Intact Papilla Research Articles

Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy

Few laparoscopic surgeons currently explore the bile duct at cholecystectomy, which has focused attention on the role of preoperative endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of duct stones. Indications for ERCP depend on the likelihood of duct pathology; clinical, biochemical, and radiologic predictive factors are well established. Expert endoscopists use ERCP sparingly, only in patients known or very likely to have duct stones, believing that the duct can be cleared after laparoscopic cholecystectomy (LC) when necessary in almost every case. Paradoxically, when the level of local ERCP expertise is modest, ERCP may be attempted before LC more often, thus leaving the option of open exploration if ERCP fails. ERCP is highly efficient in the management of patients with symptoms after LC in order to exclude, diagnose, and treat complications such as retained stones, cystic duct leaks, and strictures. Concern about performing sphincterotomy in young patients (especially those with normal-sized ducts) because of unknown long-term effects is leading some endoscopists to remove small stones through the intact papilla. Selected patients with gallbladder and duct stones may be best treated by endoscopic duct clearance alone, without cholecystectomy (unless or until symptoms develop). Overall, ERCP techniques are currently used in about 10% of patients before or after LC. Each surgical/endoscopic team should develop an algorithm to maximize the effectiveness of the combined approach and to minimize problems.

Removal of stones from the bile duct at ERCP without sphincterotomy

The main risks associated with endoscopic stone removal arise from the sphincterotomy that is performed to facilitate stone extraction. The complication rate may be higher when the bile duct is not dilated. Between January 30, 1990, and March 30, 1993, we attempted to remove stones up to 8 mm in diameter through the intact papilla, without performing sphincterotomy, in 24 patients. Nine patients underwent balloon dilation of the sphincter or of a low duct stricture to facilitate stone removal. All patients were treated successfully and are well at follow-up. Two patients (one having had balloon dilation of the sphincter) had mild pancreatitis that required 2 days in the hospital. During the same period, 215 patients were treated for duct stones 8 mm or less through a standard sphincterotomy. Complications occurred in 11 of these patients: five episodes of pancreatitis, three infections, one perforation, and two other complications. Although these two groups of patients are not directly comparable, it appears that selected stones can be extracted from the bile duct without sphincterotomy with relative safety. This technique should be studied further, especially in younger persons where sphincter preservation may be desirable.

Natriuretic effect of atriopeptin III in rats with papillary necrosis

This study compared the effects of atriopeptin III (AP III) on sodium excretion and renal interstitial hydrostatic pressure (RIHP) in control rats and in rats pretreated with 2-bromoethylamine (BEA) to produce papillary necrosis. In control rats, infusion of AP III (100 ng.kg-1.min-1) increased sodium excretion from 2.2 +/- 0.7 to 6.4 +/- 0.9 microeq.min-1.g kidney wt-1 and RIHP from 6.8 +/- 0.7 to 8.7 +/- 0.9 mmHg, whereas glomerular filtration rate and renal blood flow were unaltered. Similar results were obtained in rats pretreated with BEA 48 h before the experiment. In rats studied 6 wk after BEA treatment, the papilla was absent and there was atrophy of juxtamedullary nephrons. AP III did not alter sodium excretion or RIHP in this group of rats. These results indicate that 1) an intact renal papilla and/or juxtamedullary nephron population may be required for the natriuretic effect of AP III; 2) the papillary injury 48 h after BEA is not sufficient to abolish the natriuretic response to AP III; and 3) elevations in RIHP may play a role in the natriuretic response to AP III.

