The efficacy and safety of endoscopic sphincterotomy in patients with Sphincter of Oddi dysfunction: a systematic review and meta-analysis.

OBJECTIVE: Sphincter of Oddi dysfunction (SOD) has been used to describe patients with RUQ abdominal pain without an etiology. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of ES (endoscopic sphincterotomy) for SOD. METHODS: The study methodology follows the PRISMA guidelines. A comprehensive search was conducted using MEDLINE and EMBASE databases for RCTs with ES in patients with SOD. The primary outcome assessed was the improvement of abdominal pain after ES/sham. A random effects model was used to calculate pooled estimates for each outcome of interest. RESULTS: Of the initial 55 studies, 23 were screened and thoroughly reviewed. The final analysis included 3 studies. 340 patients (89.7% women) with SOD were included. All patients had a cholecystectomy. Most included patients had SOD type II and III. The pooled rate of technical success of ERCP was 100%. The average clinical success rate was 50%. The pooled cumulative rate of overall AEs related to all ERCP procedures was 14.6%. In the sensitivity analysis, only one study significantly affected the outcome or the heterogeneity. CONCLUSION: ES appears no better than placebo in patients with SOD type III. Sphincterotomy could be considered in patients with SOD type II and elevated SO basal pressure.

[Recurrent pancreatitis secondary to sphincter of Oddi dysfunction: case report]. / Pancreatitis recurrente secundaria a disfunción del esfínter de Oddi: presentación de un caso.

Dysfunction of the sphincter of Oddi is a rare disease that causes about 20% of recurrent idiopathic pancreatitis. In order to suspect its existence, it is mandatory to have ruled out all other causes of acute pancreatitis. Then, the disease needs to be classified by degree of dysfunction and have a manometry performed as it is considered the gold standard of diagnosis. Manometry is used to guide treatment and its method of choice is usually an endoscopic sphincterotomy. In this article a case of recurrent pancreatitis is discussed, which after a thorough study that ruled out other etiologies, was diagnosed as a pancreatic-type dysfunction of the sphincter of Oddi. The dysfunction was resolved by endoscopic sphincterotomy and the patient had a favorable course without any recurrence of symptoms.

La disfunción del esfínter de Oddi es una patología poco frecuente que es causa de aproximadamente el 20% de las pancreatitis recurrentes idiopáticas. Para sospechar de su existencia es obligatorio haber descartado todas las otras causas de pancreatitis aguda. Luego, sobre la base de la historia clínica, exámenes de laboratorio y estudio con imágenes, se debe realizar una clasificación del tipo de disfunción. Según ello, es necesario llevar a cabo una manometría, considerada el gold estándar para el diagnóstico, y guiar el método de tratamiento, siendo el de elección la esfinterotomía endoscópica. En el presente artículo se discute un caso de pancreatitis recurrente, que luego de un minucioso estudio, y habiendo descartado otras etiologías, se diagnosticó como causa la disfunción del esfínter de Oddi tipo pancreática. Se resolvió mediante esfinterotomía endoscópica, presentando una evolución favorable y sin recurrencia de la sintomatología.

Pancreatitis recurrente por disquinesia hipertónica del esfínter de oddi: tratamiento endoscópico y seguimiento a largo plazo en un caso clínico / Recurrent pancreatitis caused by oddi sphincter’s hypertonic dyskinesia: case report of endoscopic treatment and long-term follow-up

