Sphincter Of Oddi Dysfunction Type Research Articles

The efficacy and safety of endoscopic sphincterotomy in patients with Sphincter of Oddi dysfunction: a systematic review and meta-analysis.

Sphincter of Oddi dysfunction (SOD) has been used to describe patients with RUQ abdominal pain without an etiology. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of ES (endoscopic sphincterotomy) for SOD. The study methodology follows the PRISMA guidelines. A comprehensive search was conducted using MEDLINE and EMBASE databases for RCTs with ES in patients with SOD. The primary outcome assessed was the improvement of abdominal pain after ES/sham. A random effects model was used to calculate pooled estimates for each outcome of interest. Of the initial 55 studies, 23 were screened and thoroughly reviewed. The final analysis included 3 studies. 340 patients (89.7% women) with SOD were included. All patients had a cholecystectomy. Most included patients had SOD type II and III. The pooled rate of technical success of ERCP was 100%. The average clinical success rate was 50%. The pooled cumulative rate of overall AEs related to all ERCP procedures was 14.6%. In the sensitivity analysis, only one study significantly affected the outcome or the heterogeneity. ES appears no better than placebo in patients with SOD type III. Sphincterotomy could be considered in patients with SOD type II and elevated SO basal pressure.

The presence and outcome of biliary sphincter disorders in liver-transplant recipients according to the Rome IV classification.

BackgroundBiliary sphincter disorders after liver transplantation (LT) are poorly described. We aim to describe the presence and outcome of patients with papillary stenosis (PS) and functional biliary sphincter disorders (FBSDs) after LT according to the updated Rome IV criteria.MethodsWe reviewed all endoscopic retrograde cholangiopancreatographies (ERCPs) performed in LT recipients between January 2003 and December 2019. Information on clinical and endoscopic findings was obtained from electronic health records and endoscopy databases. Laboratory and clinical findings were collected at the time of ERCP and 1 month after ERCP.ResultsAmong the 1,307 LT recipients, 336 underwent 849 ERCPs. Thirteen (1.0%) patients met the updated Rome IV criteria for PS [former sphincter of Oddi dysfunction (SOD) type I] and 14 patients (1.0%) met the Rome IV criteria for FBSD (former SOD type II). Biliary sphincterotomy was performed in 13 PS and 10 FBSD cases. One month after sphincterotomy, bilirubin, gamma-glutamyl transferase and alkaline phosphatase levels decreased in 85%, 61%, and 92% of those in the PS group (P = 0.019, 0.087, and 0.003, respectively) and in 50%, 70%, and 80% of those in the FBSD group (P = 0.721, 0.013, and 0.093, respectively). All the 14 patients initially suspected of having a FBSD turned out to have a different diagnosis during the follow-up.ConclusionsPS after LT is uncommon and occurs in only 1% of LT recipients. Our data do not support the presence of an FBSD after LT. Sphincterotomy is a safe and effective procedure in LT recipients with PS.

Disfunción del esfínter de Oddi: un reporte de caso

La disfunción del esfínter de Oddi es un síndrome clínico causado por una enfermedad funcional (discinesia) o estructural (estenosis). La prevalencia estimada de disfunción del esfínter de Oddi en la población en general es del 1 %; aumentando a 20 % para pacientes con dolor persistente posterior a colecistectomía y a 70 % en pacientes con pancreatitis aguda recurrente idiopática. Se caracteriza clínicamente por la presencia de dolor abdominal, similar al cólico biliar o dolor tipo pancreático en ausencia de patología biliar orgánica; así como en pacientes con pancreatitis recurrente idiopática asociada con elevación de enzimas pancreáticas o hepáticas, y dilatación del conducto biliar o pancreático. El tratamiento para la disfunción del esfínter de Oddi tipo I se basa en la realización de esfinterotomía endoscópica, pero existe controversia en el manejo de la disfunción del esfínter de Oddi tipo II y III. En este artículo se presenta el caso clínico de una paciente de 67 años con antecedente de colecistectomía por laparotomía. Después del procedimiento quirúrgico refirió un dolor abdominal de predominio en el hipocondrio derecho tipo cólico asociado con emesis de características biliares. En el reporte de colangiorresonancia se encontró una ligera dilatación de la vía biliar intrahepática y gammagrafía con ácido iminodiacético hepatobiliar (HIDA) diagnóstica de disfunción del esfínter de Oddi. Se realizó una esfinterotomía endoscópica. En el seguimiento, dos años después, la paciente se encontraba asintomática con la disfunción del esfínter de Oddi resuelta.

