Sphincter Of Oddi Dysfunction Research Articles

Current treatment of biliary Sphincter of Oddi Dysfunction

The sphincter of Oddi is a delicate neuromuscular structure located at the junction of the biliary-pancreatic system and the duodenum. Sphincter of Oddi Dysfunction (SOD) can result in various clinical manifestations, including biliary-type pain and recurrent idiopathic pancreatitis. The management of SOD has been challenging. With the publication of the landmark Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction (EPISOD) trial and the Rome IV consensus, our clinical practice in the treatment of SOD has changed significantly in recent years. Currently, the management of type II SOD remains controversial and there is a lack of non-invasive therapy options, particularly for patients not responding to endoscopic treatment. In this mini review, we aimed to discuss the current knowledge on the treatment of biliary SOD.

The analysis of medical prescriptions for patients with duodenal ulcer in hospital setting

The analysis of medical prescriptions for patients with duodenal ulcer in hospital setting

Indication for endoscopic retrograde cholangiopancreatography and development of hemorrhage: a systematic review and meta-analysis

Abstract Background Hemorrhage is a common complication associated with endoscopic retrograde cholangiopancreatography (ERCP), usually following sphincterotomy. Studies investigating risk factors for hemorrhage including ERCP indication have been conflicting. Therefore, we conducted a systematic review and meta-analysis to characterize the association between the ERCP indication and hemorrhage. Methods Database searches of MEDLINE, EMBASE, and CENTRAL were conducted to identify articles up to December 12, 2022. Randomized trials or observational studies of adult patients undergoing ERCP were included. Quality assessment using the Cochrane Risk of Bias 2.0 and Newcastle-Ottawa Scales for randomized trials and observational studies respectively was conducted. A random effects meta-analysis generating pooled odds ratios with 95% confidence intervals was conducted. Results A total of 1323 articles were identified of which 26 were included with up to 25 121 subjects in each meta-analysis. Rates of sphincterotomy (median 96.1%; IQR 60.5–100), biliary stent placement (median 17.2%; IQR 10.6–34.4), antiplatelet use (median 6.0%; IQR 0–10.1), and anticoagulant use (median 1.9%; IQR 0%–3.2%) varied among included studies. No specific indication was associated with hemorrhage in the meta-analyses including cholangitis (OR 1.50; 95% CI 0.97–2.32), choledocholithiasis/biliary stone (OR 1.28; 95% CI 0.95–1.73), malignancy (OR 0.97; 95% CI 0.66–1.42), sphincter of Oddi dysfunction (OR 1.32; 95% CI 0.72–2.40), and acute pancreatitis (OR 0.81; 95% CI 0.44–1.49). Conclusions Overall, no indication was significantly associated with increased hemorrhage following ERCP. However, given limitations in the included studies (ie, significant heterogeneity between studies), additional research to better characterize these associations is needed. Protocol Registration Number PROSPERO (CRD42021283978).

Biliary Duct Dilatation: AJR Expert Panel Narrative Review.

Biliary duct dilatation is a common incidental finding in practice, but it is unlikely to indicate biliary obstruction in the absence of clinical symptoms or elevated levels on liver function tests (LFTs). However, the clinical presentation may be nonspecific, and LFTs may either be unavailable or difficult to interpret. The goal of this AJR Expert Panel Narrative Review is to highlight a series of topics fundamental to the management of biliary duct dilatation, providing consensus recommendations in a question-and-answer format. We start by covering a basic approach to interpreting LFT results, the strengths and weaknesses of the biliary imaging modalities, and how and where to measure the extrahepatic bile duct. Next, we define the criteria for biliary duct dilatation, including patients with prior cholecystectomy and advanced age, and discuss when and whether biliary duct dilatation can be attributed to papillary stenosis or sphincter of Oddi dysfunction. Subsequently, we discuss two conditions in which the duct is pathologically dilated but not obstructed: congenital cystic dilatation (i.e., choledochal cyst) and intraductal papillary neoplasm of the bile duct. Finally, we provide guidance regarding when to recommend obtaining additional imaging or testing, such as endoscopic ultrasound or ERCP, and include a discussion of future directions in biliary imaging.

