Contemporary Outcomes of Transduodenal Sphincteroplasty: the Importance of Surgical Quality.

BACKGROUND: Sphincter of Oddi dysfunction (SOD) is managed primarily by endoscopic sphincterotomy (ES); however, surgical transduodenal sphincteroplasty (TDS) is a treatment option for select patients. In our high-volume pancreatico-biliary practice, we have observed variable outcomes among TDS patients; therefore, we sought to determine preoperative predictors of durable improvement in quality of life. METHODS: SOD patients treated by TDS between January 2006 and December 2015 were studied. The primary outcome measure was long-term changes in quality of life after sphincteroplasty. The secondary outcome measure examined postoperative outcomes, including postoperative complications, need for repeat procedures, and readmission rates. Perioperative data were abstracted, and the SF-36 quality-of-life (QoL) survey was administered. Standard statistical analysis included non-parametric methods to examine bivariate associations. RESULTS: Eighty-eight patients had an average follow-up duration of 6.7 (± 2.9) years. Thirty (34%) patients were naïve to endoscopic therapy. Patients with prior endoscopy averaged 2.1 procedures (range 1 to 13) prior to surgery. Perioperative morbidity was 27%; one postoperative death was caused by severe acute pancreatitis. Twenty-nine (33%) patients required subsequent biliary-pancreatic procedures. QoL analysis from available patients showed that 66% were improved or much improved. With multivariable analysis including SOD type and prior endoscopic instrumentation, freedom from surgical complication was the only variable that correlated significantly with a good outcome (p < 0.02). CONCLUSION: Surgical transduodenal sphincteroplasty provides durable symptom management for select patients with sphincter of Oddi dysfunction. Minimizing surgical complications optimizes long-term outcomes.

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.

Long-term symptomatic relief following surgical sphincteroplasty for sphincter of Oddi dysfunction.

INTRODUCTION: Surgical sphincteroplasty (SS) for sphincter of Oddi dysfunction (SOD) can be performed primarily or following failed endoscopic therapy. The role of SS in an era of endoscopic management is unclear. This study presents long-term follow-up of patients who had undergone SS at a tertiary referral unit. METHODS: Patients were identified from a departmental database and sent post-operative questionnaires to review pain scores and satisfaction with the procedure. Indications, pre-operative interventions and complications were recorded. RESULTS: Seventeen patients underwent SS over 13 years. Thirteen patients had objective features of biliary obstruction (delayed excretion of isotope or elevated sphincter pressures). The positive predictive value, sensitivity and specificity of morphine 99mTc-TBIDA in this series was 100, 100 and 92%, respectively. There were 12 responders of whom all but one had symptomatic improvement. Median follow-up was 5.1 years. Pain was significantly lower following SS (16 ± 9 vs. 67 ± 11; p = 0.003) and median satisfaction with the procedure was high (95%). CONCLUSIONS: Excellent symptomatic pain relief following SS can be achieved in carefully selected patients. Manometry does not appear to be essential for diagnosing SOD and morphine provocation hepatic scintigraphy was used to reliably identify patients who would benefit from SS.

A study of preoperative factors associated with a poor outcome following laparoscopic bile duct exploration.

BACKGROUND: The aim of this study was to identify preoperative factors associated with poor outcome following laparoscopic bile duct exploration. METHODS: Data regarding potential preoperative factors were collected prospectively and from a review of patient records of 436 patients who had undergone a laparoscopic bile duct exploration. A multivariate analysis was performed to identify significant predictors of five adverse outcomes: postoperative complication (stratified), conversion to open operation, prolonged hospital stay, bile leak following choledochotomy, and failure of surgical clearance of the duct. RESULTS: The mean age was 57 years (range = 18-91) and 74% were female. No complications were experienced by 66.5% and 17% had a minor Clavien Grade I complication. There was one death. Clinically significant Clavien Grade II-V complications occurred more frequently in those of increasing age [OR = 1.03 (CI = 1.01-1.05), p = 0.02]. Increasing serum bilirubin [OR = 1.01 (CI = 1.00-1.01), p = 0.01] was associated with conversion to an open operation. Male sex [OR = 0.52 (CI = 0.27-0.99), p = 0.05], previous upper abdominal surgery [OR = 4.89 (CI = 1.10-21.74), p = 0.04], immunosuppressants [OR = 9.75 (CI = 1.06-89.93), p = 0.05], and a larger preoperative common bile duct diameter [OR = 1.16 (CI = 1.08-1.25), p < 0.001] were predictors of a prolonged hospital stay. No factors were identified as predictors of a controlled bile leak. Previous failed ERCP was not associated with adverse outcome. CONCLUSION: Laparoscopic exploration of the bile duct is safe but age, comorbidity, and degree of jaundice increase the risk slightly.