The Next EPISOD: Trends in Utilization of Endoscopic Sphincterotomy for Sphincter of Oddi Dysfunction from 2010-2019

For years, the endoscopic management of the disorder formerly known as Type III Sphincter of Oddi Dysfunction (SOD) had been controversial. In 2013, the results of the Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction (EPISOD) trial demonstrated that there was no benefit associated with endoscopic sphincterotomy for patients with Type III SOD. We aimed to assess the utilization of endoscopic sphincterotomy for patients with SOD in a large population database from 2010-2019. We searched a large electronic health record (EHR)-based dataset incorporating over 300 individual hospitals in the United States (Explorys, IBM Watson health, Armonk, NY). Using Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) we identified patients with a first-ever diagnosis of "disorder of Sphincter of Oddi" annually from 2010-2019. Subclassification of SOD types was not feasible using SNOMED-CT codes. Stratified by year, we identified the proportion of patients with newly-diagnosed SOD undergoing endoscopic sphincterotomy and those receiving newly-prescribed medical therapy. A total of 39,950,800 individual patients were active in the database with 7,750 index diagnoses of SOD during the study period. The incidence rates of SOD increased from 2.4 to 12.8 per 100,000 persons from 2010-2019 (P < .001). In parallel, there were reductions in the rates of biliary (34.3% to 24.5%) and pancreatic sphincterotomy (25% to 16.4%), respectively (P < .001). Sphincter of Oddi manometry (SOM) was infrequently utilized, <20 times in any given year, throughout the study duration. There were no significant increases in new prescriptions for TCAs, nifedipine, or vasodilatory nitrates. Among a wide range of practice settings which do not utilize routine SOM, a sudden and sustained decrease in rates of endoscopic sphincterotomy for newly-diagnosed SOD was observed beginning in 2013. These findings highlight the critical importance of high-quality, multi-center, randomized controlled trials in endoscopy to drive evidence-based changes in real-world clinical practice.

Clinical features and management of painless biliary type sphincter of Oddi dysfunction.

ObjectiveThe objective of this study was to clarify the characteristics and management of painless biliary type sphincter of Oddi dysfunction (SOD).MethodsFrom June 2002 to July 2018, 12 patients who had recurrent liver dysfunction with a dilated bile duct or acute cholestasis of unknown cause without biliary pain (painless SOD) were included in this study. These patients’ characteristics were compared with those of 36 patients with biliary type SOD based on the conventional definition (criteria-based SOD).ResultsPatients with painless SOD had significantly more prominent bile duct dilation than patients with criteria-based SOD (13.9 vs. 12.2 mm, respectively). Prophylactic biliary drainage was performed significantly more often in patients with painless SOD than criteria-based SOD (67% vs. 11%, respectively). The short-term effectiveness rate of endoscopic sphincterotomy, the symptom recurrence rate, and the incidence of adverse events were not significantly different between the two groups.ConclusionsPainless SOD is a specific subtype of biliary SOD that causes recurring liver dysfunction or acute cholestasis without biliary pain. Endoscopic sphincterotomy was effective in the present study, but the relapse rate was as high as that in typical SOD.

Modern concepts of sphincter of Oddi pancreatic dysfunction

History of study of the sphincter of Oddi (SO) is presented in a detail in the article, attention is paid to the anatomical and functional relationships of SO with the gallbladder, duodenum and pancreas. The role of SO dysfunction in the pathogenesis of pancreatitis and biliary dysfunction is described in detail, previous and modern ideas about SO pancreatic disfunction are considered. The historical features of the introduction of the term “dyspancreatism” are given, the clinical peculiarities and periods of its occurrence are listed, the pathogenetic relationship of dyspancreatism with other functional disorders, including functional dyspepsia, is described. Provisions of the IV Roman consensus are considered, confirming the relationship of pancreatic dysfunction with the occurrence of pancreatic pain and pancreatitis itself. The criteria for the diagnostics of pancreatic type SO dysfunction, formulated in the modern Rome recommendations for the diagnosis and treatment of functional gastroenterological disorders, are presented. Standard and alternative diagnostic tests are listed, which conduction will confirm the SO dysfunction. Modern approaches to the treatment of SO dysfunction are analyzed, focusing on the use of invasive treatment methods, the advantages and disadvantages of biliary and pancreatic sphincterotomy are revealed, the inexpediency of performing the endoscopic retrograde cholangiopancreatography in patients with single episode of idiopathic acute pancreatitis is proved. The need for a balanced and cautious approach to the use of invasive methods for the treatment of SO dysfunction is emphasized; prospects for further study of the pathology of this sphincter are described.

