Should the Oddis sphincter be retained? A clinical analysis of biliary metal stent implantation in patients with malignant obstructive jaundice.

OBJECTIVE: We sought to analyze the efficacy and safety of preserving the Oddis sphincter during metallic biliary stent implantation in patients with malignant obstructive jaundice. MATERIALS AND METHODS: In a retrospective analysis, 133 patients with malignant obstructive jaundice who were admitted to our hospital from January 2010 to January 2017 and who underwent metallic biliary stent implantation were divided into two groups - the Oddis sphincter retention group (n = 55) and the Oddis sphincter nonretention group (n = 78) - according to whether the Oddis sphincter was left untouched during stent placement. The patient clinical data as well as information on complications, time of stent patency, improvement in liver function, and decline of serum bilirubin were reviewed and evaluated. Statistical analysis was performed using the Statistical Package for the Social Sciences version 19.0 (IBM Corp., Armonk, NY, USA, USA) and Prism version 7 (GraphPad Software, San Diego, CA, USA). RESULTS: The median follow-up time was 9.6 months (range: 1-20 months) and there was no significant difference in general clinical information between the two groups. However, the incidence rates of acute biliary infection, recurrent biliary infection, acute pancreatitis, chronic pancreatitis, and asymptomatic pancreatic enzyme levels were higher in the Oddis sphincter retention group and the differences were all statistically significant (P < 0.05). Conversely, there were no significant differences in bilirubin decline, liver function improvement, and stent patency between the two groups (P > 0.05). CONCLUSION: Leaving the Oddis sphincter untouched during biliary stent placement can reduce the incidence of postoperative complications, while there was no effect on stent patency or jaundice relief. Therefore, it is recommended to preserve the Oddis sphincter when the stenosis is more than 3 cm above the duodenal papilla.

Sphincter of Oddi Dysfunction After Gastric Bypass: Surgical or Endoscopic Therapy?

BACKGROUND: Management of Sphincter of Oddi Dysfunction (SOD) requires advanced techniques (endoscopic retrograde cholangiopancreatography via gastrostomy [GERCP]) after Roux-en-Y gastric bypass (RYGB) for obesity. Transduodenal sphincteroplasty (TS) is also performed yet carries the risks of surgery. We hypothesized that TS would have increased morbidity and mortality but provide a more durable remission of symptoms. METHODS: All patients between 2005 and 2016 with RYGB for obesity undergoing endoscopic or surgical management for type I or II SOD were included in the study. Patients with type III SOD, or who underwent RYGB for nonobesity indications, were excluded. RESULTS: Thirty-eight patients were identified. GERCP was initially performed in 17 patients, whereas TS was performed in 21. Thirty-day mortality was 0% in our cohort, and 30-d morbidity was similar between GERCP and TS (29% versus 10%; P = 0.207). Resolution of symptoms after initial therapy was seen in 41% of GERCP (7/17) and 67% of TS (14/21) (P = 0.190), respectively, and overall after 35% (8/23) and 64% (16/24) of procedures performed (P = 0.042). Symptom resolution, as defined by the median ratio of days of total remission by total days of observed follow-up, was shorter after initial and all interventions with GERCP compared with TS (0.67 versus 1.00, P = 0.036 and 0.52 versus 1.00, P = 0.028, respectively). CONCLUSIONS: Endoscopic and surgical treatment of SOD had similar morbidity and mortality. However, treatment success and duration of remission was higher in those treated with surgery.

Adverse Events and Reinterventions Following Pancreatic Endoscopic Sphincterotomy.

