Radial sphincterotomy in endoscopic retrograde cholangiopancreatography due to extrahepatic obstructions by large stones in the common bile duct.

OBJECTIVES: The most common method of removal of calculi ("stones") from the common bile duct (CBD) is an endoscopic sphincterotomy. We wished to determine the role of an improved method of sphincterotomy in choledocholithiasis: "radial sphincterotomy". METHODS: From 2017 to 2018, 54 endoscopic retrograde cholangiopancreatography (ERCP) procedures were undertaken in patients diagnosed with choledocholithiasis. Group 1 (23 patients) received a standard "pull type" sphincterotomy. The sphincterotomy incision in group 1 was made at the 11, 12 or 1 'O' clock directions of a conventional clock depending on the anatomy of the papilla and stone size. Group 2 (31 patients) received a radial sphincterotomy. In this case, several incisions were made in the 11, 12 or 1 'O' clock directions. The main incision was applied to the transverse fold, and other radial incisions were made below the transverse fold, without going beyond the boundaries of the proposed course of the intramural part of the CBD. RESULTS: Stone size (mm) was classified as ≤5, 5-10, 10-15, 15-20 and >20. In group 1, the stone size was <20 mm in 21 patients, and >20 mm in two patients. In group 2, stones >20 mm were detected in seven patients, and in other cases the size was 15-20 mm. In patients who underwent radial sphincterotomy, post-ERCP pancreatitis was noted in one patient, and bleeding and perforations were not observed . CONCLUSIONS: Our method showed promising results, and deserves more extensive research and worldwide application. We recommend that only experienced endoscopists should undertake this novel procedure.

Tubulopapillary adenoma of the common bile duct presenting with jaundice.

In this report, an adult patient with tubulopapillary adenoma of the common bile duct that manifested with jaundice is presented. Diagnostic challenges were analyzed. Although adenomas of the common bile duct are rare, they should be kept in mind in the differentiation of lesions of this region. It should be remembered that these lesions radiologically could mimic carcinoma and choledocholithiasis. Endoscopic resection should be considered as the primary method for treatment. Histopathology is the gold standard in diagnosis.

The effects of carbon dioxide pneumoperitoneum on tyrosine hydroxylase activity.

PURPOSE: The aim of this study is to investigate the effects of carbon dioxide (CO2) pneumoperitoneum on tyrosine hydroxylase (TH) activity and total protein (TP) levels. METHODS: Forty male Sprague-Dawley rats were randomized into 10 groups, each consisting of 10 rats. Groups 1 and 2 consisted of anesthesia and sham-operated control rats, respectively. In the study groups, 10 mm Hg (group 3) and 15 mm Hg (group 4) pneumoperitoneum with CO2 were accomplished. At the end of the procedures, the brains and adrenals were removed quickly, and the hypothalamus and adrenal medulla separated, weighed, and homogenized. TH activity and TP levels were determined. RESULTS: The adrenal medulla TP and TH activity levels were decreased consistently and this decrease was significant in the sham and pneumoperitoneum groups compared with the control group (P<0.05). The adrenal medulla TP and TH activity levels were reduced significantly in group 4, as compared with the other groups (P<0.05). Elevation of hypothalamic TH activity in group 4 was significantly higher than in the other groups (P<0.05). CONCLUSIONS: These results indicate that CO2 pneumoperitoneum applied with 10 and 15 mm Hg pressure gradually decreases the adrenal medulla TH activity; TH is an indispensable enzyme for the biosynthesis of catecholamines. CO2 pneumoperitoneum with 15 mm Hg pressure significantly elevated hypothalamus TH activity.