Sphincter of Oddi dysfunction: sphincter of Oddi dysfunction or discordance? What is the state of the art in 2018?

To review important manuscripts published over the previous 2 years relative to sphincter of Oddi dysfunction (SOD). The long-term outcomes of the Evaluating Predictors and Interventions of SOD (EPISOD) trial further substantiated results from the initial EPISOD study, reinforcing that neither endoscopic retrograde cholangiopancreatography-manometry nor endoscopic sphincterotomy are appropriate for SOD type III. Pain management in the latter patients has reverted to neuromodulating agents, and recent studies have suggested a role for duloxetine and potentially acupuncture. The functional role of the sphincter of Oddi has been reiterated with a report demonstrating a higher clinically significant pancreatic fistula rate in distal pancreatectomy patients treated with higher doses of postoperative narcotics. Moreover, the injection of periampullary botulinum toxin preoperatively has been shown to decrease these fistulas in a pilot trial. Additional studies have reinforced that eluxadoline can cause sphincter of Oddi spasm and pancreatitis. In contrast to approaching patients with acute relapsing pancreatitis using endoscopic retrograde cholangiopancreatography and manometry, previous and current studies suggest that endoscopic ultrasound should be done first and the role of SOD in idiopathic acute relapsing pancreatitis remains controversial. Finally, there remain widespread disparities in practice patterns in the approach to patients currently classified as SOD type II. In contrast to historical manuscripts which stress the classical definitions of three types of SOD and their consequences, more recent manuscripts on this topic have focused on improving surgical outcomes based on the physiologic role of sphincter of Oddi, as well as the pharmacologic causes and treatments of SOD. The simplistic view that SOD, however it has been diagnosed, requires biliary or dual sphincterotomy is just that, simplistic and potentially misguided.

Post-ERCP biliary complications in patients with biliary type sphincter of Oddi dysfunction

Sphincter of Oddi dysfunction (SOD) has a high risk of post-ERCP pancreatitis. Cholangitis, colicky pain, and jaundice from cholestasis also occur after ERCP. However, these post-ERCP biliary complications have not been sufficiently evaluated in SOD. Thus, the risk factors and post-ERCP biliary complications in biliary-type SOD were evaluated. From December 1996 to January 2017, 72 patients with suspected biliary-type SOD were selected, and 60 patients who underwent ERCP were included in this study. The incidence of biliary complications compared to control group and factors associated with post-ERCP cholangitis were investigated. More frequent biliary complications, including biliary pain and abnormal liver function, occurred in SOD group than in control group, especially in type I SOD patients. Post-ERCP cholangitis occurred significantly more often with bile duct diameter ≥12 mm (26%, 5/19) than with bile duct diameter <11 mm (2.4%, 1/41; p = 0.016). Age ≥75 years was also a risk factor for post-ERCP cholangitis (p = 0.013). Multivariate analysis confirmed that bile duct diameter ≥12 mm was a significant risk factor for post-ERCP cholangitis. Post-ERCP biliary complications occurred frequently in biliary-type SOD, especially type I. Biliary diameter ≥12 mm was an important risk factor for post-ERCP cholangitis.

Sa1410 Outcomes of Endoscopic Sphincterotomy for Sphincter of Oddi Dysfunction Type III: 1 and 3 Year Data

Sa1410 Outcomes of Endoscopic Sphincterotomy for Sphincter of Oddi Dysfunction Type III: 1 and 3 Year Data

Gallbladder and Sphincter of Oddi Disorders

The concept that motor disorders of the gallbladder, cystic duct and sphincter of Oddi can cause painful syndromes is attractive and popular, at least in the USA. However, the results of commonly performed ablative treatments (cholecystectomy and sphincterotomy) are not uniformly good. The predictive value of tests that are often used to diagnose dysfunction (dynamic gallbladder scintigraphy and sphincter manometry) is controversial. Evaluation and management of these patients is made difficult by the fluctuating symptoms and the placebo effect of invasive interventions. A recent stringent study has shown that sphincterotomy is no better than sham treatment in patients with post-cholecystectomy pain and little or no objective abnormalities on investigation, so that the old concept of sphincter of Oddi dysfunction (SOD) type III is discarded. ERCP approaches are no longer appropriate in that context. There is a pressing need for similar prospective studies to provide better guidance for clinicians dealing with these patients. We need to clarify the indications for cholecystectomy in patients with Functional Gallbladder Disorder (FGBD) and the relevance of sphincter dysfunction in patients with some evidence for biliary obstruction (previously SOD type II, now called "Functional Biliary Sphincter Disorder - FBSD") and with idiopathic acute recurrent pancreatitis.

