistry is not always a benign condition. Even when prior imaging tests are negative, EUS may allow to diagnose conditions overlooked by standard diagnostic imaging.

Risk stratification for the development of post-ERCP pancreatitis by sphincter of Oddi dysfunction classification.

OBJECTIVES: To explore whether there is a difference in the frequency of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in patients with manometrically confirmed sphincter of Oddi dysfunction (SOD) types I, II, and III. METHODS: A retrospective review of all of the patients who underwent an ERCP with SOD type I or patients with manometrically confirmed SOD type II or type III (mean basal sphincter pressure ≥ 40 mm Hg) from 2006 to 2010 was performed. The primary outcome measure was development of post-ERCP acute pancreatitis in each of the SOD groups. Factors associated with acute pancreatitis in each group were examined by univariate analysis. RESULTS: We identified 147 patients with SOD. Biliary sphincterotomy was performed in all of the patients, and pancreatic sphincterotomy was performed in 68 of the 147 (46%). All of the patients underwent stenting of the pancreatic duct. Post-ERCP pancreatitis occurred in 23% of the study cohort. Patients with SOD type III had a higher frequency of post-ERCP pancreatitis compared with the SOD type I and type II groups (31% vs 20% vs 6%, respectively; P = 0.024). Those with SOD type III had a greater frequency of post-ERCP pancreatitis (odds ratio 6.7; P = 0.05) compared with those with SOD type I. Patients with SOD type III had a two times greater frequency of developing post-ECRP pancreatitis compared with those with SOD type II. CONCLUSIONS: SOD type III is strongly associated with the development of post-ERCP pancreatitis compared with SOD type I.

Complete transection of common bile duct after blunt trauma abdomen--a case report.

Isolated injury to the extrahepatic biliary system after blunt trauma is rare, Complete transection of the common bile duct is also a rare entity. Here a case of a 45-year-old male admitted with the history of blunt trauma abdomen with features of peritonitis and jaundice, found to have complete transection of common bile duct and there was no other visceral injury is reported. Cases of isolated complete transection of common bile duct in blunt trauma abdomen are rarely reported in the literature.

[Principles of direct surgical procedures on the pancreas in surgical treatment of chronic pancreatitis].

An analysis of treatment of 584 patients with complicated forms of chronic pancreatitis operated during 2000-2100 years was carried out. Quality of life of postoperative patients was estimated according to a technique of calculations of modules EORTC QLQ-C30 and EORTC QLQ-PAN26. The indicators of quality of life have improved by 19.7% in performance of saving duodenal outflow of operations of pancreatic juice. Change of the surgical strategy has led to decreased number of postoperative complications by 4.6% and to satisfactory long-term results in 92.6% of the patients.

Prospective trial comparing solid-state catheter and water-perfusion triple-lumen catheter for sphincter of Oddi manometry done at the time of ERCP.

BACKGROUND: Sphincter of Oddi manometry is the reference standard for the diagnosis of sphincter of Oddi dysfunction. Numerous studies have established ranges of normal values as well as typical readings in pathologic conditions. All these studies have been done using a water-perfused, triple-lumen catheter (TLC). A recently approved, new generation, solid-state catheter (SSC) has potential advantages, but concerns have been raised as to whether the pressures obtained by TLCs are reproducible by SSCs. To date, no data exist on the accuracy of sphincter of Oddi pressure measurements with the new-generation SSCs. OBJECTIVE: To evaluate the accuracy of the SSC by using the TLC as the reference standard. DESIGN: Prospective crossover trial. SETTING: A tertiary academic center. PATIENTS: Thirty patients with clinical indications for sphincter of Oddi manometry. INTERVENTIONS: Sphincter of Oddi manometry with TLC and SSC in the same patient. MAIN OUTCOME MEASUREMENTS: Accuracy of sphincter of Oddi pressure measurements. RESULTS: A total of 376 pressure measurements in 47 sphincter segments (24 biliary, 23 pancreatic) were obtained. Manometry results were abnormal in 10 of 24 biliary sphincters and 12 of 23 pancreatic sphincters. There was complete agreement on the final results of the sphincter of Oddi manometry (normal/abnormal) between the TLC and SSC (accuracy 100%). A split-plot analysis of the 378 individual measurements was performed. The P value of .9966 was insignificant, consistent with no catheter effect on the measurements. LIMITATIONS: Lack of blinding. CONCLUSIONS: Measurement of sphincter of Oddi pressures with the SSC is accurate, and results were essentially identical to those of the water-perfused catheter system.

