Clinical usefulness of double-guidewire technique for difficult biliary cannulation in endoscopic retrograde cholangiopancreatography.

BACKGROUND AND AIM: Although biliary cannulation with pancreatic guidewire placement (P-GW) is useful for difficult cases in endoscopic retrograde cholangiopancreatography (ERCP), the clinical significance of wire-guided cannulation with P-GW (double-guidewire technique: DGT) has not been clarified. The aim of the present study was to evaluate the usefulness of DGT for difficult biliary cannulation after unsuccessful biliary cannulation using a cannula/sphincterotome under guidance of injected contrast with P-GW (single-guidewire technique: SGT). METHODS: One-hundred and forty-six patients with difficult biliary cannulation who underwent SGT were included in this retrospective study. DGT was carried out if SGT was unsuccessful. Pancreatic duct (PD) stenting was attempted to prevent post-ERCP pancreatitis (PEP) in all patients. The success rate of cannulation and the risk factors for PEP were investigated. RESULTS: Biliary cannulation with SGT was achieved in 70%. DGT was carried out in 25 patients with unsuccessful SGT, biliary cannulation being successful in 72%. Of the 13 patients who underwent precut sphincterotomy, biliary cannulation was achieved in 46%. The incidence of PEP in patients who had undergone SGT, DGT, and precut sphincterotomy was 8% (12: mild, 8; moderate, 3; severe, 1), 4% (mild, 1), and 0%, respectively. PD stenting was successfully carried out in 86%. Multivariate analysis revealed unsuccessful PD stenting to be the only risk factor for PEP (OR 8.3, 95% CI 2.3-30). CONCLUSIONS: DGT may replace SGT or become the salvage procedure in cases of unsuccessful SGT as a result of its high success rate with an acceptable incidence of PEP. Failed pancreatic duct stenting in these techniques was frequently associated with PEP.

Duodenal switch operation for juxtapapillary duodenal diverticula.

BACKGROUND/AIMS: Since the first case of juxtapapillary diverticlum reported by Lemmel, several reports have demonstrated an association between periampullary diverticulum and gallstone disease. Thus, we compared the efficiency of the duodenal switch operation and choledchojejunostomy for patients who underwent surgery for cholangitis with juxtapapillary duodenal diverticula. METHODOLOGY: We retrospectively studied 17 patients who had cholangitis associated with juxtapapillary duodenal diverticula. These patients were divided into 2 groups on the basis of the operative procedure: the duodenal switch operation group (DS group) and the choledochojejunostomy group (CJ group). RESULTS: The mean operative time and blood loss were significantly lesser in the DS group than in the CJ group (p<0.0001 and p<0.0005, respectively); however, the duration of nasogastric suction requirement and time after which oral ingestion of solid diet could be safely resumed after surgery were significantly longer in the DS group than in the CJ group (p<0.0001 and p<0.0001, respectively). Gallstone formation after the surgery did not occur in both groups. CONCLUSIONS: Duodenal switch operation is useful and less invasive for cholangitis associated with juxtapapillary duodenal diverticula and for preventing cholangitis for a long period after the operation; however, gastric stasis still remains a problem with this procedure.

Juxtapapillary duodenal diverticula and pancreatobiliary disease.

Juxtapapillary duodenal diverticula (JPD) are observed in around 10-20% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). They are acquired extraluminal outpouchings of the duodenal wall through 'locus minoris resistance' and their incidence increases with age. They have been studied mainly with regard to their association with pancreatobiliary disease. Choledocholithiasis is considered to be strongly associated with JPD, but the role of JPD in the development of cholecystolithiasis and pancreatitis is still disputable. Since JPD are located in the vicinity of the papilla of Vater, they not only cause mechanical compression of the bile duct but also induce dysfunction of the sphincter of Oddi. They are considered to lead to bile stasis and to allow reflux from the duodenum into the bile duct, which results in an ascending infection of beta-glucuronidase-producing bacteria. The ERCP procedure can be hampered by JPD, although recent papers have reported no difference in the successful cannulation rate or complications between patients with JPD and those without JPD. Disorders caused by JPD are amenable to appropriate therapy, e.g. endoscopic sphincterotomy and surgical intervention.