Mo1403 Gastrojejunal Tube Feeding: a Potential New Treatment for Sphincter of Oddi Dysfunction Type III (SODPPP) Patients With Severe Post-Prandial Pain

Mo1403 Gastrojejunal Tube Feeding: a Potential New Treatment for Sphincter of Oddi Dysfunction Type III (SODPPP) Patients With Severe Post-Prandial Pain Tae Joo Jeon*, Byung Kyu Park, Laith H. Jamil, Simon K. Lo Cedars-Sinai Medical Center, Los Angeles, CA; Division of Gastroenterology, Inje University Sanggye Paik Hospital, Seoul, Korea (the Republic of); Division of Gastroenterology, National Health Insurance Service Ilsan Hospital, Goyang-si, Korea (the Republic of) Background: ERCP and Sphincterotomy had been widely used to evaluate and treat the Sphincter of Oddi dysfunction (SOD) type III condition until their benefit was disputed by the recent EPISOD study. Unfortunately, there is no proposed alternative to manometry-directed sphincterotomy at the present moment. Aim: To determine if gastrojejunal tube (PEGJ) feeding may have therapeutic benefits for SODPPP patients. Method: All SODPPP patients without sustained improvement after bi-ductal sphincterotomies were offered percutaneous endoscopic gastrostomy-jejunostomy tube (PEGJ) feeding. SOD III was defined by pancreatic or biliary type pain without a dilated duct or abnormal pancreatic or liver tests. PEGJ was placed in the usual fashion and inserted into the proximal antrum. PEGJ’s tip location in the proximal jejunum was confirmed with fluoroscopy. Strict NPO was kept within the first 4-6 weeks. PEGJ feeding was maintained as long as these patients needed feeding to provide nutrition or pain relief. Results: Nine highly symptomatic SODPPP patients underwent PEGJ tube insertion for feeding. All were female. Median age was 41 years old (25-53). Median duration of SOD symptoms was 27 months (22-96). All but one patient had elevated pancreatic or biliary sphincter pressure. Only one patient did not have a prior cholecystectomy. Eight patients had sphincterotomy and experienced pain improvement for a short duration (median; 8 weeks) before recurrence of symptoms. The mean duration of tube feeding was 5.08 months (S.E 1.83). Seven patients reported dramatic pain improvement. Six had less number of hospitalizations or ER visits after PEGJ feeding. Five patients were satisfied with the procedure and could return to normal daily activities while on tube feeding. Only 1 patient was not satisfied because of the lack of effectiveness. The demand of analgesics was decreased in 5 patients. Complications included prolonged tube insertion site pain-2, pinkish drainage-1, and nausea-1. Persistent insertion site pain was the reason for tube removal on day 7 in on patient. There were 4 tube malfunctions (J-tube dislodgement-2, tube coiling-1, broken tube-1). PEGJ had since been removed in 5 patients (no benefit-1, dramatic clinical improvement-1, husband’s disagreement-1, unsightly catheter-1, insertion site pain1). Interestingly, those 2 patients who had tube removal due to personal issues eventually requested PEGJ re-insertion. Conclusion: PEGJ feeding may have therapeutic benefits for the subset of highly symptomatic SOD III patients with postprandial pain exacerbations. It may represent a breakthrough in the management of these patients and should be confirmed by a larger, prospective clinical study.