Terlipressin in control of acute hemobilia during therapeutic ERCP in patient with portal biliopathy.

BACKGROUND: Portal biliopathy is a late and serious complication of extrahepatic portal venous obstruction usually manifesting with jaundice. Surgery and endoscopic therapy are the usual modalities of treatment for this condition. Endoscopic management contains inherited risk of hemobilia treatment of which is yet to be standardized. PATIENTS AND METHODS: Retrospective analysis of data from 2002 to 2007 for nonsurgical management of portal biliopathy was carried out. We encountered 4 cases of hemobilia during this period. The management and outcome of these 4 patients was analyzed. RESULTS: Median age at presentation was 39 years (22 to 50 y). All the patients had cholestatic jaundice and pain as presenting symptoms without prior history of gastrointestinal bleed. The median serum bilirubin and alkaline phosphatase values were 5 mg/dL (4.8 to 11.3 mg/dL ) and 494 IU/mL (342 to 645 IU/mL), respectively. Endoscopic retrograde cholangiography documented changes of portal biliopathy along with choledocholithiasis in all the 4 patients. An uneventful endoscopic sphincterotomy was followed by significant hemobilia during attempted stone extraction by Dormia basket/balloon. Patients were resuscitated with standard measures and injection terlipressin was started at a dose of 1 mg 4 times daily. Control of bleeding was achieved within 12 hours of infusion in all 4 patients and there was no bleed-related mortality. CONCLUSIONS: All our patients had symptomatic portal biliopathy as their first manifestation of underlying extrahepatic portal venous obstruction. Common bile duct stone extraction in patients with portal biliopathy carries a high risk of hemobilia even with balloon sweeping. Terlipressin is an effective pharmacologic treatment for hemobilia in patients with portal biliopathy.

Chronic inflammatory changes seen in gallbladders of patients with pancreatico-biliary malunion years after transduodenal sphincterotomy: is it a precursor for gallbladder carcinoma?

Common pancreaticobiliary channel malunion (PBM) is known to be associated with increased frequency of gallbladder (GB) cancer in adults. Few studies have reported the presence of histological changes in the GB following transduodenal drainage procedures in children with PBM. The aim of this study was to document the histological changes in the GB in children who underwent interval prophylactic cholecystectomy up to 18 years following PBM drainage procedure. All children who underwent open transduodenal sphincterotomy (TDS) for symptomatic PBM followed by prophylactic synchronous (open) and interval (laparoscopic) cholecystectomy between 1987 and 2007 were studied retrospectively. Eight children with PBM were identified. The median age at initial presentation and open transduodenal sphincterotomy was 8 months (1 month-3.5 years). The average interval between open TDS and prophylactic cholecystectomy was 5.5 years (0-18 years). Two children had synchronous TDS and cholecystectomy. At initial presentation, all patients presented with obstructive jaundice. Mild common bile duct dilatation was encountered in all patients. The dilated ducts returned to normal, and remained normal after transduodenal sphincterotomy. Histopathology in seven out of eight GB specimens (87.5%) showed microscopic evidence of chronic inflammation. Chronic cholecystitis (n = 7), Rokitansky-Aschoff sinuses (n = 3), cholesterosis (n = 1) and intestinal metaplasia (n = 1) were observed in the GB biopsies. Only one patient, who had TDS and a synchronous cholecystectomy in the neonatal period, did not have histological changes in the GB. Average follow-up in years ranged between 3 months and 19 years (from TDS) with a median of 8 years, and between 3 months and 6 years (from cholecystectomy) with a median of 2 years. Chronic inflammatory changes were found in seven of eight GB specimens from patients with PBM despite previous drainage procedure in six patients and in one of two patients who underwent synchronous TDS and cholecystectomy. These changes may be the precursor of malignant transformation in GB of patients with PBM.