It is frequently difficult to determine the exact cause of recurrent acute pancreatitis (RAP), which can be life threatening in several cases. Not detected biliary microlithiasis is the most frequent etiology, buthypertonic dyskinesis of Oddi’s sphincter also can cause RAP. Non-invasive diagnosis of this functional disorder is difficult, endoscopic manometry of Oddi’s sphincter allows measuring pressure in the choledochus,in the pancreatic duct and specifically in the sphincter region. Once hypertonic dyskinesis is demonstrated, the treatment option is the partial or total ablation of the sphincter, via endoscopic or surgical methods. This intervention results in an improvement or complete resolution in about 70 percent of the patients, preventing new bouts of acute pancreatitis and eventual progression to chronic disease. In this paper, we describe the history of one of our patients, who consulted more than ten years after cholecystectomy for recurrent abdominal pain and presented three episodes of acute pancreatitis. Endoscopic manometry of Oddi’s sphincter was performed in 1997, with the detection of very high pressure in biliary and pancreatic segments of the sphincter, demonstrating hypertonic dyskinesis involving both segments. A dual endoscopic sphincterotomy was performed, followed by marked reduction in the pressure of biliopancreatic ducts and Oddi’s sphincter and in abolition of choledocho-duodenal and pancreatic-duodenal gradient. She was asymptomatic till 2002, later on, she required endoscopic pneumatic dilatation of the sphincterotomy. She had no more acute pancreatitis episodes and CT scan in 2014 showed a normal pancreas.

Con frecuencia resulta difícil determinar la etiología de la pancreatitis aguda recurrente (PAR), que puede amenazar hasta la vida del paciente. Aparte de la patología litiásica biliar no diagnosticada, la disquinesia hipertónica del esfínter de Oddi (EO) causa con cierta frecuencia PAR. Su diagnóstico no invasivo es difícil, la manometría del esfínter de Oddi permite medir los valores de la presión en la vía biliar, en el conducto pancreático y en la región del esfínter. Una vez que la disquinesia hipertónica se demuestra, su tratamiento es la ablación parcial o total del esfínter, con método endoscópico o quirúrgico, con resolución del cuadro clínico en aproximadamente 70 por ciento de los pacientes, logrando evitar los nuevos brotes de pancreatitis aguda (PA) y la eventual progresión hacia pancreatitis crónica. En este trabajo describimos la historia de una paciente colecistectomizada, quien después de varios años de dolor abdominal recurrente, presentó tres brotes de PA. Manometría de EO fue realizada en 1997, detectando presiones muy elevadas, comprobando disquinesia hipertónica de los segmentos biliar y pancreático del esfínter. Se realizó esfinterotomía endoscópica doble, seguida por gran disminución de los valores de presión, abolición del gradiente colédoco-duodenal y pancreático-duodenal. Estuvo asintomática hasta el 2002, y posteriormente requirió dilatación neumática de los orificios de esfinterotomías. No ha tenido más recaídas de pancreatitis, la tomografía computada de control en noviembre de 2014 mostró un páncreas normal.

Effects of structural injure in the bile bacterial contamination after balloon transduodenal sphincteroplasty (papillary dilation) in dogs / Efeitos da lesão estrutural na contaminação bacteriana biliar após a esfincteroplastia transduodenal (dilatação papilar) em cães

PURPOSE: To evaluate, in dogs, the biliary sphincter subjected to dilation by hydrostatic balloon by the point of view of structural alterations of the papilla and the biochemestry and bacterial contamination of the bile. 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). Blood samples collected on times t(0day), t(7days) and t(28days) were subjected to dosages of alkaline phosphatase (ALP) and gamma-glutamyltransferase (GGT) for cholestasis evaluation. The collected material from the gall bladder at the same times were registered and numbered to be submitted to culture in BHI, blood agar (rich, non-selective element) and Mac Conkey (selective element for Gram-negative bacillus. On the 28th day three fragments of the papilla were tranversally cut by the choledoc axis 3mm from the duodenal papilla and the cuts, stained with hematoxylin-eosin and Masson's tricome, were evaluated according to their inflammatory reaction. RESULTS: The GGT and ALP averages on the three periods in the groups A and B did not show significant differences, not being characterizes the cholestasis. The bacterian contamination was significantly higher in GA (2,19) than in GB (1,96); the contamination was lower in the initial time compared with 7 and 28 days (t0