Mo1404 Outcomes of Endoscopic Sphincterotomy for Sphincter of Oddi Dysfunction Type III: the EPISOD Trial Revisited

Mo1404 Outcomes of Endoscopic Sphincterotomy for Sphincter of Oddi Dysfunction Type III: the EPISOD Trial Revisited

Nuclear Medicine Scintigraphy (NMS) Results Predict Symptom Resolution After Sphincterotomy in Patients With Sphincter of Oddi Dysfunction (SOD)

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincter of Oddi manometry is the gold standard test for diagnosis of SOD, but is associated with high risk of complications. A nuclear medicine scintigraphy (NMS) test is a safe, non-invasive, alternative test for evaluation of biliary SOD. ERCP with biliary sphincterotomy is the standard treatment for SOD. Our study aim is to assess the utility of NMS results in predicting symptom resolution after sphincterotomy in patients with SOD type 2. Methods: In this retrospective cohort study, patients who underwent both NMS and sphincterotomy for SOD type 2 between 2007 and 2014 were included. Patient demographics, clinical symptoms, laboratory tests, imaging studies, endoscopic ultrasound, and ERCP findings were recorded. The NMS results were reported on a scoring system ranging from 0 to 12. The symptom resolution after sphincterotomy was stratified into “no response,” “partial response,” or “complete response.” We compared the sphincterotomy response with NMS score results using the analysis of variance (ANOVA) or the Kruskal-Wallis tests for continuous variables and Pearson’s chi-squared tests or Fisher’s exact tests for categorical factors (P<0.05 for significance). The results were adjusted for age, sex, gender, history of smoking, and alcohol use using logistic regression analysis. We used SAS version 9.2 soft ware for the analysis. Results: A total of 30 patients with SOD type 2 met the inclusion criteria. Average age was 47 years and 87% (n=26) were female. During a mean follow-up of 20.6 months, none of the patients achieved complete response, while 57% (n=17) patients had partial response after sphincterotomy. Subjects with partial response were more likely to have abnormal NMS results (p<0.001) as well as higher scores in NMS test (p<0.001). Significance for these findings was maintained even after adjusting for age, gender, and history of smoking or history of alcohol use. A total NMS score of 5 or more would provide sensitivity of 82%, and specificity of 92% (area under the curve=0.93) for prediction of partial symptom resolution after sphincterotomy. Among NMS components, bile duct emptying score (p<0.002), bowel visualization score (p<0.002), and bile duct prominence score (p<0.003) were better predictors compared to peak time score (p=0.073). Conclusion: NMS total score was found to provide accurate prediction of symptom resolution after sphincterotomy. These findings are helpful to stratify patients based on the safe, non-invasive NMS test results that would be benefit from biliary sphincterotomy.

OC-073 Use Of Botulinum Toxin To Predict Manometry Results In Type Iii Sphincter Of Oddi Dysfunction; A Retrospective Single Centre Review

IntroductionManagement of type III sphincter of Oddi dysfunction (SOD) remains controversial. A recent large multi centre study of manometry and sphincterotomy in type III SOD (EPISOD)1 found that sphincterotomy was...

Su1654 Botulinum Toxin Injection As a Predictive Tool in the Diagnostic and Therapeutic Approach for Sphincter of Oddi Dysfunction Type III in Pediatrics

Su1654 Botulinum Toxin Injection As a Predictive Tool in the Diagnostic and Therapeutic Approach for Sphincter of Oddi Dysfunction Type III in Pediatrics

Su1539 A Trial of Rectal Indomethacin to Prevent Post-ERCP Pancreatitis in Patients With Sphincter of Oddi Dysfunction Type 3

Prophylactic pancreatic duct (PD) stenting is an established means to prevent post-ERCP pancreatitis(PEP) in patients with suspected sphincter of Oddi dysfunction (SOD) who undergo manometry. Recent data has suggested that rectal indomethacin can also reduce the incidence of PEP in high risk patients.

Su1655 Attitudes and Practices Regarding Type II Sphincter of Oddi Dysfunction (SOD): a Comparative Survey Study of Expert Biliary Endoscopists and Referring Gastroenterologists

Su1655 Attitudes and Practices Regarding Type II Sphincter of Oddi Dysfunction (SOD): a Comparative Survey Study of Expert Biliary Endoscopists and Referring Gastroenterologists

Can patient and pain characteristics predict manometric sphincter of Oddi dysfunction in patients with clinically suspected sphincter of Oddi dysfunction?