OBJECTIVES: Pancreatic endoscopic sphincterotomy (PES) is an independent risk factor for short- and long-term adverse events (AEs) of endoscopic retrograde cholangiopancreatography. We sought to measure PES-specific AEs and trends in the use of PES. METHODS: This was a retrospective cohort of consecutive patients who underwent first-time PES between June 2008 and June 2015. Indications for PES were dichotomized: (1) structural pathology (chronic pancreatitis and local complications of acute pancreatitis) and (2) suspected sphincter pathology (idiopathic recurrent acute pancreatitis and sphincter of Oddi dysfunction). Rates of AEs and pancreatic orifice reinterventions were measured, with reintervention rates limited to those having a minimum of 12-month follow-up. RESULTS: Of 567 patients, 198 (34.9%) underwent PES for structural and 369 (65.1%) for suspected sphincter pathology. Rates of post-endoscopic retrograde cholangiopancreatography pancreatitis and unplanned hospitalization were high when PES was originally performed for suspected sphincter pathology (12.6% and 14.6%, respectively). The overall reintervention rate was 28.9% and significantly greater for sphincter (41.7%) compared with structural pathology (13.5%, P = 0.005). CONCLUSIONS: The likelihood of reintervention after PES is high, particularly when the primary indication is suspected sphincter pathology such as idiopathic recurrent acute pancreatitis. Further prospective studies are needed to clarify if and when this maneuver confers significant benefit to patients.

[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.

If you suffer from type-2 diabetes mellitus, your ERCP is likely to have a better outcome

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Bacteriobilia: un problema sin resolver / Bacteriobilia: a non-resolved problem

La vía biliar habitualmente es estéril, y el aislamiento de microorganismos (bacteriobilia) se ha relacionado con diversos factores, como la edad, el drenaje biliar previo a la cirugía de páncreas o la litiasis biliar. Los gramnegativos continúan siendo los microorganismos más frecuentes, especialmente Escherichia coli. Entre los grampositivos cabe destacar a Enterococcus spp. Actualmente, existe controversia acerca de si la presencia de bacteriobilia tiene impacto en la mala evolución de la enfermedad biliar o de los procedimientos quirúrgicos o en las tasas de mortalidad, con complicaciones como infecciones del sitio quirúrgico o bacteriemia. En los pacientes de mayor riesgo, como los inmunosuprimidos o en los que se practica duodenopancreatectomía, los cultivos sistemáticos de bilis, aunque no existan datos clínicos de infección, pueden ser necesarios para iniciar tratamiento antibiótico o para reducir su espectro (AU)

Bile duct is usually sterile, and the isolating of microorganisms (bacteriobilia) has been related to some factors, such as age, biliary drainage before pancreatic surgery or bile duct stones. Gramnegative strains remain the most frequent pathogens, especially Escherichia coli. Among grampositives Enterococcus spp should be mentioned. Currently, there is controversy about whether the presence of bacteriobilia has an impact on unfavorable outcome of biliary disease or surgical procedures or mortality rates, with complications such as surgical site infections or bacteremia. In high-risk patients, such as immunosuppressed or those underwent pancreaticoduodenectomy, bile duct cultures performed routinely, even if there are not clinical data of infection, could be necessary in order to start antibiotic treatment or to reduce its spectrum (AU)

Innervation of Extrahepatic Biliary Tract, With Special Reference to the Direct Bidirectional Neural Connections of the Gall Bladder, Sphincter of Oddi and Duodenum in Suncus murinus, in Whole-Mount Immunohistochemical Study.

Sphincter of Oddi dysfunction is one of the most important symptoms in post-cholecystectomy syndrome. Using either electrical or mechanical stimulation and retrogradely transported neuronal dyes, it has been demonstrated that there are direct neural pathways connecting gall bladder and the sphincter of Oddi in the Australian opossum and the golden hamster. In the present study, we employed whole-mount immunohistochemistry staining to observe and verify that there are two different plexuses of the extrahepatic biliary tract in Suncus murinus. One, named Pathway One, showed a fine, irregular but dense network plexus that ran adhesively and resided on/in the extrahepatic biliary tract wall, and the plexus extended into the intrahepatic area. On the other hand, named Pathway Two, exhibiting simple, thicker and straight neural bundles, ran parallel to the surface of the extrahepatic biliary tract and passed between the gall bladder and duodenum, but did not give off any branches to the liver. Pathway Two was considered to involve direct bidirectional neural connections between the duodenum and the biliary tract system. For the first time, morphologically, we demonstrated direct neural connections between gall bladder and duodenum in S. murinus. Malfunction of the sphincter of Oddi may be caused by injury of the direct neural pathways between gall bladder and duodenum by cholecystectomy. From the viewpoint of preserving the function of the major duodenal papilla and common bile duct, we emphasize the importance of avoiding kocherization of the common bile duct so as to preserve the direct neural connections between gall bladder and sphincter of Oddi.