Sleeve sphincter of Oddi (SO) manometry: a new method for characterizing the motility of the sphincter of Oddi.

BACKGROUND/PURPOSE: Perfused multilumen sphincter of Oddi (SO) manometry is accepted as the gold standard for diagnosis of SO dysfunction. However, this technique is associated with a relatively high incidence of post-procedure acute pancreatitis. In addition, triple-lumen manometry recordings may be difficult to interpret, as movement may produce artifacts. We have refined the development of a sleeve sensor for human SO manometry. This assembly aims to overcome the above limitations. In this study the accuracy of sleeve SO manometry (SOM) has been evaluated and compared with standard triple-lumen perfused SOM. METHODS: Patients undergoing SO manometric studies consented to having both standard triple-lumen and sleeve SOM. A total of 32 paired studies were performed in 29 patients. Diagnosis was made only from standard triple-lumen SOM and the patient treated accordingly. For each study, SO basal pressure, contraction, amplitude, and frequency were recorded. RESULTS: There was no statistically significant difference in the recordings of SO basal pressure, contraction, amplitude, and frequency between the two techniques. A strong correlation was demonstrated between SO basal pressure determined with the two catheters. The accuracy of sleeve SOM is comparable to standard triple-lumen SOM, with less movement artifact. One patient developed mild post-manometric pancreatitis. CONCLUSIONS: The sleeve catheter records SO pressures with comparable values to standard triple-lumen SOM. The sleeve assembly potentially can replace the use of the perfused triple-lumen catheter for the objective diagnosis of SO dysfunction.

Establishment of an animal model of biliary ischemic stenosis with clamping in mice.

OBJECTIVE: The objective of this study was to explore a method to establish biliary ischemic stenosis in mice. METHODS: After the optimal time of biliary ischemia was determined, 20 Kunming mice were equally divided into 2 groups. In the experimental group a 0.4-cm length of common bile duct was clamped for 90 minutes with 2 micro-vessel clamps (width = 0.1 cm). The common bile duct was not clamped in the control group. Twenty-one days later, biliary tract visualization was performed in all mice. Blood samples were collected from the inferior vena cava to determine the serum levels of total bilirubin (TBIL) and alanine aminotransferase (ALT). Meanwhile, samples of the common bile duct and liver tissue were extracted for microscopic examination to observe morphological changes. RESULTS: In the experimental group, obvious dilatation of the common bile duct appeared over the clamp site. There was no dilatation of the common bile duct in the control group. Twenty-one days later, serum levels of TBIL and ALT were significantly higher among the experimental compared with the control group. Microscopic examination showed that the part of common bile duct at the clamp site was significantly expanded, with a smaller or occluded bile duct lumen necrotic mucosa with determination, and tubular wall with fibrosis and excrustation. A few dead liver cells and many inflammatory cells were observed in liver tissue samples. CONCLUSIONS: A biliary ischemic stenosis model was established using a clamping method in mice, which may provide a reliable technique for basic and clinical research into mechanisms of biliary ischemic stenosis after liver transplantation.

Participation of bone marrow cells in biliary fibrosis after bile duct ligation.