Sphincter of Oddi Dysfunction: A Narrative Review

Sphincter of Oddi Dysfunction: A Narrative Review

Sphincter of Oddi Dysfunction Induces Gallstone by Inhibiting the Expression of ABCB11 via PKC-α.

The abnormal increase of Oddi sphincter pressure and total bile duct pressure may play an important role in the formation of cholesterol stones, but the specific molecular mechanism is still unclear. This study aims to investigate it through in vitro and in vivo experiments. A mouse model of Oddi sphincter dysfunction was constructed by stone-inducing diet. We compared the two groups with PKC-α inhibitor GÖ6976 and PKC-α agonist thymeleatoxin. Oddi sphincter pressure and total bile duct pressure were measured. Biochemical analysis of total cholesterol, bile acid and bilirubin was then conducted. The histopathologic changes of bile duct were observed by HE staining and the ultrastructure of liver cells and surrounding tissues was observed by transmission electron microscopy. Through the above experiments, we found that the change of PKC-α expression may affect the formation process of gallstones. The relationship between PKC-α and ABCB11 was further verified by in vitro and in vivo experiments. Our results suggest that ABCB11 and PKC-α are co-expressed in the tubule membrane of hepatocytes and interact with each other in hepatocytes. The high cholesterol diet further enhances the activation of PKC-α and thus reduces the expression of ABCB11. The formation of cholesterol stones is associated with the down-regulation of ABCB11 expression in the tubule membrane of hepatocytes due to kinase signaling. This is the first study to demonstrate that sphincter of Oddi dysfunction induces gallstones through PKC-α inhibition of ABCB11 expression.

Post-endoscopic retrograde cholangiopancreatography pancreatitis: a review

Endoscopic retrograde cholangiopancreatography (ERCP) has continued to develop over recent decades with regard to both indications for its use and improvements in technique. The most common complication is post-ERCP pancreatitis (PEP) with incidence rates being reported at ~10%. The exact mechanism of PEP is unknown but is likely multifactorial with papillary edema contributing to the activation of the inflammatory cascade playing an important role. Selected risk factors include patient-related factors (female sex, younger age, sphincter of Oddi dysfunction, and history of PEP) and procedure-related factors (difficult cannulation, multiple pancreatic duct guidewire passes, pancreatic acinarization, multiple pancreatic duct contrast injections, and precut sphincterotomy). Several preventative prophylactic strategies have been posited; however, current guidelines recommend the use of rectal non-steroidal anti-inflammatory drugs (NSAIDs), aggressive intravenous (IV) fluid hydration, and pancreatic duct stents. Appropriate patient selection and the use of noninvasive imaging modalities for diagnosis of pancreaticobiliary abnormalities is a key aspect in prevention. Future studies continue to explore various pharmacologic, procedure-related, and combination strategies for prevention and will be important as the use of ERCP continues to grow.

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.

Possibilities of modern pharmacotherapy in patients with dysfunction of the sphincter of Oddi

Pain in the right hypochondrium is one of the most frequent complaints in patients with diseases of the biliary system. According to statistics, every tenth person experiences unpleasant sensations in the upper right abdomen after drinking alcohol, fatty, fried or salty food, as well as after psychoemotional and physical exertion. The most common of the pathologies of the biliary system is the sphincter of Oddi dysfunction (SOD). SOD is a clinical syndrome caused by a functional disorder of sphincter of Oddi (SO), which leads to the development of abdominal pain syndrome, increased activity of liver and / or pancreatic enzymes, dilatation of the common bile duct and the main pancreatic duct. One of the methods of treatment of SOD is drug therapy, accompanied by the following groups of drugs: antispasmodics, nitrates, choleretics, antidepressants, etc. At the same time, many medications show low efficacy against SOD, or cause pronounced side effects. At present, for the treatment of sphincter of Oddi dysfunction, the domestic drug from the group of myotropic antispasmodics, hymecromon, Holicron, has the optimal characteristics in terms of price-quality ratio in the Russian pharmacological market. The drug has a selective antispasmodic effect on SO, and also has a choleretic effect. Mechanism of antispasmodic action is an increase in the concentration of nitric oxide (II) and cyclic mononucleotides, which through a cascade of biochemical reactions leads to a decrease in the number of calcium ions in the cell and a decrease in the tone of smooth myocytes of SO and gallbladder. The drug is absorbed into the blood in a small amount, which excludes its systemic effect and determines the selectivity of the effect on the biliary system. According to the results of clinical testing and consideration of a specific clinical case, it can be concluded that the use of hymecromone (Holicron) reduces the severity of pain syndrome and reduces dyspepsia syndrome, good tolerability and absence of side effects that would require withdrawal of the drug are also recorded.