Biliopancreatic-type postcholecystectomy pain, without significant abnormalities on imaging and laboratory test results, has been categorized as "suspected" sphincter of Oddi dysfunction (SOD) type III. Clinical predictors of "manometric" SOD are important to avoid unnecessary ERCP, but are unknown. To assess which clinical factors are associated with abnormal sphincter of Oddi manometry (SOM). Prospective, cross-sectional. Tertiary. A total of 214 patients with suspected SOD type III underwent ERCP and pancreatic SOM (pSOM; 85% dual SOM), at 7 U.S. centers (from August 2008 to March 2012) as part of a randomized trial. Pain and gallbladder descriptors, psychosocial/functional disorder questionnaires. Abnormal SOM findings. Univariate and multivariate analyses assessed associations between clinical characteristics and outcome. The cohort was 92% female with a mean age of 38 years. Baseline pancreatic enzymes were increased in 5%; 9% had minor liver enzyme abnormalities. Pain was in the right upper quadrant (RUQ) in 90% (48% also epigastric); 51% reported daily abdominal discomfort. Fifty-six took narcotics an average of 33 days (of the past 90 days). Less than 10% experienced depression or anxiety. Functional disorders were common. At ERCP, 64% had abnormal pSOM findings (34% both sphincters, 21% biliary normal), 36% had normal pSOM findings, and 75% had at least abnormal 1 sphincter. Demographic factors, gallbladder pathology, increased pancreatobiliary enzymes, functional disorders, and pain patterns did not predict abnormal SOM findings. Anxiety, depression, and poorer coping were more common in patients with normal SOM findings (not significant on multivariate analysis). Generalizability. Patient and pain factors and psychological comorbidity do not predict SOM results at ERCP in suspected type III SOD. ( NCT00688662.).

Self-Administered Electroacupuncture Provides Symptomatic Relief in a Patient with Sphincter of Oddi Dysfunction: A Patient's Report

A 46-year-old woman with differentially diagnosed sphincter of Oddi dysfunction (SOD) type III is described. After two and a half years of managing the condition with a conventional medical/pharmacological approach, the patient's symptoms worsened and she sought complementary approaches, starting traditional acupuncture treatment before receiving training from a practitioner of Western medical acupuncture to self-administer electroacupuncture. The frequency and intensity of severe night-time pain attacks reduced and, additionally, self-administered manual acupuncture during pain attacks resulted in quick, lasting, complete symptomatic pain resolution. This is the first published case report using electroacupuncture in the clinical management of this condition. It shows patient-administered electroacupuncture as a low-risk well-tolerated procedure which provided effective pain relief and reduced the frequency and severity of pain attacks. Self-administered acupuncture could be considered as a potential complementary medical approach for patients with SOD type III before resorting to endoscopic SO manometry and sphincterotomy which carry significant associated risks of pancreatitis.

Sphincter of Oddi Manometry in a Community Hospital

Purpose: Sphincter of Oddi dysfunction (SOD) is a relatively common disorder and is underrecognized in the community setting. Sphincter of Oddi manometry (SOM) is the accepted gold standard for diagnosis of SOD. SOM is usually utilized at a tertiary or university hospital. Reports in the community setting are limited since SOM is not widely available. We started offering SOM at our community hospital in December 2011. Objective: To retrospectively evaluate the technical success rate, and complications of SOM in the community setting. Methods: We performed ERCP with SOM on 64 patients between December 2011 and February 2013 at Silver Cross Hospital. There were 61 females. All of our patients were symptomatic and were suspected of having SOD type 3 or 2. Thirty eight patients had recurrent right upper quadrant pain. Twenty patients had recurrent idiopathic pancreatitis or epigastric pain with radiation to the back (pancreatic type pain). Six patients had epigastric and RUQ pain. All procedures were performed by one therapeutic endoscopist, who is fellowship trained in the procedure and has performed SOM at his previous institution. Only four nurses were trained in advanced endoscopy and SOM (the therapeutic team), and assisted with all the procedures. Lehman manometry catheter was used in all patients. Results: Successful cannulation of desired duct was achieved in 58 patients. Both ducts were cannulated and pressure measured in 48 patients. A pancreatic stent 5 F x 3 cm, 3 F x 8 cm, or 5 F x 5 cm was placed in 56 patients. Elevated pressures were found in 56 patients. Our overall success rate for desired duct was 90%. Success rate for dual duct manometry was 75%. Seven patients developed mild pancreatitis that subsequently resolved within 2-3 days. Two of these patients did not have pancreatic stent placed. In all 64 patients, there was no reported bleeding or perforation. Fifty nine patients followed-up; the symptoms had resolved in 47 patients, and improved in eight patients. Conclusion: SOM is not widely available and thus SOD is under diagnosed. Our preliminary data suggests that SOM can be safely and successfully performed in the community setting. The endoscopist and nursing staff need to be well trained, and have significant experience when performing SOM.