Transduodenal sphincteroplasty for sphincter of Oddi dysfunction

Abstract

Presenter: Morgan Bonds MD | Virginia Mason Medical Center Background: Sphincter of Oddi dysfunction is a rare condition resulting in the non-calculous obstruction of pancreatic and biliary secretions at the pancreaticobiliary junction. Most cases are treated via endoscopic sphincterotomy. However, when this fails, surgical intervention is necessary. We present a video of transduodenal sphincteroplasty, an uncommon procedure in the modern era. Methods: A 64 year old woman presented to our institution after 10 years of recurrent epigastric pain and nausea after previous cholecystectomy. She was diagnosed with type III sphincter of Oddi dysfunction. Initially, she underwent two years of endoscopic interventions including endoscopic sphincterotomy, biliary and pancreatic stents, and botulinum toxin injections. She responded to these treatments for 3-4 months before her symptoms returned. Given that she responded to botulinum toxin injections, it was felt she had an incomplete sphincterotomy due to a long Sphincter of Oddi and, for this reason, she was evaluated for a transduodenal sphincteroplasty to complete her sphincterotomy. Results: The video demonstrates the key steps to completing a sphincterotomy via transduodenal sphincteroplasty. The Ampulla of Vater was identified through a lateral duodenotomy. Full thickness sutures were placed at the one o’clock and eleven o’clock position between the duodenal mucosa and the bile duct. Cautery completed the sphincterotomy between these stitches, dividing a band of scar tissue. Pancreatogram confirmed the pancreatic duct remained patent and choledochoscopy ensured there were no retained stones within the bile duct. Unfortunately, the patient's symptoms returned 3 months postoperatively. Conclusion: Transduodenal sphincteroplasty is a procedure that is rarely performed in the era of endoscopic sphincterotomy. This video demonstrates the key steps for successfully performing this procedure. It also presents the challenges of managing patients with type III sphincter of Oddi dysfunction. While the operation described is a safe and effective way of completing a long biliary sphincterotomy, the long term benefits can be difficult to predict.