Repeat Sphincterotomy Research Articles

Treatment of anal fissure: a survey of surgical practice in Australia and New Zealand.

The aim was to determine whether or not the clinical management of anal fissure in Australia and New Zealand accords with published guidelines. A comprehensive survey based on common clinical scenarios was distributed to 206 colorectal surgeons in Australia and New Zealand. The response rate was 44% (91 surgeons). For 19 topic areas, only seven (37%) reached consensus (defined as > 70% majority opinion). Of these, six (86%) agreed with guideline recommendations. Twelve (63%) topic areas demonstrated community equipoise (defined as less than or equal to 70% majority opinion), of which five (42%) agreed with guideline recommendations and seven (58%) disagreed with guidelines. Of the seven topics that disagreed with guidelines, three were based on moderate quality evidence (first line management of acute anal fissure in a young patient, fissure healing and faecal incontinence rates following anocutaneous flap) and four were based on low quality evidence (length of sphincter division during a lateral sphincterotomy in women, management of chronic low-pressure anal fissures postpartum, fissure healing rate following anoplasty with botulinum toxin or sphincterotomy and faecal incontinence rates following repeat sphincterotomy for recurrence). Consensus and/or agreement with guidelines were more prevalent in management when medical therapy failed. While areas of consensus mostly agreed with guideline recommendations, there remain many areas of community equipoise which warrant further research.

PD04-11 LONG TERM URODYNAMIC RESULTS FOLLOWING EXTERNAL SPHINCTEROTOMY IN SPINAL CORD INJURY PATIENTS

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Neurogenic Voiding Dysfunction I1 Apr 2018PD04-11 LONG TERM URODYNAMIC RESULTS FOLLOWING EXTERNAL SPHINCTEROTOMY IN SPINAL CORD INJURY PATIENTS Andrew Margules, Lawrence Lee, Whitney Smith, Mihir Shah, Alana Murphy, Akhil Das, and Patrick Shenot Andrew MargulesAndrew Margules More articles by this author , Lawrence LeeLawrence Lee More articles by this author , Whitney SmithWhitney Smith More articles by this author , Mihir ShahMihir Shah More articles by this author , Alana MurphyAlana Murphy More articles by this author , Akhil DasAkhil Das More articles by this author , and Patrick ShenotPatrick Shenot More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.289AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES External sphincterotomy is a commonly employed to allow safe, simple urologic management of spinal cord injured (SCI) males. Long-term outcome data following external sphincterotomy is limited. We evaluated the long-term results of primary external sphincterotomy using urodynamic and clinical endpoints. METHODS Ninety seven SCI (85 quadriplegic, 12 paraplegic) male patients with Neurogenic detrusor overactivity (NDO) and detrusor-external sphincter dyssynergia (DESD) underwent Nd:Yag laser sphincterotomy between 1992 and 2000. 73 patients (mean age 27.6 years) with yearly follow-up urodynamic studies of at least 5 years were included in this study. Mean clinical and urodynamic follow-up is 14.8 years. RESULTS Voiding pressure remained <50 cm H2O in 84 % (57/73), 81% (27/36) %, and 80% (23/29) of patients at 5, 10, and 15 years respectively. Post-void residual (PVR) begins to significantly increase approximately five years following spincterotomy without an associated increase in voiding pressure. Recurrent sphincter obstruction was seen in 10% (7/73) patients prompting repeat sphincterotomy. Clinical and urodynamic findings suggestive of impaired detrusor contractility was noted in 21% (15/73), 33% (12/36), and 59% (17/29) of patients at 5, 10 and 15 years following initial sphincterotomy. In addition, 41 % (30/73) were on either intermittent catheterization, or had an indwelling catheter. Hydronephrosis was present in 7% (5/73) patients at the time of the initial procedure and resolved after sphincterotomy. No patient developed recurrent hydronephrosis during the follow-up period. CONCLUSIONS Although voiding pressures and upper tracts remains stable following laser external sphincterotomy, PVR is seen to steadily increase beginning approximately five years following the procedure indicating a trend toward impaired detrusor contractility that accounts for the majority of failures. Patients should be counseled that external sphincterotomy is associated with significant long term failure rates. Further studies are needed to define the natural history of bladder dysfunction in SCI to determine whether this finding of progressive detrusor underactivity occurs in untreated patients who reflexively void. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e81-e82 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Andrew Margules More articles by this author Lawrence Lee More articles by this author Whitney Smith More articles by this author Mihir Shah More articles by this author Alana Murphy More articles by this author Akhil Das More articles by this author Patrick Shenot More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Mo1299 Endoscopic Papillary Large Balloon Dilation Can Reduce the Re-Recurrence Rate in Patients With Recurrent Bile Duct Stones, Compared With Repeat Sphincterotomy