[Papilla Vateri restenoses after papillosphincterotomy].

Biliary tract was investigated in 105 patients after endoscopic papillosphincterotomy for choledocholithiasis and papillostenosis. The follow-up revealed papillary restenosis in 8,6%, which occurred during first 2 years after the procedure. Short cut of the duodenal papilla and intramural part of the common bile duct and anamnestic papillostenosis and septic cholangitis proved to be the main reasons of the papillary restenosis.

[Improvement of endoscopic treatment of the acute cholecystitis].

Treatment results of 763 patients with acute cholecystitis were analyzed. Destructive forms of the disease was diagnosed by the ultrasound examination in all cases. Choledocholithiasis was diagnosed in 35 (4.6%), choledocholithiasis with papilla Vatery stricture was in 9 (1.2%) patients and isolated papilla Vatery stricture was registered in 5 (0.7%) patients. All patients were attempted to treat laparoscopically with the use of original "Device for antegrade papillotomy" and "Method of antegrade bipolar papillosphincterotomy". Authors state, that a final decision about the possibility of endoscopic treatment of the acute cholecystitis can be made after detection of anatomical structures of the Calo triangle. By complicated forms of the disease a one-stage laparoscopic treatment should be preferred. Endoscopic papillosphincterotomy should be performed only by the enblocked concrement of the papilla Vatery.

Three Cases of Ampullary Neuroendocrine Tumor Treated by Endoscopic Papillectomy: A Case Report and Literature Review.

We herein report three cases of patients with an ampullary neuroendocrine tumor (NET), who underwent endoscopic papillectomy (EP). No tumor recurrence or metastasis was detected in the patients for more than two years after EP. Generally, surgical resection is recommended for ampullary NETs by the European Neuroendocrine Tumor Society. However, as EP is less invasive than surgical resection, there are some reports of low-grade small ampullary NETs curatively treated by EP with long-term follow-up. We consider that EP may be a curative treatment for small and low-grade ampullary NETs without regional or distant metastasis.

Carcinoid of ampulla of Vater.

Carcinoid tumors of ampulla are rare clinical entities. They form 0.35% of all the gastrointestinal carcinoids. So far, only 109 cases have been reported in the literature, mostly as individual case reports. Since the metastatic potential and the tumor size have no correlation, unlike in duodenal carcinoids, pancreatoduodenectomy is considered the treatment of choice. Here we present a case of carcinoid of ampulla presenting to our department.

Manometric and radiographic evaluation of transduodenal sphincteroplasty (papillary dilation) in dogs.

PURPOSE: To evaluate, in dogs, the functions of biliary sphincter subjected to dilation hydrostatic balloon by the point of view of the radiographic and manometric alterations. METHODS: Twenty dogs were submitted to laparotomy, duodenotomy, and enlargement of the major duodenal papilla- GA(n=10) - with balloon of 8mm inflated with pressure of 0,5atm, during 2 minutes or to the sham procedure - GB(n=10). The computerized manometry and the cholangiography were done before and immediately after the initial procedure, one and four weeks after the dilation or the sham. It was calculated from the radiographic images: the mean, standard deviation, absolute and percentual variation of the diameter measures of the papilla. It was measured: the basal pressure in the papilla region, the contraction amplitudes and the choledoc pressure in all observation times (t0, t7 and t28). RESULTS: There was not differences in the diameter measures of the papilla in t0 (GA=5,14 +/- 1,1) (GB=4,64 +/-0,9), as well as in the absolute (0,14 mm) or relative (-2,7%) variations. In the animals of GA the papilla basal pressure measure was found to be smaller in t28 (11,1) than in t0 (18,6) and t7 (16,2). The contraction amplitudes measures were significantly smaller in the postoperatory times (post-t0, t7 and t28) when comparing to the initial time (pre-t0), in the animals of groups A and B. The average pressure values in the choledoc were also smaller in t28 (7,5) than in t0 (17,8) and t7 (12,6) in the animals of GA. CONCLUSION: the function of the major duodenal papilla is partially committed with the dilation, therefore it provoked the basal pressure decrease and compromising of the capacity of sphincter in its cyclical contractions up to the 28 days of observation.