BACKGROUND AND AIM: Bone marrow derived cells are involved in the process of hepatic fibrosis secondary to chronic injury. However, it is not yet known how quickly this event occurs in acute fibrosis models. The purpose of this study was to determine the role of bone marrow cells in rapid fibrosis following bile duct ligation in mice using green fluorescent protein (GFP) expressing bone marrow cells. METHOD: After whole body irradiation, 1 x 10(6) donor whole bone marrow cells from green fluorescent protein(+/-) mice were transplanted into C57BL/6 recipients via the tail vein. Four weeks after bone marrow transplantation, chimeric mice were subjected to common bile duct ligation, and livers of these animals were histologically examined after bile duct ligation using anti-fibroblast specific protein (FSP)-1 antibody and anti-alpha-smooth muscle actin (alpha-SMA) antibody. RESULTS: Periductal fibrosis consisting of fibroblast specific protein-positive cells was demonstrated histologically as early as day 7. Most of the fibrotic cells were green fluorescent protein-negative, however, a significant number of cells were green fluorescent protein-positive and some were also anti-FSP or alpha-SMA-positive. CONCLUSION: Differentiation of bone marrow derived cells into activated fibroblast and myofibroblast-like phenotypes occurs in the very early course of periductal fibrosis following bile duct ligation, suggesting a new strategy for prevention of biliary fibrosis by inhibiting migration of bone marrow cells to liver.

Prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography.

BACKGROUND: Sphincter of Oddi manometry is the gold-standard method for sphincter of Oddi dysfunction. The prevalence of sphincter of Oddi dysfunction among patients referred to endoscopic retrograde cholangiopancreatography is largely unknown. AIM: To evaluate prospectively the prevalence of biliary sphincter of Oddi dysfunction (B-SOD) among Brazilian patients referred to endoscopic retrograde cholangiopancreatography and to study the safety of sphincter of Oddi manometry in this setting. METHODS: Biliary sphincter of Oddi manometry was intended in 110 patients referred to endoscopic retrograde cholangiopancreatography. The number of attempts to obtain deep cannulation with the manometry catheter was recorded and patients were divided into two groups: up to 5 (easy cannulation) and >5 attempts (difficult cannulation). RESULTS: Sphincter of Oddi manometry was successful in 71/110 patients (64.5%). Sphincter of Oddi dysfunction was found in 18/71 patients (25%). Endoscopic retrograde cholangiopancreatography findings were: normal in 16, biliary stones in 39, malignant biliary strictures in 9 and benign biliary strictures in 7. There was no statistical difference in sphincter of Oddi dysfunction prevalence regarding disease, gender or difficulty of cannulation. Only 2/71 patients developed post-procedure mild pancreatitis. CONCLUSIONS: We have found a high prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography. Gender, nature of disease or difficulty of cannulation did not influence the prevalence of sphincter of Oddi dysfunction among these patients. Sphincter of Oddi manometry is a safe procedure for the evaluation of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography.

Prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography

BACKGROUND: Sphincter of Oddi manometry is the gold-standard method for sphincter of Oddi dysfunction. The prevalence of sphincter of Oddi dysfunction among patients referred to endoscopic retrograde cholangiopancreatography is largely unknown. AIM: To evaluate prospectively the prevalence of biliary sphincter of Oddi dysfunction (B-SOD) among Brazilian patients referred to endoscopic retrograde cholangiopancreatography and to study the safety of sphincter of Oddi manometry in this setting. METHODS: Biliary sphincter of Oddi manometry was intended in 110 patients referred to endoscopic retrograde cholangiopancreatography. The number of attempts to obtain deep cannulation with the manometry catheter was recorded and patients were divided into two groups: up to 5 (easy cannulation) and >5 attempts (difficult cannulation). RESULTS: Sphincter of Oddi manometry was successful in 71/110 patients (64.5 percent). Sphincter of Oddi dysfunction was found in 18/71 patients (25 percent). Endoscopic retrograde cholangiopancreatography findings were: normal in 16, biliary stones in 39, malignant biliary strictures in 9 and benign biliary strictures in 7. There was no statistical difference in sphincter of Oddi dysfunction prevalence regarding disease, gender or difficulty of cannulation. Only 2/71 patients developed post-procedure mild pancreatitis. CONCLUSIONS: We have found a high prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography. Gender, nature of disease or difficulty of cannulation did not influence the prevalence of sphincter of Oddi dysfunction among these patients. Sphincter of Oddi manometry is a safe procedure for the evaluation of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography.