Glycosaminoglycans of the rat renomedullary interstitium: Ultrastructural and biochemical observations

The rat renal papillary interstitium which contains abundant proteoglycans is a unique area important in renal function. These proteoglycans were studied ultrastructurally by ruthenium red fixation and staining and phosphate-buffered fixation before and after enzyme digestion. A tissue culture of rat renomedullary interstitial cells, the predominant cell of the renal papillary interstitium, was studied for its ability to synthesize proteoglycans and the proteoglycans were then analyzed. Tissue slices of whole rat renal inner medulla were also evaluated for their synthetic ability. In combination, these studies indicate that the dominant glycosaminoglycan is hyaluronic acid. The tissue culture of rat renal medullary interstitial cells synthesized glycosaminoglycans and on analysis, hyaluronic acid was found to be the cheif glycosaminoglycan secreted by the renomedullary interstitial cells. Combined with the removal of the proteoglycans from tissue by leech hyaluronidase and testicular hyaluronidase, this suggests that the dominant glycosaminoglycan is hyaluronic acid. Hyaluronic acid is also synthesized by the intact papilla confirming the findings with the tissue culture. However, in addition, sulfated glycosaminoglycans were also synthesized by the intact papilla, presumably the product of the noninterstitial components of the papilla.

Variation of membrane properties in hair cells isolated from the turtle cochlea.

1. Hair cells were enzymatically isolated from identified regions of the turtle basilar papilla and studied with the patch-electrode technique. The experimental aim was to relate the resonance properties seen during current injection to the membrane currents measured in the same cell under whole-cell voltage clamp. 2. Solitary hair cells had resting potentials of about -50 mV, and produced a damped oscillation in membrane potential at the onset and termination of a small current step; the resonant frequency varied from 9 to 350 Hz between cells, and was correlated with the region of papilla from which a cell had been isolated. The inferred frequency map was consistent with the tonotopic arrangement described previously in the intact papilla. 3. Depolarizations from the resting potential under voltage clamp activated a large net outward current with a steep voltage dependence, and the steady-state current-voltage relationship was strongly rectified about the resting potential. Input resistances tended to be smaller in cells with higher resonant frequencies, although there was no concurrent variation in membrane area as inferred from the cell capacitance. 4. The kinetics of the outward current evoked by a small depolarizing step depended upon the resonant frequency, fo, of the hair cell, and were slower in low-frequency cells. On repolarization to the resting potential the current decayed exponentially with a time constant that changed from 150 ms in the lowest-frequency cell to less than 1 ms in the highest-frequency one. The time constant was approximately proportional to 1/f0(2). 5. Following repolarization to different membrane potentials, the tail current was found to reverse around -80 mV, indicating that the outward current was due mainly to K+. 6. The outward current was abolished by extracellular application of 25 mM-tetraethylammonium chloride (TEA), or on exchange of Cs+ for K+ in the intracellular medium filling the recording electrode, each experiment supporting the contention that K+ is the major current carrier. Such treatments also removed the oscillations in membrane potential evoked by imposed current steps. 7. Addition of TEA or intracellular perfusion with Cs+ also revealed a fast inward current with an ionic sensitivity consistent with its being carried by Ca2+. Like the K+ current, the Ca2+ current was activated by small depolarization from the resting potential, and over this voltage range it was about five to ten times smaller than the K+ current. Its activation was more rapid than the fastest outward currents in high-frequency cells.(ABSTRACT TRUNCATED AT 400 WORDS)

Renal response to atrial natriuretic factor in rats without intact papillae.

In order to examine the contribution of renal papilla to atrial natriuretic factor (ANF)-induced diuresis, clearance studies were done in rats with intact papillae and bromoethylamine hydrobromide (BEA)-induced papillary necrosis. Papillary necrosis did not attenuate the diuretic and natriuretic response to ANF. In a moderately hydropenic state, urine flow and fractional water excretion were rather more increased in papillary necrosis rats than in papilla-intact ones. In a volume-expanded state, both groups had a similar diuretic response to ANF. Present data indicate that the existence of intact renal papilla is not essential for ANF-induced diuresis. Furthermore, it is suggested that absolute magnitude of ANF-induced diuresis may be dependent on its extrapapillary action(s).