Sphincter of Oddi disorder (SOD): Is it necessary to investigate and treat?

Sphincter of Oddi disorder (SOD) is a part of functional gastrointestinal disorder which is a non-calculous obstructive disorder. This disease is more common in middle-aged women with a prevalence of around 1.5% but in patients with post-cholecystectomy syndrome (PCS) the prevalence rate is markedly higher (9-55%). This high variability maybe attributed to lack of uniformity in patient selection criteria, definition of SOD, and the diagnostic method used. Abdominal pain is the most common symptom occurring due to obstruction at the SO leading to ductal hypertension, ischemia from spastic contraction and hypersensitivity of papilla. Clinical diagnosis of SOD can be achieved by Rome III criteria. Various classifications are used (Milwaukee billiary and modified Milwaukee group classification) for billiary and pancreatic SOD. Not a single non-invasive method is diagnostic. Sphincter of Oddimanometry (SOM) is the gold standard method for evaluating and deciding the management of an SOD patient. The symptomatic relief rate varies from 55% to 95%, so risk-benefit ratio should be evaluated with each patient.

Pathologic T1 subclassification of ampullary carcinoma with perisphincteric or duodenal submucosal invasion: Is it T1b?

CONTEXT: In ampullary carcinoma staging, T1 is defined as a tumor limited to the ampulla of Vater or the sphincter of Oddi, and T2 is defined as invasion into the duodenal wall. However, the definition of duodenal wall invasion is vague. Ampullary carcinoma that invades beyond the sphincteric of Oddi (perisphincteric invasion) or into the duodenal submucosa could be considered pT1b because submucosal invasion is classified as pT1b in gastrointestinal tract tumors. However, there are no data regarding T subclassifications for ampullary carcinoma with perisphincteric or duodenal submucosa invasion. OBJECTIVE: To determine the T subclassification of ampullary carcinoma that invades into perisphincteric or duodenal submucosa. DESIGN: Pathologically proven ampullary carcinomas with T1 or T2 were reviewed (n = 105). We reclassified tumors as pT1a that were limited to within the sphincter of Oddi (n = 40; 38%), as pT1b for tumors that invaded beyond the sphincter of Oddi or into the duodenal submucosa (n = 25; 24%), and as pT2 for tumors that invaded into duodenal proper muscle (n = 40; 38%). RESULTS: Lymph node metastasis and recurrence were absent in ampullary carcinoma with pT1a, whereas nodal metastasis were noted in 24% (6 of 25) and 40% (16 of 40) of the ampullary carcinomas with pT1b and pT2, respectively. Tumor recurrence/metastasis rate of ampullary carcinoma with pT1b and pT2 was 44% (11 of 25) and 40% (16 of 40), respectively. The 5-year disease-free-survival rates from ampullary carcinoma with pT1a, pT1b, and pT2 were 95% (38 of 40), 56% (14 of 25), and 58% (23 of 40), respectively (P = .003). The 5-year overall survival from ampullary carcinoma with pT1a, pT1b, and pT2 was 98% (39 of 40), 72% (18 of 25), and 60% (24 of 40), respectively. CONCLUSIONS: The clinicopathologic outcome of ampullary carcinoma with a pT1b subclassification was worse than it was for T1a and approached the outcome for pT2.

Influence of paeoniflorin on intracellular calcium ion concentration in the sphincter of Oddi of hypercholesterolemic rabbits.

This study aimed to investigate the influence of hypercholesterolemia (HC) on intracellular calcium ion concentration in the sphincter of Oddi (SO) of rabbits and the influence of paeoniflorin on intracellular calcium ion concentration in the hypercholesterolemic rabbit SO. Sixteen purebred New Zealand rabbits were randomly divided into two groups: the control group and the HC model group (8 rabbits in each group). The control group was fed standard diet. The HC group was fed standard diet plus cholesterol for a total of 8 weeks to induce and establish the rabbit HC model. The SO segment of HC rabbits was taken and enzyme treated to obtain SO cells. After primary culture, immunohistochemical analysis was performed. Fluo-3/AM was used to load SO cells, and then intracellular calcium ion concentration was determined by confocal microscopy. Intracellular calcium ion in the SO of the HC group was higher than that of the normal group; intracellular calcium ion in the HC rabbit SO of the paeoniflorin group was lower than that of the control group, where the paeoniflorin effect was greater with higher concentrations. High cholesterol caused an increase in intracellular calcium ion concentration in the rabbit SO, and paeoniflorin can reduce intracellular calcium ion concentration in the HC rabbit SO in a concentration-dependent manner.