Perfusion cholangiomanometry with papillary stimulation by dilute hydrochloric acid.

A modification of cholangiomanometry in which the papilla of Vater was stimulated by hydrochloric acid was devised as a means to evaluate the papillary function. Manometric tracings could be classified into four patterns according to the mode of response to hydrochloric acid of the papilla. Pattern I was the type in which a group of regular, high-amplitude spikes appeared within 60 seconds after the onset of perfusion. This represented a normally functioning papilla. Pattern II was characterized by rhythmic occurrence of low-amplitude waves. This represented a reversible papillitis as evidenced by the fact that postoperatively such cases exhibited pattern I results as examined through T tube. In pattern III the perfusion pressure remained flat, showing no reaction waves. This represented an incompetent papilla. The pattern III patients with conditions which were reversible responded to intravenous pentazocine. In pattern IV the perfusion pressure continued to increase without reaction waves, representing cicatricial stenosis of the papilla or incarcerated stone in the papilla. This method of cholangiomanometry was thus found to be useful for selecting candidates for sphincteroplasty.

Anomalous location of the papilla of Vater.

The location of the papilla of Vater in the third (horizontal portion) of the duodenum is a rare finding. In this report the thirty-eighth case is described and the available world literature is reviewed.

The role of juxtapapillary duodenal diverticulum in the formation of gallbladder stones.

BACKGROUND/AIMS: Juxtapapillary diverticula (JPD) are considered to be associated with choledocholithiasis but not with cholecystolithiasis. However, there have been few comparative studies on the relationship between JPD and cholecystolithiasis under strict matching for sex and age. METHODOLOGY: Among 4542 consecutive ERCPs at Tokyo Metropolitan Komagome Hospital, 549 patients who were 63 years of age or older were enrolled in this study and were matched for sex and age. They were divided into two groups: with and without JPD. Firstly, the frequency of cholecystolithiasis was compared between the two groups. Next, we recruited 83 patients whose JPD size could be measured by the ERCP films and investigated the relationship between JPD size and gallstones. RESULTS: We found no correlation between JPD and the overall frequency of cholecystolithiasis. However, an analysis of 83 patients with measurable JPD revealed that the size of JPD was closely linked to the occurrence of cholecystolithiasis. The JPD size was statistically larger in patients with cholecystolithiasis than those without. Moreover, when the mean diameter of JPD was 20 mm or more, the incidence of cholecystolithiasis rose up to 73.3%, which was significantly greater compared to the incidence in patients without JPD (p< 0.05). CONCLUSION: A larger JPD may play a role in the formation of gallbladder stones.

Pathophysiology after pylorus-preserving pancreatoduodenectomy: a comparative study of pancreatogastrostomy and pancreatojejunostomy.

BACKGROUND/AIMS: Pylorus-preserving pancreatoduodenectomy using the pancreatogastrostomy technique may result in pancreatic exocrine insufficiency and obstruction of the pancreatic duct. A prospective randomized comparison of pancreatogastrostomy and pancreatojejunostomy was therefore performed to assess pathophysiologic changes after pylorus-preserving pancreatoduodenectomy. METHODOLOGY: The study population consisted of 23 patients (pancreatogastrostomy: 10, pancreatojejunostomy: 13) who were observed for 2 years. RESULTS: Neither physical condition (dietary intake, body weight, performance status, and frequency of bowel movements) nor nutritional parameters (serum levels of total protein, albumin, total cholesterol, and cholinesterase) differed significantly between the two groups; these parameters recovered to pre-operative levels within 1 year in both groups. Changes in pancreatic function diagnosis (PFD) test results were similar between the two groups. The glucose tolerance test results revealed deterioration of glucose tolerance in 2 patients (20%) in the pancreatogastrostomy group and 3 patients (23%) in the pancreatojejunostomy group. In 2 of 3 patients in each group with non-dilated pancreatic ducts before surgery, the pancreatic ducts dilated after surgery. Diabetes developed after surgery in one such patient in each group. No significant differences were observed between the two groups with respect to changes in glucose tolerance test results and the diameter of the pancreatic duct. CONCLUSIONS: This prospective randomized study demonstrates no difference in pathophysiologic changes between patients undergoing pancreatogastrostomy or pancreatojejunostomy after pylorus-preserving pancreatoduodenectomy, at least in the first 2 years.