OBJETIVO: Avaliar, em cães, a papila duodenal maior submetida à dilatação por balão hidrostático sob o ponto de vista das alterações estruturais da papila e da bioquímica e contaminação bacteriana da bile. MÉTODOS: Vinte cães foram submetidos a laparotomia, duodenotomia, dilatação da papila maior GA (n=10) - com balão de 8mm insuflado com pressão de 0,5atm, durante 2 minutos ou ao procedimento simulado - GB(n=10). Amostras de sangue coletadas nos tempos t(0dia), t(7dias) e t(28dias) foram submetidas às dosagens da fosfatase alcalina (FA) e gama-glutamil-transferase (GGT) para avaliação da colestase. Material colhido da vesícula biliar nos mesmos tempos foi registrado e numerado para ser submetido à cultura em BHI, ágar sangue (meio rico não seletivo), e Mac Conkey (meio seletivo para bacilos Gram-negativos). No 28°. dia três fragmentos da papila forma cortados transversalmente ao eixo do colédoco a 3mm da papila duodenal e os cortes corados em hematoxilina-eosina e tricômio de Masson e avaliados quanto a reação inflamatória. RESULTADOS: As médias da GGT e da FA nos três períodos nos grupos A e B não mostraram diferenças significantes, não sendo caracterizada a colestase. A contaminação bacteriana foi significante maior em GA(2,19) que no GB(1,96); a contaminação foi menor no tempo inicial em relação aos 7 e 28 dias( t0

Effects of structural injure in the bile bacterial contamination after balloon transduodenal sphincteroplasty (papillary dilation) in dogs.

PURPOSE: To evaluate, in dogs, the biliary sphincter subjected to dilation by hydrostatic balloon by the point of view of structural alterations of the papilla and the biochemestry and bacterial contamination of the bile. 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 0,5 atm, during 2 minutes or to the sham procedure - GB(n=10). Blood samples collected on times t(0 day), t(7 days) and t(28 days) were subjected to dosages of alkaline phosphatase (ALP) and gamma-glutamyltransferase (GGT) for cholestasis evaluation. The collected material from the gall bladder at the same times were registered and numbered to be submitted to culture in BHI, blood agar (rich, non-selective element) and Mac Conkey (selective element for Gram-negative bacillus. On the 28th day three fragments of the papilla were tranversally cut by the choledoc axis 3mm from the duodenal papilla and the cuts, stained with hematoxylin-eosin and Masson's tricome, were evaluated according to their inflammatory reaction. RESULTS: The GGT and ALP averages on the three periods in the groups A and B did not show significant differences, not being characterizes the cholestasis. The bacterian contamination was significantly higher in GA (2,19) than in GB (1,96); the contamination was lower in the initial time compared with 7 and 28 days (t0

[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.

Management of choledocholithiasis found during laparoscopic cholecystectomy: a strategy based on the use of postoperative endoscopic retrograde cholangiography and sphincterotomy.

BACKGROUND: Several strategies have been proposed for the diagnosis and management of common bile duct stones in candidates for laparoscopic cholecystectomy. METHODS: Clinical characteristics, treatment, and outcome of five patients in whom CBDS were demonstrated by intraoperative cholangiography during a laparoscopic cholecystectomy were analyzed. All patients were treated by endoscopic sphincterotomy. Post-treatment outcome was emphasized. RESULTS: Mean age of the patients was 55 years. Four were female and one male. Preoperative liver function tests were within normal range in all patients. Duct stones of a mean size of 0.8 cm were found in the lower third of the biliary tree. Four were retrieved by endoscopic sphincteroplasty using a Dormia basket and in one patient after an unsuccessful endoscopic attempt, an open choledochoduodenostomy was performed. There were no post-treatment complications. At a mean follow-up of 2 years no evidence of recurrent common bile duct obstruction has been found in any patient. CONCLUSIONS: This small series supports the use of postoperative endoscopic retrograde cholangiography and sphincteroplasty in patients with unsuspected common bile duct stones found during laparoscopic cholecystectomy. Retrieval of the stones immediately after surgery at the operative room is recommended.

