Many faces of pancreaticobiliary reflux.

Pancreaticobiliary reflux may occur either as a result of an anatomically abnormal pancreaticobiliary junction or because of a functionally impaired sphincter despite a normal radiological appearance. It is associated with a wide spectrum of biliary diseases, including gall bladder and bile duct carcinoma. Pancreaticobiliary maljunction and related biliary reflux have been studied extensively in Southeast Asian populations and associations with choledochal cyst and biliary malignancy defined. However, reflux in the absence of ductal malunion has only been described relatively recently and its significance with respect to biliary malignancy requires clarification. We present four cases of pancreaticobiliary reflux to demonstrate the varied associations of this under-recognized disorder and review the related management issues.

Variaciones anormales en la ubicación del Esfínter de Oddi (ampolla de Váter) y su importancia en la presentación clínica en pacientes con colecistitis litiásica biliar benigna / Abnormalities in the region of the Oddi’s Sphincter (Vater’s blister) and their important in patients with benign biliary lithiasic cholecystitis

Tipo de estudio: prospectivo, descriptivo, realizado durante el período noviembre 2005 a junio 2006 en el hospital “Luis Vernaza”, sala “Santa Cecilia”. Objetivo: conocer la incidencia de las variaciones anatómicas anormales mediante el uso de la técnica de la colangiografía intraoperatoria realizada durante la colecistectomía; determinar la importancia clínica de la ubicación del esfínter de Oddi en el duodeno. Resultados: de un universo de pacientes, de sexo femenino, se obtuvo el siguiente porcentaje de variaciones anatómicas: 47 pacientes cuyo esfínter de Oddi fue ubicado en posición normal, es decir en la segunda porción 8 pacientes en la primera porción del duodeno y 5 en la tercera porción. Conclusión: pacientes que presentaron variedades anatómicas anormales del esfínter de Oddi presentaron cuadro clínico más severo.

Prospective and descriptive carried out from November 2005 to June 2006 at the “Luis Vernaza” Hospital, “Santa Cecilia” Room. Objective: to be aware of the prevalence of abnormal anatomic variations through the technique of intraoperative bile duct X-ray carried out during the cholecystectomy; and determine the clinical importance of the location of the Odd’s Sphincter in the duodenum. Results: in a sample of 60 female patients the following percentages of anatomic variations were found: 47 patients whose Oddi’s Sphincter was located in a normal second portion. 8 patients in the first portion of the duodenum and 5 of them in the third portion. Conclusion: patients with abnormal anatomic variations of Oddi’s Sphincter presented a more severe pathological clinical case.

Congenital dilatation of the common bile duct and pancreaticobiliary maljunction: clinical implications.

CLINICAL CONDITIONS AND DIAGNOSIS: Congenital dilatation of the common bile duct is a disease in which the extrahepatic bile duct, or both the extra and intrahepatic bile ducts, is dilated in various ways. Pancreaticobiliary maljunction is a disease in which the pancreatic duct meets the bile duct outside of the duodenal wall beyond the sphincter Oddi. Recently, these diseases have been thought to be closely related to each other but to be different malformations. Biliary tract carcinoma, especially bile duct carcinoma, is found in about 30% of patients with congenital dilatation of the bile duct. The concomitance of bile and pancreatic juice and their stasis in the biliary tract induce cellular proliferation and reproduction and stimulate genetic alterations in biliary epithelium, which may play an important role in carcinogenesis of the bile duct. THERAPEUTIC STRATEGIES: Endoscopic retrograde cholangiopancreatography is useful for examining pancreaticobiliary maljunction. The operation is dilated bile duct resection and hepaticojejunostomy, which ensure that pancreatic juice and bile do not mix in the bile duct. Gallbladder carcinoma develops in more than 90% of pancreaticobiliary maljunction without bile duct dilatation.

Endoscopic sphincterotomy is a useful preoperative management for refractory pancreatitis associated with pancreaticobiliary maljunction.