Early effects of standard and pylorus-preserving pancreatectomy on myoelectric activity and gastric emptying.

BACKGROUND/AIMS: The main concern about pylorus preserving pancreatectomy (PPP) is delayed gastric emptying (GE). Both cancer and surgical procedures cause damage to the enteric nervous system and induce profound changes in gastric motility and emptying. The aim was to evaluate the effects of primary disease and type of surgical procedure used (standard pancreatoduodenectomy, SP vs. PPP) on myoelectric activity (MA), and solid and liquid GE in pancreatectomy patients. METHODOLOGY: Twenty-eight subjects were included, 18 after Whipple (group A) and 10 after a Traverso (group B) procedure. MA was captured by cutaneous electrodes (Synectics) and simultaneously LGE tested with ultrasonography. On separate days, the SGE of a radiolabelled meal was measured. MA and GE studies were done before and within three months after surgery. RESULTS: Before surgery LGE/SGE were delayed in 5/8 patients in group A and 2/2 in group B. Gastric dysrhythmia was observed in 6 patients in group A and 1 in group B. After PPP, the nasogastric tube was removed within 8.4+/-4.9 days and after SP within 4.6+/-4.1 days. GE studies showed accelerated LGE/SLG in 16/12 and delayed in 6/5 patients, respectively, in group A and B. Dysrhythmia was observed in 16 patients in group A and in 4 in group B. There was a strong relationship between SGE delay and dysrhythmia in patients after PPP. CONCLUSIONS: We conclude that papilla of Vater neoplasia damages mechanisms responsible for gastric emptying to a lesser extent than pancreatic cancer. In patients after PPP, post-operative MA disturbances are partially responsible for delayed GE.

A peroperative test of the function of the sphincter of Oddi.

A simple peroperative flow test has been developed to help detect organic stenosis of the Ampulla of Vater. The influence of glucagon and propantheline bromide on the flow of saline through the Ampulla during operation in 79 patients was measured. By measuring the flow rate of saline before and after the administration of glucagon to patients the effective diameter of the sphincter of Oddi and its ability to relax could be deduced. Glucagon was found to be most effective in relaxing the Ampulla. For the test to be successful impacted stones must be excluded by cholangiography, but free lying stones do not affect the test. In 7 of the 62 patients receiving glucagon flow was slow and the sphincter failed to relax. Two of these patients had impacted stones and were treated by ampullary dilatation and the other 5 (who had no stones showing on X-rays) were treated by trans-duodenal sphincterotomy; 2 of these patients were found to have small non-obstructing stones impacted at the Ampulla.

[Pathophysiology of pancreatico-duodenectomy according to Traverso-Longmire. Clinical and instrumental study]. / Fisiopatologia della duodenocefalopancreasectomia sec. Traverso-Longmire. Studio clinico e strumentale.

The authors report their experience with 9 patients, affected by pancreatic and periampullary carcinoma, treated using pancreaticoduodenectomy with pyloric preservation. They analyse the physiopathology of this technique, by the light of the international reports, and note the advantages that this technique allows about the nutritional status and the quality of life of the patients operated on.

[Pyloric exclusion for disinsertion of the papilla following closed trauma of the abdomen. Apropos of 2 cases]. / Exclusion pylorique pour désinsertion de la papille par traumatisme fermé de l'abdomen. A propos de deux cas.

Two cases of disinsertion of the papilla following closed trauma to the abdomen were treated by suction of the papilla by a Y loop associated with temporary pyloric exclusion, gastroenterostomy and a feeding jejunostomy. The postoperative course was uneventful in the two patients. This technique is therefore indicated for associated pancreatic lesions which do not require cephalic duodenopancreatectomy.

[Value of the endoscopic sphinctero-papillotomy by surgical radiocholangiodebitometry]. / Valoración de la esfinteropapilotomía endoscópica (EPE) mediante radiocolangiodebitometría operatoria (rcdm).