Derivación biliointestinal en lesiones de la vía biliar extrahepática / Hepatic-jejunostomy in biliary tract injury

Se revisa la morbilidad y mortalidad de las técnicas de derivación biliointestinal para lesiones benignas y malignas de la vía biliar extrahepática. La hepaticoyeyunostomía en Y de Roux es la técnica más frecuentemente empleada y se hacen comentarios basados en la experiencia personal de 30 casos de obstrucción biliar

Sphincter of Oddi dysfunction in children with recurrent pancreatitis and anomalous pancreaticobiliary union: an etiologic concept.

BACKGROUND: The exact cause of recurrent pancreatitis among patients with anomalous pancreaticobiliary union is not known. Sphincter of Oddi dysfunction has been implicated as a mechanism. This study evaluated sphincter of Oddi function in children with anomalous pancreaticobiliary union and recurrent pancreatitis and assessed the results of endoscopic sphincterotomy in the management of this condition. METHODS: We retrospectively reviewed 128 endoscopic retrograde cholangiopancreatographic (ERCP) studies performed on children older than 1 year and adolescents with pancreaticobiliary disease. In 64 instances, ERCP was performed because of recurrent pancreatitis. Nine patients underwent sphincter of Oddi manometry followed by endoscopic sphincterotomy, and these patients were included in this study. A basal pressure greater than 35 mm Hg was considered diagnostic for sphincter of Oddi dysfunction. Follow-up data were obtained retrospectively from the patients' relatives and referring physicians. RESULTS: An anomalous pancreaticobiliary union was found in 18 of 64 (28%) patients with recurrent pancreatitis. The 9 patients who underwent sphincter manometry and endoscopic sphincterotomy were 5 girls and 4 boys 2.9 to 17 years of age (mean 7.8 years). A choledochal cyst was found in 7 of these 9 patients. Two patients had anomalous pancreaticobiliary union without common bile duct dilatation. All 9 patients had sphincter of Oddi dysfunction (mean basal pressure 96 +/- 37.8 mm Hg, range 48 to 156 mm Hg). The length of the common channel was 22.8 +/- 5.5 mm, and the length of the sphincter of Oddi segment was 12.1 +/- 1.9 mm (p < 0.001). In all patients the sphincter of Oddi segment was located within the duodenal wall. The mean follow-up period after endoscopic sphincterotomy was 26.4 months (range 18 to 38 months). Eight patients had excellent results defined as absence of symptoms and no subsequent episodes of acute pancreatitis. Treatment of 1 patient was considered moderately successful because the patient still had occasional pain without pancreatic enzyme elevation but no subsequent episodes of acute pancreatitis. One patient had mild postprocedural pancreatitis. CONCLUSIONS: Recurrent pancreatitis and anomalous pancreaticobiliary union are associated with sphincter of Oddi dysfunction in children and adolescents. Endoscopic sphincterotomy is beneficial to these patients.

[Endoscopic management of biliary fistula]. / Manejo endoscópico de la fístula biliar.

OBJECTIVE: To assess safety and efficacy of endoscopic therapy for patients with a postoperative biliary fistula. BACKGROUND: Biliary fistula that occur after operations on the biliary tract may be due to bile duct injury or distal bile duct obstruction. These fistulas has been managed with surgical correction. At present, endoscopic methods of improving biliary drainage has been found to be highly successful in the management of postsurgical biliary leaks. PATIENTS-METHODS-RESULTS: By endoscopic cholangiopancreatography (ERCP) we diagnosed 35 patients (23 females and 12 males) with postoperative biliary fistula. Four patients had history of laparoscopic cholecystectomy. We used endoscopic sphincterotomy (18 cases) or endoprosthesis placement (17 cases) in the treatment. Seventeen patients with fistula plus common bile duct (CBD) stones and one patient with benign papillary stenosis were treated with endoscopic sphincterotomy alone. Seventeen patients without CBD stones were treated with only endoprosthesis placement. A second ERCP confirmed healing of the leakage after 4-16 weeks. CONCLUSIONS: Postoperative bile leakage could be diagnosed safely and effectively by ERCP, subsequent endoscopic management in most cases is successful. Sphincterotomy alone is the preferred treatment for biliary fistula-complicating surgery for gallstone disease. Alternatively, when a fistula is large, endoscopic placement of an endoprosthesis can be proposed as the first treatment.