Endoscopic sphincterotomy (EST) is used as a standard method for treating common bile duct (CBD) stones. EST carries a substantial risk of recurrent CBD stones (4-24%). Also, the re-recurrence rate (36%) is higher than the recurrence rate after EST. However, there is no established endoscopic procedure to decrease the re-recurrence of CBD stones. In a few publications, endoscopic papillary large balloon dilation (EPLBD) alone seemed to be a feasible and safe technique for the treatment of recurrent stones in patients with previous EST.

Is the Complication Rate the Same for Index Versus Repeat Biliary Sphincterotomy?

Introduction: Much has been written about the complication rate related to biliary sphincterotomy. These reports have primarily included only patients undergoing initial biliary sphincterotomy. There are limited data regarding the outcome in patients undergoing repeat biliary sphincterotomy. Patients and Methods: From 1/2000 to 9/2003, 1210 ERCP were performed for indications of biliary disease. Of these, 842 pts underwent biliary sphincterotomy. There were 299 men, 543 women, mean age 58 years. Of these, 372 (44.2 %) were repeat procedures performed for recurrence or incomplete treatment of biliary disease requiring biliary sphincterotomy. Of these, 75 were men and 297 were women, mean age 53 years. Indications for sphincterotomy included: choledocholithiasis in 477, biliary pancreatitis in 42, bile duct stricture in 231, ampullary adenoma in 7, polycystic liver disease in 2 and bile leak in 43 and sphincter of Oddi dysfunction in 40. Of the 372 patients with recurrent or incomplete treatment of biliary disease, indications included: choledocholithiasis in 229, biliary pancreatitis in 6, bile duct stricture in 92, bile leak in 17, SOD in 28. Of the repeat procedures, 287of the index biliary sphincterotomies were performed at another institution. All procedures performed at our institution were done using 30 mm cutting wire sphincterotomes with a 5 mm tip. Sphincterotomies were performed with a cut-to- coagulation ration of 2 to 1. All procedures were performed by experienced biliary endoscopists. Results: Of the 470 pts with index biliary sphincterotomy, complications included acute pancreatitis in 26 pts (5.5%), perforation in 5 (1%), bleeding in 8 (1.7%), aspiration pneumonia in 1 (0.01%). Of the patients with repeat biliary sphincterotomy, complications included: acute pancreatitis in 3 (1%), perforation in 29 (8%), and bleeding in 19 (5%). There was no mortality in either group. Conclusions: 1.The complication rate after biliary sphincterotomy differs between index and repeat procedures; 2.The incidence of perforation and bleeding is significantly increased after repeat sphincterotomy; 3. Acute pancreatitis is significantly decreased as a complication after repeat biliary sphincterotomy; 4. Technical modifications are needed to decrease (hopefully abolish) these complications; 5. A prospective multicenter study with a larger number of patients is warranted.