First results of a prospective study about behavior evaluation of endoscopic sphincterotomy of the ampulla of Vater (EPE) through a serial surgical debitometric (RCDM) assessment are analyzed. Five patients submitted to an EPE looking for a biliary tract decompression because of clinical reasons, prior their surgical cholecystectomy, are comparatively evaluated by serial RCDM with regard to 24 patients receiving a broad transduodenal sphincteroplasty (EPTD). Normal debitometric values (N greater than or equal to 13 cc/min.) were obtained from a sample of 673 surgically explored patients. Debitometric behavior of EPE were comparable in all cases and over our standard (mean = 18.6 +/- 2.3 cc/min.); they showed no differences to surgical EPTD patients (x = 18.3 +/- 2.0 cc/min.). Despite uniform results in the EPE group, a more extensive sample is necessary for definitive conclusions; serial surgical RCDM in patients who received EPE, in spite of limited indications, seems to be a valuable method to analyze early functional events after the procedure.

[Oddi's sphincter dysfunction]. / Sphincter Oddi dysfunktion.

Dysfunction of the sphincter of Oddi (SOD) is an uncommon condition which must be considered in cases of persistent pain in the upper abdomen following uncomplicated cholecystectomy, when disease in other organs, such as gastric ulcer, esophagitis and pancreatitis has been eliminated. The pathogenesis is not fully elucidated, but it is assumed that the cholecystectomy in some cases induces an increased tendency to spasm in the sphincter of Oddi (SO), and, perhaps in connection with an increased sensitivity to pressure elevations in the biliary tree, results in attacks of pain. Whether fibrosis (stenosis) of the SO due to instrumentation or passage of stones is part of the etiology is obscure. Endoscopic retrograde cholangiopancreaticography with papillary manometry should be performed in all cases where SOD is suspected. An elevated basal pressure in SO seems to be the best indicator of SOD. In cases unresponsive to conservative treatment, endoscopic sphincterotomy may be considered. This treatment is not finally evaluated, but apparently the effect is good, especially in patients with elevated basal pressure in SO. It is emphasized that the knowledge of the behavior and regulation of SO is incomplete and that this should be remembered when criteria for SOD are applied.

[Observations on the function of Oddi's sphincter in patients with primary bile duct stones].

We recorded the pressure of Oddi's sphincter (SO) in 54 patients with gall stones and 25 patients as controls who had no biliary disease. Endoscopic manometry used in this study recorded the dynamic changes of the intraluminal pressure of SO as well as the static pressure of the common bile duct. It was found that in control group, common bile duct pressure was 1.54 +/- 0.15 kPa, basic pressure of SO 2.12 +/- 0.22 kPa, SO-bile duct pressure difference 0.58 +/- 0.07 kPa, and SO peak pressure 5.56 +/- 0.47 kPa, respectively. There was no significant difference between patients with gallbladder stones and secondary cholelithiasis and those in control group. But the pressure of SO was significantly lower in patients with primary bile duct stones than that in controls. This phenomenon indicates that in such patients the contraction strength of SO is weak or lost. This may explain retrograde cholangitis often seen in some patients. We suggest that in order to prevent retrograde cholangitis, adequate procedure should be taken in operation on patients with functional impairment of SO.

[Ectopic openings of the common bile duct. A contribution to the physiological study of the sphincter of Oddi (author's transl)]. / Les abouchements ectopiques du cholédoque. Contribution à l'étude de la physiologie du sphincter d'Oddi.

Two cases of ectopic openings of the common bile duct are reported. In one case there was a congenital short duct opening into DI, the presence of a spontaneous duodenobiliary reflux due to absence of the papilla being demonstrated by clinical and radiological examinations. The other patient had a long duct opening into D3 and no duodenobiliary reflux, but with an intact sphincter of Oddi explored in detail by means of combined choledochoduodenal manometry. These two cases demonstrate that the duodenal wall has only a moderate effect in preventing duodenobiliary reflux. The essential element is the sphincter of Oddi: if present, there is no reflux, if absent, reflux occurs.