Transduodenal Sphincteroplasty: A Visual Case Study

BackgroundSphincter of Oddi dysfunction is a challenging and rare clinical entity resulting in pancreatobiliary pain and stasis of bile and pancreatic juice. This problem was classically treated with surgical therapy, but as classification of the disease has changed and newer methods of endoscopic evaluation and therapy have evolved, operative transduodenal sphincteroplasty is now generally reserved as a final therapeutic option for these patients. In this video and manuscript, we describe our approach to operative transduodenal sphincteroplasty in a patient with type I Sphincter of Oddi dysfunction. MethodsA 50-year-old female with history of Roux-en-Y gastric bypass presented with episodic right-upper-quadrant and epigastric abdominal pain with associated documented elevations in liver chemistries. Preoperative cross-sectional imaging demonstrated dilation of her common bile duct. After multidisciplinary discussion, the decision was made to pursue operative transduodenal sphincteroplasty. ResultsAll key operative steps of the transduodenal sphincteroplasty are demonstrated in the embedded video. Key operative steps include laparotomy, generous Kocher maneuver, and duodenotomy over the ampulla, allowing access for sequential biliary and pancreatic sphincterotomies and sphincteroplasties with absorbable suture. The duodenotomy and abdominal fascia are then closed. Our patient underwent sequential diet advancement and was discharged to home on postoperative day five. At clinic follow-up, pancreatobiliary-type pain had resolved. ConclusionThe embedded video demonstrates a case of operative transduodenal sphincteroplasty, which can provide durable results in appropriate patient populations.

Sphincter of Oddi dysfunction: do not forget to look for opiates!

Sphincter of Oddi dysfunction: do not forget to look for opiates!

Sphincter of Oddi dysfunction: beware of opiates, but not only! Response to Alexandre Pariente

Sphincter of Oddi dysfunction: beware of opiates, but not only! Response to Alexandre Pariente

Analysis of risk factors and construction of predictive model for post-endoscopic retrograde cholangiopancreatography pancreatitis

Objective: To explore the risk factors of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and to establish a predictive model.
 Methods: This was a retrospective observational study. Patients diagnosed with calculous cholangitis and treated with ERCP (n=998) in The First People’s Hospital of Linping District from January 2014 to September 2022 were included. Risk factors of PEP were identified using univariate and multivariate logistic regression, and a nomograph prediction model was established based on the identified independent risk factors.
 Results: PEP occurred in 52 patients (5.2%). Logistic regression analysis showed that common bile duct diameter, history of PEP, operation time, intubation frequency, pancreatic ducts visualization, and Sphincter of Oddi dysfunction (SOD) were independent risk factors for inducing PEP (P<0.05). The calibration curve showed that the predicted probability of occurrence of the nomograph model was consistent with the actual probability of occurrence. The C-index value calculated by the Bootstrap method was 0.966, suggesting the nomograph prediction model has a good discrimination ability. The AUC of the nomograph prediction model ROC curve was 0.966 (95% CI: 0.857-0.941), suggesting good prediction efficiency, and the decision analysis curve shows a high value.
 Conclusions: Independent risk factors for PEP are large diameter of common bile duct, history of pancreatitis, long operation time, high intubation frequency, pancreatic ducts visualization, and SOD. The nomogram prediction model based on the above independent risk factors has good prediction ability.
 doi: https://doi.org/10.12669/pjms.39.6.7972
 How to cite this: Zhu P. Analysis of risk factors and construction of predictive model for post-endoscopic retrograde cholangiopancreatography pancreatitis. Pak J Med Sci. 2023;39(6):---------. doi: https://doi.org/10.12669/pjms.39.6.7972
 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Dysfunction of Biliary Sphincter of Oddi-Clinical, Diagnostic and Treatment Challenges.