Safety of extension of a previous endoscopic sphincterotomy: a prospective study

Objectives Data in the literature regarding complication risks after the extension of a previous endoscopic biliary sphincterotomy (repeat endoscopic biliary sphincterotomy) are limited and controversial. To explore this issue, we prospectively studied complications after repeat sphincterotomy and compared them with those of biliary endoscopic sphincterotomy in consecutive patients with choledocholithiasis. Methods A total of 250 patients underwent endoscopic biliary sphincterotomy and 81 underwent extension of a previous one. All patients had choledocholithiasis and were enrolled using specific criteria, excluding parameters predisposing to increased postsphincterotomy complications. Results The overall complication rate was 2.46% in the repeat sphincterotomy and 8.4% in the sphincterotomy group ( p > 0.05). Complications for the repeat sphincterotomy and initial sphincterotomy groups, respectively, were as follows: bleeding, 2.46% and 2.8%; pancreatitis, 0% and 4.8% ( p < 0.05); cholangitis, 0% and 0.4%; perforation, 0% and 0.4%; and hyperamylasemia, 3.7% and 12.8% ( p < 0.05). There were no deaths. Bleeding episodes in the former group occurred when repeat sphincterotomy was performed early after the primary one. Conclusions Repeat sphincterotomy is a safe technique for the treatment of patients with choledocholithiasis and seems to be as safe as initial sphincterotomy. It is not associated with increased hemorrhage risk. There is a trend toward a higher risk of hemorrhage when repeat sphincterotomy is performed early. Repeat sphincterotomy is safer than the initial sphincterotomy with respect to pancreatic complications.

Safety of extension of a previous endoscopic sphincterotomy: a prospective study.

Data in the literature regarding complication risks after the extension of a previous endoscopic biliary sphincterotomy (repeat endoscopic biliary sphincterotomy) are limited and controversial. To explore this issue, we prospectively studied complications after repeat sphincterotomy and compared them with those of biliary endoscopic sphincterotomy in consecutive patients with choledocholithiasis. A total of 250 patients underwent endoscopic biliary sphincterotomy and 81 underwent extension of a previous one. All patients had choledocholithiasis and were enrolled using specific criteria, excluding parameters predisposing to increased postsphincterotomy complications. The overall complication rate was 2.46% in the repeat sphincterotomy and 8.4% in the sphincterotomy group (p > 0.05). Complications for the repeat sphincterotomy and initial sphincterotomy groups, respectively, were as follows: bleeding, 2.46% and 2.8%; pancreatitis, 0% and 4.8% (p < 0.05); cholangitis, 0% and 0.4%; perforation, 0% and 0.4%; and hyperamylasemia, 3.7% and 12.8% (p < 0.05). There were no deaths. Bleeding episodes in the former group occurred when repeat sphincterotomy was performed early after the primary one. Repeat sphincterotomy is a safe technique for the treatment of patients with choledocholithiasis and seems to be as safe as initial sphincterotomy. It is not associated with increased hemorrhage risk. There is a trend toward a higher risk of hemorrhage when repeat sphincterotomy is performed early. Repeat sphincterotomy is safer than the initial sphincterotomy with respect to pancreatic complications.

Sphincterotomy-associated biliary strictures: Features and endoscopic management

Background: “Sphincterotomy stenosis” is a recognized late complication of endoscopic biliary sphincterotomy. The narrowing is limited to the biliary orifice and can be managed simply by repeat sphincterotomy. A similar but poorly characterized post-sphincterotomy complication involves narrowing that extends from the biliary orifice for a variable distance along the bile duct, beyond the duodenal wall. This lesion cannot be managed by repeating the sphincterotomy. Methods: Six patients (3 men) are described with sphincterotomy associated biliary strictures, all smooth and high grade, presenting at a median of 19 months (range 8 to 60 months) after sphincterotomy. Further sphincterotomy was not possible as an intra-duodenal segment of bile duct was no longer visible. Endoscopic management consisted of serial incremental stent exchange at 2- to 4-month intervals. The goal of therapy was to place two 11.5F stents side-by-side. Results: Stricture resolution was documented by cholangiography in all patients. One patient with a stricture resistant to treatment required three 10F stents side-by-side, and another underwent treatment to a maximum of adjacent 11.5F and 7F stents. Two 11.5F stents were eventually placed in the other four patients. Overall median duration of stent placement was 12.5 months. At a median of 26.5 months of stent-free follow-up, all patients remain asymptomatic. Conclusion: Sphincterotomy-associated biliary strictures are a distinct late complication of biliary sphincterotomy. These recalcitrant lesions are not amenable to repeat sphincterotomy; however, the results of this study suggest that they may be managed successfully by serial placement of stents of incrementally increasing diameter. (Gastrointest Endosc 2000;52:494-9).