BACKGROUND: Pancreatitis associated with pancreaticobiliary maljunction (PBM) is commonly treated nonoperatively before surgery. It is, however, sometimes uncontrollable, and little has been reported about the management. METHODS: Focusing on the preoperative management, we reviewed clinical courses of 4 PBM cases (ages 1 to 7 years old). Each had pancreatitis that was totally resistant to medical treatment and was applied endoscopic sphincterotomy (ES). RESULTS: The first case underwent percutaneous transhepatic catheter drainage (PTCD) primarily. In spite of daily lavage using the drainage tube for a week, plugs located in the common channel were not removed, and clinical findings were not improved. Therefore, ES followed by removal of protein plugs was performed to improve pancreatitis dramatically. Through this experience, 3 subsequent cases with refractory pancreatitis all underwent successful ES primarily soon after the medical treatments turned out to be ineffective. In all 4 cases, protein plugs were impacted in common channels, and ES could successfully remove the plugs that were impossible to remove by using PTCD. Improved preoperative pancreaticobiliary decompression by ES shortens the duration of recalcitrant acute pancreatitis associated with PBM allowing for a subsequent safe operation. CONCLUSIONS: Endoscopic sphincterotomy is one of the useful preoperative managements for refractory pancreatitis associated with PBM.

Unión biliopancreática anómala. Una enfermedad no exclusiva de pacientes orientales / Pancreatobiliary maljunction. Not only an Eastern disease

La union biliopancreática anómala se produce cuando el conducto biliar y pancreático se unen fuera de la pared duodenal, sin que parezca existir el mecanismo esfinteriano del Oddi. Se ha pensado que esta es una enfermedad predominantemente de pacientes orientales. Sin embargo, cada vez se hacen más diagnósticos en otros grupos poblacionales. Presentamos el caso de una mujer de 41 años con dolor epigástrico intermitente y elevación leve de la amilasa. El diagnóstico no se pudo realizar por medio de una colangiopancreatografía por resonancia magnética, quizás por falta de experiencia. Se diagnosticó por medio de una colangiopancreatografía retrógrada endoscópica. En ella se apreció una unión biliopancreática anómala de ángulo agudo, con una unión compleja entre el colédoco y el conducto pancreático. Se observó también una dilatación fusiforme de la vía biliar y del hepático principal izquierdo. Se remitió a la paciente para una resección del conducto biliar y un procedimiento derivativo quirúrgico. Sin embargo, quizás también por falta de experiencia, se decidió el seguimiento periódico de la paciente. En conclusión, la unión biliopancreática anómala se diagnostica también en poblaciones occidentales y se precisa más experiencia en su diagnóstico y tratamiento

Pancreatobiliary maljunction, an extramural junction of the pancreatic and biliary ducts in the duodenum, apparently beyond the scope of intramural sphincter function, is thought to be a preferential disease of Eastern people. However, this diagnosis is increasingly being made in other populations. We present a 41-year-old woman who presented with intermittent epigastric pain and mild raise in amylase levels. MRCP did not offer a definitive diagnosis, perhaps because of lack of experience in this disease. Finally, ERCP showed a pancreatobiliary maljunction, type acute angle, but with a complex connection between the choledocus and the pancreatic duct. Fusiform dilation of the common bile duct and of the left main hepatic duct were also present. The patient was referred for extrahepatic biliary resection and a diversion procedure. But also because of lack of experience in this disease, a wait-and-see approach was undertaken. In conclusion, pancreatobiliary maljunction will be increasingly diagnosed in western communities and more diagnostic and therapeutic experience will be needed

Selective sphincteroplasty of the papilla in cases at risk due to atypical anatomy.