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.

Sonographic demonstration of duodenobiliary reflux with soda enhancement.

Cholangitis rarely occurs after sphincteroplasty if there is no biliary obstruction. We report the case of a patient who developed recurrent cholangitis despite having a patent biliary tract after sphincteroplasty. Duodenobiliary reflux was demonstrated on sonography after enhancement of the reflux flow with a novel oral contrast agent, a carbonated soda beverage. Sonography with contrast enhancement provided by soda solution may prove satisfactory to detect duodenobiliary reflux after sphincteroplasty safely, effectively, and economically.

Alteraciones de la continencia fecal en el tratamiento quirúrgico de la fisura anal crónica / Disturbance of fecal continence following surgery for chronic anal fissure

Objetivo. Determinar la tasa de incontinencia anal tras esfinterotomía lateral interna subcutánea en pacientes diagnosticados de fisura anal crónica. Pacientes y métodos. Cien pacientes consecutivos diagnosticados de fisura anal crónica y que presentaban una continencia fecal perfecta antes de la intervención fueron incluidos en el estudio. A todos los pacientes se les realizó una esfinterotomía lateral interna subcutánea. La continencia de los pacientes se valoró en consulta, antes de la operación y un año después mediante la escala de Miller et al. El análisis estadístico se realizó mediante los tests t de Student y de 2.Resultados. De los 100 pacientes incluidos en el estudio, 56 eran varones. La edad media fue de 45,2 años (intervalo, 24-88). Un año después de la operación, el 29 por ciento de los pacientes encuestados refirió alteraciones de la continencia fecal. De ellos, el 26 por ciento presentó alteraciones en la continencia de gases. Un 3 por ciento tuvo episodios de incontinencia para gases y para heces sólidas. Además, entre ambos grupos hubo 4 pacientes que presentaron incontinencia cuando padecían diarrea. No se observaron diferencias en la edad ni en el sexo entre los pacientes que presentaron alteraciones de la continencia y los que no la presentaron. Conclusiones. Nuestro estudio muestra que aunque esta técnica quirúrgica sea la mejor para tratar la fisura anal crónica, presenta una tasa grande de alteraciones de la continencia fecal, hecho que debería ser conocido por los pacientes a los que se les ofrezca esta intervención (AU)

[Endoscopic, percutaneous and laparoscopic treatment for acute biliary pancreatitis]. / Traitement endoscopique, percutané et coelioscopique des pancréatites aiguës biliaires.

AIM OF THE STUDY: The aim of this study is to evaluate the results of acute gallstone pancreatitis treatment and to discuss indications in relation with the different forms of the disease. MATERIAL AND METHOD: From january 1992 to june 2001, 137 patients have been treated for an acute gallstone pancreatitis. Diagnostic criteria were given by the history, clinical examination, biochemical and radiological findings. After exclusion of patients with a systemic disease, a group of 129 patients have been enrolled in a treatment regimen with an endoscopic retrograde cholangiopancreatography (ERCP) and eventual sphincterotomy, a percutaneous US-guided cholecystostomy (PC) when necessary and an elective laparoscopic cholecystectomy. RESULTS: ERCP has been successfully performed in 121/129 patients. A PC has been performed in 5/8 patients of the failed endoscopic procedure and in 14 with acute cholecystitis. Retrograde and percutaneous cholangiographies showed main bile duct stones in 89 patients, a dilatation of the main bile duct without stones in 26 patients and a negative finding in 6 patients. An endoscopic sphincterotomy has been performed in 117 patients. A laparoscopic cholecystectomy has been performed in 118 patients. Mortality and morbidity rates were 1.6 and 10.3%, respectively. CONCLUSION: ERCP and sphincterotomy seem to be indicated in all patients observed during the first 72 hours. Endoscopic treatment and percutaneous procedure make it possible to reduce at a very low rate the cases with an unfavourable course of the disease. A definitive treatment may then be performed by the way of a laparoscopic cholecystectomy.

Transduodenal sphincterotomy in laparoscopic era.