[Stenosing papillitis--a problem of miniinvasive surgery].

The results of conduction of endoscopic transpapillary interventions in 976 patients, suffering stenosing papillitis in 2000 - 2014 yrs, were summarized. In 48 (4.9%) patients complications have had occurr, all the patients are alive.

[Effectiveness of treatment of pancreatic disorders in children (based on catamnesis)].

In the article results of supervision of the patients with chronic pancreatitis and dysfunction of Oddi's sphincter, pancreatic type, in polyclinic were presented. Among them: 50 children received in clinic therapeutic complex offered by us which included: phytoenzyme, spasmolytic and antioxidant. 50 children were treated in traditional way. Screening of functional condition of the pancreas revealed decreasing percentage of moderate exocrine insufficiency of pancreas (10% of incidences) in children with recurrent course of pancreatitis. In long-lasting course of pancreatitis in this group percentage of patients with moderate exocrine insufficiency was decreased due to 15%. At the same time, in patients with moderate and severe exocrine insufficiency (55 and 20% subsequently) which improves non complete efficiency of basic therapy.

Modelling of the pathological bile flow in the duct with a calculus.

The aim of the present paper is to develop an analytical model for description of the pathological bile flow in the major duodenal papilla duct with a calculus. The problem is separated into two parts. The first part deals with determination of bile behaviour and constitutive relation parameters of the pathological bile. The viscosity vs. shear rate, the viscosity vs. time, and shear stress vs. shear rate dependences are obtained for different types of bile taken from patients of different age and sex. As a result, the approximation of curves described by the Casson equation was obtained. It was shown that the pathological bile is a thixotropic non-Newtonian fluid. The second part is directly related to modelling of the bile flow in the duct with a calculus. As a result of solving the problem, the bile velocity profile, flow rate vs. time, and bile pressure vs. calculus radius were obtained. The dependences obtained may play an important role in the assessment of an indication to operation.

Can red cell distribution width help to discriminate benign from malignant biliary obstruction? A retrospective single center analysis.

BACKGROUND/AIMS: Differentiation of benign obstructive jaundice from malignant obstructive jaundice still remains difficult, despite improvements in diagnostic modalities. The aim of this study is to evaluate the usefulness of red cell distribution width (RDW) in differentiating benign and malignant causes of obstructive jaundice. METHODOLOGY: One hundred and ninety four consecutive patients (101 malignant, 93 benign) with a history of obstructive jaundice were reviewed in the period between January 2008 and August 2009. Definition of biliary strictures was suggested by cholangiographic features and supported by brush cytology, fine needle aspiration (FNA) and the presence of mass or metastases by imaging and/or clinical followup. Patients were divided into two groups, benign and malignant, based on the discharge diagnosis. RESULTS: The receiver operating characteristic analysis showed that a RDW of 14.8% was the best cut-off value for predicting a malignant biliary stricture with a sensitivity of 72% and a specificity of 69% (AUC=0.755, 95% CI=0.649-0.810). RDW was increased (>14.8%) in 31.6% of benign cases and 68.4% of malignancies. Depressed RDW levels (<14.8%) were found in 72.9% of benign cases and 27.1% of malignancies, which was statistically significant (p<0.001). CONCLUSIONS: Our results show that RDW is useful in the differentiation of benign from malignant causes of biliary obstruction when using an optimized cut-off value. In patients in whom biliary obstruction is suspected, an elevated RDW value may be a reliable additional predictor for differentiating the underlying etiology of biliary obstruction.

[A modern look at benign stenosing lesions. Etiology and pathogenesis of diagnostic capabilities. A systematic review].

