Noncalculous Obstruction Research Articles

Transduodenal sphincteroplasty for sphincter of Oddi dysfunction

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.

The effect of adding gentamicin to contrast media for prevention of cholangitis after biliary stenting for non-calculous biliary obstruction, a randomized controlled trial

Cholangitis is the most common infectious complication of ERCP. In vitro studies showed that addition of aminoglycosides to contrast medium was effective in reducing cholangitis but the results of clinical trials are conflicting. We studied the effect of adding gentamicin to contrast medium in reducing the rate of post-ERCP cholangitis in patients with non-calculous obstructive jaundice. All patients with non-calculous obstructive jaundice who underwent endoscopic biliary stenting at the Shariati Hospital, Tehran, between December 2009 and October 2010 were enrolled in the study. Gentamicin (10mg) or distilled water was added to each 10cc contrast medium during ERCP. Intravenous antibiotics were administered before and after the procedure in all patients. After ERCP and stent deployment, patients were followed for 72h for symptoms and signs of cholangitis. A total of 114 patients were eligible for the study. Of these, 57 patients were included in each group. Cholangiocarcinoma was the most prevalent diagnosis. The obstruction was relieved in all patients by stenting. Five patients in each group (8.8%) developed cholangitis. There was no significant difference in the incidence of cholangitis between the two groups (p = 1.000). With adequate drainage of the obstructed biliary tract by proper stenting, adding gentamicin to contrast media had no significant effect on incidence of post-ERCP cholangitis.

Sphincter of oddi dysfunction

Sphincter of Oddi dysfunction (SOD) is a benign noncalculous obstruction of bile or pancreatic drainage at the level of the sphincter of Oddi. The disorder is clinically associated with either biliary pain or idiopathic pancreatitis, depending on the portion of the sphincter affected. Patients with suspected SOD are subdivided into three categories: these are type I, II, and III, depending on associated clinical evidence for the diagnosis. Multiple noninvasive tests have been utilized to aid in the diagnosis but have been complicated by poor sensitivity and specificity. Sphincter of Oddi manometry is the gold standard for confirming the diagnosis, although questions remain about its sensitivity and specificity. Sphincterotomy of the affected portion of the sphincter is the treatment of choice and has been shown effective for palliation of symptoms in two sham-controlled studies of patients with suspected type II biliary SOD.

The effect of CT urography in the diagnosis of non-calculous urinary obstruction diseases

Objective To evaluate the diagnostic effect of CT urography (CTU) in patients with non-calculous obstructive diseases of urinary tract.Methods Forty cases with non-calculous urinary obstruction underwent helical CT during nephrographic and excretory phases.Three dimensional CTU was obtained with the reconstruction of excretory phase axial images through the workstation.Results 24 of 40 cases with benign obstruction had a slight or severe urinary dilation.Among them,18 congenital urinary malformations showed specific findings.Four ureteric inflammations revealed a gradual taper of the lumen just like a beak,and another two prostatic hypertrophy appeared oval impression upon the middle of the posterior bladder.Six intrinsic and 10 extrinsic tumors were seen irregular filling defects of the urinary tracts as well as soft tissue mass surrounding the obstructive site,accompanied by the middle urinary dilation in 12 cases and severe in four.Meanwhile,bilateral ureterohydronephroses were also found in four extrinsic tumors.In six patients with unilateral nonfunctioning urinary tracts,CTU could be imaged with minimum intensity projection (MinIP) and then be merged with contralateral maximum intensity projection (MaxIP).Conclusion CTU is an effective modality in the evaluation of non-calculous urinary obstruction diseases.

DIAGNOSIS OF URETERAL OBSTRUCTION IN PATIENTS WITH COMPROMISED RENAL FUNCTION: THE ROLE OF NONINVASIVE IMAGING MODALITIES

We compared the role of noncontrast computerized tomography (NCCT), magnetic resonance urography (MRU), and combined abdominal radiography (KUB) and ultrasonography (US) in the diagnosis of the cause of ureteral obstruction in patients with compromised renal function. The study included 149 patients, of whom 110 had bilateral obstruction and 39 had obstruction of a solitary kidney. Therefore, the total number of renal units was 259. All patients had renal impairment with serum creatinine greater than 2.5 mg/dl. Besides conventional KUB and US all patients underwent NCCT and MRU. The gold standard for diagnosis of the cause of obstruction included retrograde or antegrade ureterogram, ureteroscopy and/or open surgery. The sensitivity, specificity and overall accuracy of NCCT, MRU, and combined KUB and US in the diagnosis of ureteral obstruction were calculated in comparison with the gold standard. The definitive cause of ureteral obstruction was calculous in 146 and noncalculous in 113 renal units, including ureteral stricture in 65, bladder or ureter in 43, extraurinary collection in 3 and retroperitoneal fibrosis in 2. The site of stone impaction was identified by NCCT in all 146 renal units (100% sensitivity), by MRU in 101 (69.2% sensitivity), and by combined KUB and US in 115 (78.7% sensitivity) with a difference of significant value in favor of NCCT (p <0.001). Ureteral strictures were identified by NCCT in 18 of the 65 cases (28%) and by MRU in 54 of 65 (83%). Bladder and ureteral tumors causing ureteral obstruction could be diagnosed in approximately half of the patients by NCCT (22 of 43) and in all except 1 by MRU (42 of 43). NCCT and MRU could identify all extraurinary causes of obstruction. Overall of the 113 kidneys with noncalculous obstruction the cause could be identified by MRU in 101 (89% sensitivity), by NCCT in 45 (40% sensitivity), and by combined KUB and US in only 20 (18% sensitivity) with a difference of significant value in favor of MRU (p <0.001). In patients with renal impairment due to ureteral obstruction NCCT has superior diagnostic accuracy for detecting calculous causes of obstruction but MRU is superior for identifying noncalculous lesions.

A prospective, randomized clinical investigation ofcholecystoenterostomy and choledochoenterostomy

A prospective, randomized clinical trial was conducted to assess the efficacy of bilioenteric bypass in noncalculous distal biliary obstruction. Thirty-one patients required bypass for either malignant obstruction or chronic pancreatitis and were randomized into two groups: cholecystoenterostomy or choledochoenterostomy with cholecystectomy. Nine bypasses failed after cholecystoenterostomy and two after choledochoenterostomy (p less than 0.04). Eight of the 9 failures occurred in the subgroup of 22 patients with malignant biliary obstruction. In this subgroup, five bypasses failed within 90 days of operation, all after cholecystoenterostomy (p = 0.03 compared with choledochoenterostomy). The results indicate that choledochoenterostomy is the superior operation for malignant distal biliary obstruction. Additional studies will be necessary to identify the procedure of choice for benign noncalculous obstructions.

Complicated Recurrent Noncalculous Obstruction at the Ureteropelvic Junction in a Solitary Kidney

Complicated Recurrent Noncalculous Obstruction at the Ureteropelvic Junction in a Solitary Kidney

Intubated Ureterotomy: Experimental Work and Clinical Results

Intubated Ureterotomy: Experimental Work and Clinical Results