RACIONAL: Manometria do esfíncter de Oddi é o método padrão-ouro para o diagnóstico da disfunção do esfíncter de Oddi. Atualmente, a prevalência de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica é desconhecida. OBJETIVOS: Avaliar prospectivamente a prevalência de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica e estudar a segurança da manometria do esfíncter de Oddi nesses pacientes. MÉTODO: Neste estudo, 110 pacientes encaminhados à colangiopancreatografia retrógrada endoscópica foram submetidos a manometria do esfíncter de Oddi biliar. Com base no número de tentativas de canulação da papila os pacientes foram divididos em dois grupos: até cinco tentativas (canulação fácil) e mais de cinco tentativas (canulação difícil). RESULTADOS: Manometria do esfíncter de Oddi foi realizada com sucesso em 71/110 pacientes (64,5 por cento). Disfunção do esfíncter de Oddi foi encontrada em 18/71 pacientes (25 por cento). Os achados das colangiopancreatografia retrógrada endoscópica foram: estudo normal em 16, coledocolitíase em 39, estenose biliar maligna em 9 e estenose biliar benigna em 7. Não foi observada diferença estatística na prevalência de disfunção do esfíncter de Oddi considerando-se a natureza da doença, sexo ou a dificuldade de canulação. Somente 2/71 pacientes evoluíram com pancreatite pós-procedimento de leve intensidade. CONCLUSÃO: Encontrou-se alta prevalência de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica. Sexo, natureza da doença ou dificuldade de canulação não mostraram influência na prevalência da disfunção nestes pacientes. Manometria do esfíncter de Oddi mostrou-se um procedimento seguro na pesquisa de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica.

Sphincter of Oddi dysfunction in children.

Sphincter of Oddi dysfunction (SOD) is a clinical entity caused by a primary motility alteration of either the biliary or the pancreatic sphincter. SOD is a rare condition that has been scarcely reported in children. Most of the reported literature has been in children with idiopathic recurrent pancreatitis. These children are treated endoscopically by dual sphincterotomy of the pancreatic and common duct sphincters. However, the safety and efficacy of sphincter of Oddi manometry and sphincterotomy in the pediatric population await further study.

Transhepatic balloon dilation of anastomotic biliary strictures in liver transplant recipients: the significance of a patent hepatic artery.

PURPOSE: To determine the significance of hepatic artery steno-occlusive disease on the patency of anastomotic biliary strictures in liver transplant recipients after transhepatic balloon dilation. MATERIALS AND METHODS: A retrospective review of records of all patients undergoing transhepatic balloon dilation for anastomotic biliary strictures after orthotopic liver transplantation was performed over an 8-year period. Patency of the anastomosis was based on subsequent cholangiography. The presence of hepatic artery steno-occlusive disease was determined by Doppler ultrasound and/or angiography. The anastomotic biliary stricture patency rates were calculated by the Kaplan-Meier method. RESULTS: Thirty-eight patients who had undergone liver transplants underwent 53 balloon dilations for anastomotic biliary strictures (nine patients for arterial disease, 26 patients had patent arteries and three patients had arteries of indeterminate patency). Eight of the 53 strictures treated (15%) were refractory to balloon dilation: 10.5% of first comers and 27% of restenotic lesions. Two of the 53 strictures treated (4%) had significant complications: hemobilia requiring blood transfusion and ductal rupture. One-year cumulative primary patency rates for anastomotic biliary strictures for patients with arterial disease, patent hepatic arteries, and all-comers were: 0%, 45% (P = .01), and 36%, respectively. One-year cumulative primary patency rates for choledocho-choledocal and choledocho-jejunal anstomoses in patients with patent arteries were 43% and 48%, respectively (P = .10). CONCLUSIONS: In the presence of hepatic artery disease there is a lower patency of anastomotic biliary strictures after balloon dilation. Imaging of the hepatic artery should be considered to stratify patients who will have a successful outcome.