ABSTRACT
BACKGROUND: Acalculous biliary pain may be due to gallbladder dyskinesia or sphincter of Oddi (SO) hypertension. These two etiologies are difficult to differentiate because the gallbladder ejection fraction may be low and the SO manometry results may be abnormal in both. Cholecystectomy is advised for patients with biliary dyskinesia, but it often exacerbates biliary pain for patients with SO hypertension. The biliary pain response to relaxation of the SO using botulinum toxin may indicate appropriate treatment for patients with acalculous biliary pain. METHODS: The protocol-based management of 25 patients with acalculous biliary pain and two gallbladder ejection fraction estimations less than 40% who had 100 units of botulinum toxin injected into their SO musculature to relax the sphincter has been audited. Patients whose pain was temporarily relieved after botulinum toxin injection were offered endoscopic biliary sphincterotomy, and patients who failed to experience benefit after botulinum toxin injection were assessed for laparoscopic cholecystectomy. RESULTS: Botulinum toxin was injected into the SO of 25 patients, with 11 experiencing temporary biliary pain relief. Of these patients, 10 consented to undergo endoscopic biliary sphincterotomy, with relief of biliary pain in all cases. A total of 14 patients had a negative response to botulinum toxin treatment, with 10 of these patients progressing to laparoscopic cholecystectomy, which resulted in biliary pain relief in eight cases. CONCLUSION: Botulinum toxin-induced relaxation of the SO may help to direct appropriate therapy for patients with acalculous biliary pain. The data from this study supports the establishment of a randomized clinical trial.
Subject(s)
Biliary Dyskinesia/diagnosis , Botulinum Toxins, Type A , Cholecystectomy, Laparoscopic , Colic/surgery , Muscle Hypertonia/diagnosis , Patient Selection , Sphincter of Oddi Dysfunction/diagnosis , Sphincter of Oddi/drug effects , Sphincterotomy, Endoscopic , Adult , Aged , Biliary Dyskinesia/complications , Biliary Dyskinesia/surgery , Botulinum Toxins, Type A/administration & dosage , Botulinum Toxins, Type A/pharmacology , Botulinum Toxins, Type A/therapeutic use , Cholangiopancreatography, Endoscopic Retrograde , Colic/drug therapy , Colic/etiology , Colic/physiopathology , Diagnosis, Differential , Duodenoscopes , Female , Humans , Injections, Intramuscular , Male , Middle Aged , Muscle Hypertonia/complications , Muscle Hypertonia/surgery , Muscle Relaxation/drug effects , Sphincter of Oddi/physiopathology , Sphincter of Oddi Dysfunction/complications , Sphincter of Oddi Dysfunction/surgery , Young AdultABSTRACT
A retrospective outcomes study was performed on 25 consecutive acetabular reconstructions of major segmental defects by using an oblong-shaped cementless implant. All patients had combined acetabular defects (type III) as defined by the American Academy of Orthopaedic Surgeons classification of acetabular bone deficiency. Long-term follow-up was performed at an average of 11 years postoperatively. Clinical and radiographic outcomes were measured. Failures were defined by component revision or clear radiographic evidence of loosening. Six patients died before final evaluation, and 4 patients did not have complete radiographic data, leaving 14 patients (15 hips) for final analysis. At final follow-up, only 3 of the implants had failed and were revised. There was 1 case of a well-functioning implant with circumferential radiolucency; otherwise, there was no evidence of loosening among the remaining implants.