Indications for transduodenal sphincterotomy have been reduced in recent years, mainly because of the development of endoscopic sphincterotomy and laparoscopic procedures. Endoscopic treatment is effective, but it is necessary to carefully evaluate its indications because the incidence of early and late complications is not negligible. Laparoscopic procedures require advanced and expensive technologies and considerable laparoscopic experience. Transduodenal sphincterotomy is safe and effective, if correctly performed. Some risk factors appear to be related to the incidence of complications that do not significantly differ from those following endoscopic sphincterotomy. Transduodenal sphincterotomy may be still indicated in selected cases, and for this reason it should be considered an essential part of the knowledge of a general surgeon.

Operative treatment for chronic pancreatitis pain.

BACKGROUND: Management of pain is the most frustrating problem associated with chronic pancreatitis. Pain is progressive and difficult to quantify. Uncontrolled, it eventually destroys the patient's quality of life, leading to drug addiction. STUDY DESIGN: This study reports the results of 258 operations on 239 consecutive patients treated for pain related to chronic pancreatitis between 1969 and 1999. The operations performed were 42 pancreaticoduodenectomies, 48 side-to-side pancreaticojejunostomies, 68 distal pancreatectomies, 21 85% to 95% distal pancreatectomies, 70 cystenterostomies and 9 sphincteroplasties. Efforts were made to choose the operation most appropriate for the pathological conditions encountered in each patient. Results of treatment were satisfactory if patients were entirely relieved of pain and unsatisfactory if there was any residual pain. Presence or absence of pain was based on patient's own evaluation at the time of their last followup examination. RESULTS: Results were overall satisfactory in 71% of patients after pancreaticoduodenectomy, 68% after side-to-side pancreaticojejunostomy, 69% after distal pancreatectomy; 69% after 85% to 95% distal pancreatectomy, 51% after cystenterostomy, and 44% after sphincteroplasty. The mean followup of patients was 4 y (range 0 to 23 y). CONCLUSIONS: The cause of chronic pancreatitis is obscure. As a consequence, there have been few advances in the treatment of this condition. There are new techniques to resect the pancreas, but the results are little better than those obtained with older methods. Advances in the treatment of chronic pancreatic pain will come from knowledge concerning its cause. Discovery of mechanisms stimulating the pathways that lead to the perception of pain and methods for interruption of these mechanisms may provide new treatments.

Long-term effects of transduodenal sphincterotomy: symptoms and hepatobiliary function.

BACKGROUND/AIMS: Endoscopic sphincterotomy is widely used in treating common bile duct stones, but the long-term effects of destroying the sphincter of Oddi are not known. This study investigated the long-term (15-20 years) effects of transduodenal sphincterotomy on gastrointestinal symptoms and hepatobiliary function in a retrospective controlled study. METHODOLOGY: Between 1974 and 1977, choledocholithotomy was performed in 131 patients either transduodenally (60 patients) or via choledochotomy (71 patients). For the retrospective part of the study, all hospital records, death certificates and autopsy reports were reviewed. Twenty-seven patients who could be reached and volunteered to participate (12 and 15, respectively) were re-examined. In the re-examination part of the study, a standard questionnaire interview, laboratory tests, quantitative cholescintigraphy and ultrasonography were performed. RESULTS: The hospital mortality for the primary operations was 0.8%, 0% for the transduodenal sphinterotomies and 2% for the choledochotomies; the difference was not significant. During the follow-up period, no significant differences could be seen in the death rate or in the causes of death between the study groups. During re-examination, flatulence was found to be more common in the choledochotomy subgroup (7/15 vs 2/12, p<0.05). In the laboratory tests, conjugated bilirubin and serum aspartate amino transferase levels were higher in the transduodenal subgroup than in the choledochotomy subgroup (3.3 umol/L, SD 0.4 vs 2.2 umol/L, SD 0.2, p<0.02; and 25 U/L, SD 12.6 vs 18.6 U/L, SD 5.0, p<0.05, respectively). Furthermore, 6/12 (50%) of the transduodenal subgroup had elevated serum alanine aminotransferase, aspartate aminotransferase or amylase levels, as compared to 1/15 (7%) in the choledochotomy subgroup (p<0.02). In terms of ultrasonography, in the choledochotomy subgroup, the common bile duct diameter was larger than 8 mm in 8/15 (53%) patients, as compared to 1/12 (8%) in the transduodenal subgroup (p<0.02). In terms of quantitative cholescintigraphy, in 9/12 (75%) patients of the transduodenal subgroup, the hilum-duodenum transit time was less than 10 minutes, as compared to 4/12 (47%) of the choledochotomy subgroup. CONCLUSIONS: Transduodenal sphincterotomy results in decreased flatulence and enhanced common bile duct drainage, even in the long-term period, but slightly higher serum liver funtion tests, when compared to supraduodenal choledochotomy.