Quality of Life after Active Urological Management of Chronic Spinal Cord Injury in Eastern Taiwan

Objective: Motor cycle accidents are the major cause of head injury and spinal cord injury (SCI) in Taiwan. The incidence of SCI in Hualien county is the highest in the world. In a community hospital in Hualien, active urological management was carried out for SCI patients with voiding dysfunctions and urological complications. This study was conducted to assess the success of active urological management. Methods: From 1988 to 1996, in the urological department, 251 SCI patients with varying voiding dysfunctions or urological complications were managed with various surgical or nonsurgical procedures according to their underlying pathologies. The satisfaction rate and quality of life index were assessed before and after active urological treatment. Results: There were 118 patients with cervical SCIs, 93 patients with thoracic or lumbar SCIs, and 40 patients with sacral SCIs or infrasacral neuropathy. After initial managements, 174 patients were able to pass urine by themselves, by clean intermittent self-catheterization (CISC) or with an indwelling Foley catheter. The remaining 77 patients suffering from severe dysuria, urinary incontinence, hydronephrosis and frequent urinary tract infections were managed with various surgical procedures. The procedures included external sphincterotomy (n = 30), enterocystoplasty (n = 28), autoaugmentation (n = 6), continent urinary diversion (n = 7), periurethral Teflon injection (n = 3), and transurethral resection of the prostate (n = 3). After treatment, hydronephrosis resolved in 100% of the kidney units; frequent symptomatic urinary tract infection improved in 83.3% after external sphincterotomy and 75% after enterocystoplasty and continent diversion; while urinary incontinence disappeared or improved in 93% after enterocystoplasty and autoaugmentation. The total satisfaction rate was 84.4% after the surgical procedures. The mean quality of life index improved from –1.27 ± 0.39 to +1.54 ± 0.38 after management. However, some complications such as mucus secretion (76.5%), abdominal pain (20.6%), loose stool (23.5%) and frequent stone formation (11.8%) still bothered the patients undergoing enterocystoplasty and continent diversion. Repeat sphincterotomy was necessary in 16.7% of patients, and 50% were not satisfied with total incontinence after external sphincterotomy. During the follow-up period, 87% of all patients had ≥1 yearly episode of urinary tract infection after spinal injury and 11 patients died of urosepsis. Conclusions: Active urological management to improve quality of life and to treat urological complications in SCI patients is mandatory. After long-term follow-up, SCI patients can be free of indwelling catheters, hydronephrosis usually resolves and urinary tract infections are infrequent.

Long-term follow-up of sphincterotomy in the treatment of autonomic dysreflexia.

Autonomic dysreflexia (AD) is a syndrome affecting a majority of patients with high spinal cord lesions. An association between AD and detrusor-sphincter dyssynergia (DSD) is often seen. Between 1980 and 1988 we performed 51 transurethral sphincterotomies in 38 patients. Twelve of these patients underwent procedures primarily for the prevention of AD related to bladder distension. This study presents their long-term follow-up. One patient was lost to follow-up secondary to unrelated death; the remaining 11 patients were followed on average 117.5 months (94-154) after the initial operative procedure. Repeat sphincterotomy was required in 9 of 11 patients (82%). Six (66%) of these were performed within 24 months. One patient (11%) required delayed sphincterotomy greater than 100 months from the initial procedure. Overall, sphincterotomy was successful in controlling symptoms of AD in 10 of 11 (91%) patients. No major complications were recorded. Sphincterotomy is a safe and effective treatment for AD associated with DSD, however long-term urologic follow-up and management are necessary.

Postendoscopic Sphincterotomy Stenosis

We report on two patients. The first patient is a 62-year-old female patient who had cholecystectomy in 1970, and in whom two small bile duct stones were removed after endoscopic sphincterotomy in 1987. Within two months of this procedure, she developed three episodes of documented acute pancreatitis. The other patient, a 58-year-old female, developed acute pancreatitis three months after an endoscopic sphincterotomy for stones in the common bile duct. In both patients, ERCP revealed a cicatricial stenosis of the common bile duct and the pancreatic duct. The condition was resolved by repeat sphincterotomy. The first patient needed repeated endoscopic insertion of bilioduodenal endoprostheses and an endoprosthesis in the pancreatic duct. It is interesting to note that, in contrast to surgical reports, very few postpapillotomy stenoses are reported by endoscopists.