Biliary Sphincter of Oddi dysfunction (SOD) is one of the main causes of post-cholecystectomy pain. In this review, we aimed to provide an update on the current knowledge on biliary SOD, with an emphasis on diagnostics and therapy. Overall, current but scarce data support biliary sphincterotomy for patients with type 1 and 2 SOD, but not for type 3. However, sphincterotomy is associated with post-treatment pancreatitis rates of from 10% to 15%, thus calling for improved diagnostics, patient selection and treatment modalities for SOD. The role of pharmacologic therapy for patients with SOD is poorly explored and only two randomized controlled trials are available. Currently, studies comparing treatment outcomes are few. There is an unmet need for randomized sham/placebo-controlled clinical trials related to both pharmacological and non-pharmacological treatments of SOD.

Постхолецистектомічний синдром: новий погляд на давню проблему та можливості патогенетичної терапії

In the article, from the modern standpoint, the pathogenetic and clinical characteristics of PCS as a dysfunction of the sphincter of Oddi are given, the mechanisms for the development of this pathology, the principles of therapy with the inclusion of the drug Rowachol, containing six plant monoterpenes, are disclosed. The materials of our own observations of the treatment of patients with Oddi sphincter dysfunction after laparoscopic cholecystectomy by Rowachol are presented. Anti-inflammatory, litholytic, hypocholesterolemic and pleiotropic effects of Rowachol have been proved. Rowachol should be positioned as a pathogenetic natural remedy for treatment of Oddi sphincter dysfunction and biliary sludge in patients undergoing cholecystectomy for cholelithiasis.

Risk factors for ERCP-related complications and what is the specific role of ASGE grading system.

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the main therapeutic and sometimes diagnostic methods in biliary and pancreatic diseases. A grading system for the difficulty of ERCP (grade one to four, the higher grade represents the more complexity of the procedure) has been developed by the American Society for Gastrointestinal Endoscopy (ASGE). This study aimed to assess the prevalence of ERCP-related complications, their common risk factors, and specifically the role of difficulty of the procedure based on ASGE grading. This cross-sectional study was performed on 620 ERCP-operated patients over 4 years in two tertiary referral centers affiliated with Isfahan University of Medical Sciences. Data about the difficulty of procedures based on the ASGE grading scale, complications including pancreatitis, bleeding, infection, perforation, arrhythmia, respiratory suppression, aspiration, and major common risk factors were collected. The overall prevalence of complications was 11.6% including pancreatitis 8.2%, perforation 0.8%, gastrointestinal bleeding 1.3%, cholangitis 2.4%, and cardiopulmonary problems 0.5% (arrhythmia 0.3% and respiratory depression 0.2%). Patients with pancreatic contrast injection (66.7% vs. 11.3% P = 0.04) and sphincter of Oddi dysfunction (SOD) (44.4% vs. 11.1%; P = 0.01) showed a statistically significant higher overall complication rate. The association of these risk factors remained significant in multivariable logistic regression analysis. Patients with pancreatic contrast injection also showed a statistically significant higher prevalence of post-ERCP pancreatitis (66.7% vs. 11.3% P = 0.04). Furthermore, a significantly higher prevalence of arrhythmia (3.6% vs. 0; P = 0.008) was observed among patients with difficult cannulation. Based on the ASGE difficulty grading score, most of the patients were classified as grade 2 (74.2%) and 3 and 4 (23.4%). No statistically significant difference was noted between the difficulty-based groups in terms of complications. The current study showed that the most critical risk factors of ERCP-induced complications were pancreatic contrast injection and SOD. ASGE grading scale for ERCP complexity did not predict the occurrence of complications in our study population.