AIM: To analyze the indications, efficacy and safety of sphincteroplasty in our centre. METHODS: A retrospective study of sphincteroplasty in 53 cases of papilla at high risk was performed in 2004-2006. The procedure consisted of duodenoscopy with Olympus TJF 145 Videoduodenoscope, approach to the biliary tract using a catheter with a guidewire, and dilatation of the papilla with a dilatation balloon catheter using a syringe with a manometer for control of the filling pressure. RESULTS: The indications included intradiverticular papilla in 26 patients (49%), stenosis of a previous sphincterotomy in 19 patients (35.8%), small size of the papilla in 4 patients (7.5%), Billroth II gastrectomy in 3 patients (5.6%), and coagulopathy in one patient (1.9%). The efficacy was 97.8%, with all the calculi extracted from the common bile duct in 84.4% of the patients, even though 21 of the patients (39.6%) had calculi with a diameter equal to or greater than 10 mm. Seven patients (13.2%) presented complications: haemorrhage in 1 patient (1.9%) and mild pancreatitis in 6 patients (11.3%). The mean hospital stay in case of complications was of 3 +/- 0.63 d. CONCLUSION: Sphincteroplasty is highly effective, with a complication rate similar to that of sphincterotomy, furthermore, the complications are of low clinical importance. The use of the 10 mm balloon makes it possible to extract calculi with a diameter of over 15 mm and to extract more than 3 calculi without increasing the rate of complications and reduces the need to resort to lithotripsy or rescue sphincterotomy.

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.

Pancreaticobiliary long common channel syndrome and congenital anomalous dilatation of the choledochal duct--study of 46 patients.

Retrospectively evaluated clinical, radiological and anatomical findings of 46 patients with tubular or cystic dilated choledochal ducts indicate the following conclusion: Pathological stricture of the sphincter of Oddi system, including a hypertrophic and spastic portion of the sphincter choledochus inferior, called "narrow segment", raises the pressure in the choledochal duct to pathological levels and consequently causes a dilatation of the duct during a specific embryonic phase. Such a pathological sphincter of Oddi system develops if a long common channel persists as the result of a disturbance in the development of the distal choledochal and pancreatic duct. This statement contradicts the classical conception which assumes that a reflux of pancreatic juice into the choledochal duct causes ductal dilatation. Authors who are in favor of this conception propose that pancreatic juice causes weakness of the ductal wall, which may be dilated in the embryonic period. However, the findings of the series evaluated here show that dilatation of the duct may also originate without any reflux of pancreatic juice into the choledochal duct if a "narrow segment" exists above the junction of the pancreatic and choledochal ducts. For this reason, pancreatic juice reflux cannot be the condition sine qua non in the development of choledochal duct dilatation. Similarly the pathologic junction angulation can only be an optional factor in this autogenetic anomaly. With regard to a pathological sphincter of Oddi system the question arises whether a partial or complete myotomy of the muscular sphincter may be able to remedy the dilatation and avoid resection of the choledochal duct.(ABSTRACT TRUNCATED AT 250 WORDS)

Esfinteroplastía transduodenal del Oddi-Boyden para libre flujo bilio-pancreático / Transduodenal sphynteroplasty of the Oddi-Boyden for the free bile-pancreatic flow

En 58 pacientes se ejecutó la ETOB para probar su utilidad en estenosis, coledecolitiasis y en pancreatitis biliar en un período de seguimiento de 14 meses a 11 años tres meses. La ETOB, se llevó a cabo en 33 casos (27 por ciento)por coledocolitiasis. Excepto en un caso, el resto presentaron cálculos en la vesícula o en el colécodo. en 39 pacientes (67 por ciento) con colangiografía previa a la ETOB el diámetro delo colédoco midio en x= 1.6 cm. A las 24 horas y entre el tercer a quinto día por postoperatorio la amilasa y la bilirrubina en sangre disminuyeron indicando el restablecimiento del libre flujo biliopancreático soportado después por la colangiografía postoperatoria con el pasaje rápido del contraste al duodeno y por la disminución significativa del diámetro del colédoco (p menor que 0.05). La morbimortalidad fue de 24.5 por ciento y 1.7 por ciento respectivamente. Los resultados fueron malos en dos casos, regulares en un caso y buenos en 55 (94.6 por ciento) quienes estuvieron libres de síntomas de enfermedad obstructiva biliar a través del seguimiento. Se concluye que la ETOB es útil para restablecer el libre flujo biliar o biliopancreático en casos de estenosis, coledocolitiasis y pancreatitis biliar