[Endoscopic biliary drainage in acute suppurative cholangitis]. / El drenaje biliar endoscópico en colangitis supurativa aguda.

Acute suppurative cholangitis is a life-threatening condition and prompt biliary decompression (BD) is essential for survival. The evolution of thirty-one patients (21 women and 10 men, mean age 64 years) with acute suppurative cholangitis attended from February 1989 to February 1994 treated by endoscopic cannulation and sphincterotomy for biliary drainage were retrospectively reviewed. The mean hospital stay was 18 +/- 12 days and during hospitalization there were 5 deaths, none related to biliary drainage. Sixteen patients had previous cholecystectomy, 12 patients had previous cholangitis in the last year, 23 patients had choledocholithiasis and an additional three patients pancreatobiliary neoplasias and common duct stones. Only 67.7% showed the classic Charcot's triad (fever, abdominal pain and jaundice). Total bilirubin, aspartate aminotransferase, alanine aminotransferase and total leukocytes decreased significantly (p < 0.05) after BD. Retroperitoneal perforation was the only complication is a safe and effective procedure for emergency biliary decompression in the treatment of acute suppurative cholangitis.

[Management of difficult cases of biliary lithiasis]. / Manejo de la litiasis biliar difícil.

UNLABELLED: To assess that insertion of a biliary endoprosthesis is a safe and effective treatment in patients with retained common bile duct stones (CBDS). BACKGROUND: Before 1974, surgical exploration including cholecystectomy with choledochotomy was the only effective treatment for CBDS. However, morbi-mortality increases rapidly in the elderly and is over 10% in patients over 65, particularly if other serious medical conditions are present. Endoscopic sphincterectomy is now an established procedure, with a success rate of about 90%, complications are relatively rare, and mortality is about 1%. However, the size and number of the stones, the appearance of the terminal bile duct and presence of peripapillary diverticulum influence the outcome. At the present time technique of fragmenting the stones using intracorporeal electrohydraulic, extracorporeal shock waves or laser lithotripsy would be seen to be an attractive alternative approach. Endoprosthesis insertion is a safe, effective and cheap treatment in CBDS. PATIENTS, METHODS AND RESULTS: 40 patients with unextractable CBDS were studied and treated with endoscopic stenting. Four patients were lost for follow-up. The remaining patients comprised 29 females and 7 males, with a mean age of 67 years. Four patients underwent surgical treatment for post-sphincterotomy haemorrhage (1 patient), internal endoprosthesis migration (1 patient) and peripapillary diverticulum (2 patients). In 7 high-risk patients with large CBDS, recurrent obstructive jaundice was successfully treated by replacing the endoprosthesis. In 6 of them we added medical treatment with ursodeoxycholic acid and after 24 months follow-up, the stones disappeared. In 13 patients the endoprosthesis were inserted temporally, and in a second approach we removed the CBDS by mechanical lithotripsy. The remaining 12 patients were still alive without symptoms after a follow-up of 24 months. CONCLUSIONS: On the basis of these findings we therefore concluded that endoscopic insertion of a biliary endoprosthesis is a safe and effective treatment for CBDS in patients in whom endoscopic sphincterotomy and attemps to remove the stones are not successful.

[Endoscopy and laparoscopy in the treatment of lithiasic cholecystitis associated with benign bile duct obstruction]. / Endoscopía y laparoscopía en el tratamiento de la colecistitis litiásica asociada a obstrucción benigna de vía biliar.