[Surgical treatment of chronic pancreatitis with predominant cephalic involvement by double Wirsung duct diversion and restoration of permeability of the cephalic duct]. / Traitement chirurgical de la pancréatite chronique avec atteinte céphalique prédominante par double dérivation wirsungienne et reperméabilisation canalaire céphalique.

The aim of this study is to assess the long-term results of an original surgical technique for the treatment of patients suffering from painful chronic pancreatitis. From 1981 to 1994, 54 patients with chronic painful pancreatitis were operated, by means of an original duct drainage procedure, named by the authors "double drainage" because it consists of a large transduodenal sphincterotomy and a long pancreatic duct, accompanied by repermeabilization of the cephalic pancreatic duct. This procedure was used exclusively for type I pancreatitis with major lesions in the head of the gland (calcified stones, narrowing of the ducts, inflammatory process). There were 40 men and 14 females in this series. No perioperative mortality and a low morbidity (22%) were observed. Mean follow-up in 52 patients was 56 months (median: 59.5 months). The 5- year actuarial survival was 85.2% and 81% were free of pain (91% when the pancreatic duct was dilated to > 6 mm) versus 63% when the pancreatic duct was (6 mm) (p < 0.01). These excellent results should serve as a baseline for any alternative treatment of this category of painful chronic pancreatitis patients.

Experimental transduodenal diathermic sphincterotomy in pigs.

Transduodenal diathermic sphincterotomy was performed in nine pigs of the large White breed, weighing 70-80 kg. The Erbotom T 400 diathermy unit equipped with a needle knife was used to incise the duodenal papilla and its sphincter. The animals were divided into three groups and the results of the operation were estimated 2, 8 and 12 weeks after surgery. After the respective survival period was over, the animals were examined post mortem to macroscopically inspect the surgery site and take samples for histopathological and histochemical investigations. Histopathological preparations were stained with haematoxylin and eosin as well as by Hale-Müller's or Frankel's methods. Histochemical investigations were performed to determine the activity of three enzymes: alkaline phosphatase, acid phosphatase and succinate dehydrogenase. The present study has revealed that diathermic incision of the duodenal papilla and its sphincter gives very good results as confirmed by the findings of macroscopic as well as histopathological and histochemical investigations.

Avaliaçäo quantitatifa do refluxo duodenogástrico após colecistectomia e esfincteroplastia transduodenal: estudo experimental em cäes / Quantitative avaluation of the duodenogastric reflux after cholescystectomy and transduodenal sphincteroplasty: experimental study in dogs

O papel exercido pela colecistectomia e pela esfincteroplastia transduodenal sobre o refluxo duodenogástrico(RDG) permanece controvertido e da esfincteroplastia transduodenal sobre o RDG. MÉTODO. 40 cäes foram distribuidos em quatro grupos: grupo controle (C) (n=12), grupo colecistectomia (Co) (n=10), grupo esfincteroplastia transduodenal (Es) (n=10) e grupo colecistectomia mais esfincteroplastia transduodenal (Co+Es) (n=8). O RDG foi avaliado pela injeçäo intravenosa do 99mTecnésio-DISIDA, injetado por via intravenosa, seguida de aspiraçäo do conteúdo gástrico. O resultado foi expresso como a percentagem do radiotraçador injetado recuperada no aspirado gástrico. RESULTADOS. O RDG foi significativamente maior no grupo Co+Es (média: 2,26 ñ 2,69 por cento) que nos grupos C (média: 0,23 ñ 0,26 popr cento), Co média: 1,52 ñ 1,77 por cento) e Es (média: 1,23 ñ 1,23 por cento) (p<0,05). O RDG näo diferiu significativamenteentre os grupos C, Co e Es (p>0,05). CONCLUSAO. Os resultados mostram que colecistectomia aumenta o refluxo duodenogástrico apenas quando associada à esfincteroplastia