The problem of nonneoplastic stenosis of major duodenal papilla is on joint of gastroenterology and surgery and present a challenge for physicians. This article reviews what is known about the pathogenesis, epidemiology and diagnostics of papillostenosis and sphincter of Oddi dysfunction.

The size of the papilla of Vater and its relation to its height in comparison with the visibility of the sphincter of Oddi before and after cholecystectomy.

This study investigated the changes in the surface area and height of the papilla of Vater (PV) and the visibility of the sphincter of Oddi complex (SOK) using endoscopic ultrasound (EUS) examinations of 80 patients with symptomatic gallstones before and at 3 and 6 months after cholecystectomy. Following surgery, 50 patients experienced early atypical symptoms characteristic of postcholecystectomy syndrome (PCS) and 30 patients were asymptomatic. The PV measurements were greater in all patients compared with normal reference values and increased significantly from before surgery to 3 months postsurgery. At 6 months postsurgery, both the surface area and height of the PV had significantly decreased to preoperative values but remained higher than normal. The proportion of patients with a visible SOK had increased by 3 months postsurgery but had reduced again by 6 months. There were no significant differences between symptomatic and asymptomatic patients, suggesting that the changes observed in the PV and SOK do not explain the presence of the atypical symptoms of PCS.

Pseudotumor of the distal common bile duct at endoscopic retrograde cholangiopancreatography.

BACKGROUND: Prior studies have described a pseudocalculus appearance in the distal common bile duct as a normal variant at cholangiography. The objective of this study was to describe the occurrence of pseudotumor in the distal common bile duct at endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Nine patients who underwent ERCP between May 2004 and July 2008 were identified as having a transient eccentric mural-based filling defect in the distal common bile duct. A single reader systematically reviewed all studies and recorded the imaging findings. RESULTS: The mean diameter of the filling defect was 9 mm (range, 5 to 11). Eight patients had resolution of the filling defect during the same ERCP or on a subsequent ERCP, and in two of these patients the inferior border of the filling defect was not well visualized. The other patient underwent surgical resection of a presumed tumor with no evidence of malignancy on surgical pathology. CONCLUSION: An eccentric mural-based filling defect in the distal common bile duct can be artifactual in nature and may reflect transient contraction of the sphincter of Oddi. Recognition of this pseudotumor may help avoid unnecessary surgery.

Moderate and severe postendoscopic retrograde cholangiopancreatography pancreatitis despite prophylactic pancreatic stent placement: the effect of early prophylactic pancreatic stent dislodgement.

BACKGROUND: Placement of prophylactic pancreatic stents (PPS) is a method proven to reduce the rate and severity of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk patients; however, PPS do not eliminate the risk completely. Early PPS dislodgement may occur prematurely and contribute to more frequent or severe PEP. OBJECTIVE: To determine the effect of early dislodgement of PPS in patients with moderate or severe PEP. METHODS: A total of 27,176 ERCP procedures from January 1994 to September 2007 for PPS placement in high-risk patients were analyzed. Patient and procedure data were analyzed to assess risk factors for PEP, and to evaluate the severity of pancreatitis, length of hospitalization and subsequent complications. Timing of stent dislodgment was assessed radiographically. RESULTS: PPS were placed in 7661 patients. Of these, 580 patients (7.5%) developed PEP, which was graded as mild in 460 (6.0%), moderate in 87 (1.1%) and severe in 33 (0.4%). Risk factors for developing PEP were not different in patients who developed moderate PEP compared with those with severe PEP. PPS dislodged before 72 h in seven of 59 (11.9%) patients with moderate PEP and five of 27 (18.5%) patients with severe PEP (P=0.505). The mean (± SD) length of hospitalization in patients with moderate PEP with stent dislodgement before and after 72 h were 7.43 ± 1.46 days and 8.37 ± 1.16 days, respectively (P=0.20). The mean length of hospitalization in patients with severe PEP whose stent dislodged before and after 72 h were 21.6 ± 6.11 and 22.23 ± 3.13 days, respectively (P=0.96). CONCLUSION: Early PPS dislodgement was associated with moderate and severe PEP in less than 20% of cases and was not associated with a more severe course. Factors other than ductal obstruction contribute to PEP in high-risk patients undergoing ERCP and PPS placement.