OBJECTIVE: To analyze the efficacy of a combined approach using ERCP plus laparoscopic cholecystectomy in the treatment of gallstones associated to benign common bile duct obstruction. DESIGN: Prospective study. SETTING: Tertiary-care medical center. PATIENTS: From a total of 270 laparoscopic cholecystectomies performed between October 1991 and January 1994, a group of 25 patients in whom preoperative ERCP was performed to rule out bile duct obstruction was selected for analysis. RESULTS: Choledocholithiasis was documented in nine patients (36%). In eight of them, stones were retrieved by ERCP. The diagnosis of odditis was established in five patients and a papilotomy was performed. The entire bile duct was normal in 11 cases. All patients in whom the common bile duct was normal, or cleared endoscopically, underwent laparoscopic cholecystectomy uneventfully. There was one complication of papilotomy. Duodenal perforation occurred in one patient who ultimately died. CONCLUSION: The combined approach using ERCP followed by laparoscopic cholecystectomy seems to be adequate for the treatment of gallstones associated to bile duct obstruction.

Cirugía en la vía biliar principal / Surgery for the common bile duct

Se realiza un estudio prospectivo de 248 pacientes ingresados en el Servicio de Cirugía General del Hospital "Dr. Agostinho Neto", a los que se les efectuaron 256 (1,8 porciento) operaciones sobre la vía biliar principal en un período de 10 años. La tasa por 10 000 habitantes adultos es de 7. Los pacientes de la década de los 60 años fueron los más afectados (19,4 porciento), con un promedio de edad de 47,6 años y una desviación estándar de 16,9. Las operaciones más frecuentemente realizadas fueron la coledocotomía (67,2 porciento), la coledocoduodenostomía y la esfinterotomía con esfinteroplastía (10,5 porciento, respectivamente).La primera complicación posoperatoria específica fue la litiasis residual del colédoco (4,5 porciento). La mayor mortalidad por proceder quirúrgico la tuvo la operación de Whipple (45,4 porciento) y las causas directas de muerte fueron la atelectasia y el tromboembolismo pulmonar <25 porciento, respectivamente). La información se procesó en una microcomputadora marca SAMSUNG CJ 6581 y el paquete de programa estadístico MICROSTAT

Papilotomía quirúrgica transduodenal: aspectos técnicos en 20 años de experiencia con aporte al diseño instrumental / Transduodenal surgical papillotomy: technical aspects in 20 years experience with an instrumental design contribution

En contraste con la aparente proscripción del procedimiento en nuestro medio, los autores, sin entrar a discutir las indicaciones exponen su aporte instrumental y los detalles de técnica que en 20 años de experiencia le permiten afirmar que la papilotomía quirúrgica no aumenta la morbimortalidad de la simple colecistetomía en ausencia de las terribles complicaciones y de la mortalidad que amenaza la bibliografía. En la discusión de los resultados y de la consulta bibliográfica resulta la prodigalidad actual del procedimiento endoscópico y la validez del procedimiento quirúrgico en la seguridad del apoyo instrumental y la perfección técnica

Transduodenal sphincteroplasty--how we do it

Transduodenal Sphincteroplasty can be performed in a simple reproducible and low morbidity fashion. The surgical technique used by the Department of Surgery of the Mayagüez Medical Center is presented

Papilotomía quirúrgica transduodenal: aspectos técnicos en 20 años de experiencia con aporte al diseño instrumental / Transduodenal surgical papillotomy: technical aspects in 20 years experience with an instrumental design contribution

En contraste con la aparente proscripción del procedimiento en nuestro medio, los autores, sin entrar a discutir las indicaciones exponen su aporte instrumental y los detalles de técnica que en 20 años de experiencia le permiten afirmar que la papilotomía quirúrgica no aumenta la morbimortalidad de la simple colecistetomía en ausencia de las terribles complicaciones y de la mortalidad que amenaza la bibliografía. En la discusión de los resultados y de la consulta bibliográfica resulta la prodigalidad actual del procedimiento endoscópico y la validez del procedimiento quirúrgico en la seguridad del apoyo instrumental y la perfección técnica (AU)

Transduodenal sphincteroplasty--how we do it.

Transduodenal Sphincteroplasty can be performed in a simple reproducible and low morbidity fashion. The surgical technique used by the Department of Surgery of the Mayagüez Medical Center is presented.