Malignant esophagopulmonary fistula treated by fiberoptic intubation of a prosthesis

ously for decompression of the bile ducts in acute obstructive suppurative cholangitis caused by stones as well as for direct stone dissolution.1o In this case the endoscopic insertion of a nasobiliary tube through the intact papilla and drainage with slight suction led to a sufficient reduction of the biliary pressure so that the flow of bile through the abdominal drain stopped immediately and the fistula closed.

Endoscopic removal of common bile duct stones through the intact papilla after medical sphincter dilation

Recently, glyceryl trinitrate was shown to effectively dilate the smooth muscle of the sphincter of Oddi. This information was applied to endoscopic therapy of bile duct stones. In 21 patients a total of 32 common bile duct stones, 6–12 mm ( x¯ = 8.7 mm) in diameter, were removed through the intact sphincter after its medical dilation by administration of 1.2–3.6 mg glyceryl trinitrate. Thirty of 32 stones could be extracted without difficulty. The remaining two concrements had to be crushed by endoscopic mechanical lithotripsy before removal. No complications were observed during or after the procedure. Follow-up manometric examinations showed the papillary function to be well preserved. We therefore consider this new, safe, and easy method to be the treatment of choice for the removal of small- and medium-sized bile duct stones.

Effect of glyceryl trinitrate on the sphincter of Oddi motility and baseline pressure.

It is widely accepted that glyceryl trinitrate (GTN) effectively dilates the smooth muscles of blood vessels. A similar effect has been postulated on the smooth muscles in the gastrointestinal tract. In this study the motility of the sphincter of Oddi and the common bile duct pressure as determined by endoscopic manometry was investigated in nine patients before and after sublingual application of 1.2 mg GTN (nitro group). Eight untreated patients served as controls. Three minutes after application of GTN the papillary contraction amplitude decreased from 69.3 +/- 4.3 mmHg to 36.8 +/- 5.1 mmHg (p less than 0.005) and the papillary baseline pressure fell from 8.9 +/- 0.6 mmHg to 2.9 +/- 0.2 mmHg (p less than 0.005) respectively. The contraction frequency in the nitro group and all motility parameters in the control group remained unchanged. These results indicate that GTN does not influence the sphincter of Oddi motility, but it relaxes very effectively the sphincter of Oddi muscle. Thus, GTN should be taken into account for the treatment of biliary colic. In our endoscopic unit GTN proved to be useful as premedication for endoscopic examinations, particularly for the removal of small and medium size common bile duct stones through the intact papilla.

Endoscopic management of biliary calculi.

In a logical extension of the diagnostic capability of endoscopic retrograde cholangiopancreatography, a number of procedures have been developed to relieve biliary tract obstruction, with the indication for each depending mainly on stone size. Thus the smallest stones can be flushed or extracted through an intact papilla of Vater, larger ones after the papilla or sphincters are cut endoscopically. Clinical results are detailed.

The effect of papillectomy on renal function in the rat during hydropenia and after an acute saline load.

The effect of unilateral papillectomy on renal function in the rat was compared with the effect of partial nephrectomy which produced a similar decrease in glomerular filtration rate (G.F.R.) in the presence of an intact papilla. Under hydropenic conditions the kidney with papillectomy had a higher urine flow rate, sodium excretion rate, fractional sodium excretion, and osmolar clearance, while urine osmolality was lower. After an acute saline load the differences in sodium and water excretion disappeared, and fractional excretion of sodium and water were significantly higher in both types of kidney damage than in the contralateral control kidney. Free water reabsorption was lower in the papillectomized kidney after saline loading. Thus removal of the papilla resulted in abnormalities in the renal handling of salt and water which varied with the state of hydration of the animal and which were distinct from the effects of a reduction in G.F.R. by partial nephrectomy. It was concluded that the site of nephron loss, whether mainly in the renal medulla or in the cortex, may be another factor, in addition to G.F.R. and tubular reabsorption, which influences sodium and water excretion by the moderately damaged kidney.