Risk Factors Related to Early Biliary Complications After Liver Transplantation: a Single-Center Analysis

The aim of this study was to evaluate the risk factors of early biliary complications (EBC) after liver transplantation (LT) and seek effective treatments based on our single-center experience. A total of 124 adult patients were divided into a non-EBC group and EBC group. EBC usually accounts for biliary leakage, biliary stricture, biliary stones, sphincter of Oddi dysfunction, and transient jaundice within 3 months after LT. Statistical analysis including logistic regression was performed to determine EBC risk factors. All procedures complied with the Helsinki Congress and the Declaration of Istanbul. Non-EBC (n=95) and EBC (n=29) were finally compared, which had no difference in their general characteristics. EBC occurred in 29 patients (26.92%): 1 biliary hemorrhage (3.45%), 7 biliary leakage (24.13%), and 16 biliary stricture (55.18%), and 5 others (17.24%). Of all EBC patients, endoscopic retrograde cholangiopancreatography (68.96%) was higher used to deal with complications than conservative treatment (10.35%), percutaneous transhepatic cholangial drainage (17.24%), and surgical treatment (3.45%). On univariate analyses, risk factors for EBC were bilirubin (P = .014), warm ischemia time (WIT) (P = .020), second WIT (P = .042), and operative time (OT) (P = .033). On multivariate analysis, independent risk factors for BC were WIT (P = .011) and OT (P = .049). The presence of WIT and OT were the independent risk factors for the development of EBC. In addition, we also confirmed that endoscopic retrograde cholangiopancreatography was beneficial and safe in the management of EBC after LT.

Effect of sphincter of Oddi dysfunction on the abundance of biliary microbiota (biliary microecology) in patients with common bile duct stones.

Biliary calculi, a common benign disease of the gastrointestinal tract, are affected by multiple factors, including diet, lifestyle, living environment, and personal and genetic background. Its occurrence is believed to be related to a change in biliary microbiota. Approximately 10%-20% of symptomatic patients with cholecystolithiasis have choledocholithiasis, resulting in infection, abdominal pain, jaundice, and biliary pancreatitis. This study aimed to determine whether a dysfunction in the sphincter of Oddi, which controls the outflow of bile and separates the bile duct from the intestine, leads to a change in biliary microbiota and the occurrence of biliary calculi. Forty patients with cholecystolithiasis and choledocholithiasis were prospectively recruited. Bile specimens were obtained, and biliary pressure was measured during and after surgery. The collected specimens were analyzed with 16S rRNA gene to characterize the biliary microbiota. The risk factors of common bile duct calculi were analyzed numerically combined with the pressure in the sphincter of Oddi. Different biliary microbiota were found in all cases. Patients with sphincter of Oddi dysfunction had significantly increased biliary microbiota as well as significantly higher level of systemic inflammation than patients with normal sphincter of Oddi. The systemic inflammatory response of patients with sphincter of Oddi dysfunction is more severe, and their microbial community significantly differs from that of patients with normal sphincter of Oddi, which makes biliary tract infection more likely; furthermore, the biliary tract of patients with sphincter of Oddi dysfunction has more gallstone-related bacterial communities.

Recurrent acute pancreatitis: a diagnostic and a therapeutic dilemma

Although uncommon, surgeons and physicians are sometimes confronted with patients who presents with recurrent episodes of acute pancreatitis. When two or more episodes of acute pancreatitis occur without an identifiable cause, it is referred to as Recurrent Acute Pancreatitis (RAP). In such patients, selecting the most appropriate management strategy continue to pose a challenge due to multiple aetiological factors, associated conditions, microanatomical and pathological processes and complex immunological mechanisms of this condition. The identifiable causes of RAP such as bile duct stones, biliary sludge or crystals, Sphincter of Oddi Dysfunction (SOD), pancreatic duct obstructions due to benign and malignant neoplasms, genetic mutations, Pancreatic Divisum (PD), metabolic disorders, alcohol consumption and smoking may be identified in some patients. There are several other rare conditions which may be associated with RAP. However, in about 30%, no cause/s can be identified. Diagnosis is further complicated by the fact that, although the gland may appear morphologically normal following the initial episode of Acute Pancreatitis (AP), in some patients, evidence of Chronic Pancreatitis (CP) may manifest later. Furthermore, there is an ongoing debate as to whether, recurrent bouts of pancreatitis following the first; the Sentinel Acute Pancreatitis episode in patients who are 'immunologically' predisposed may lead to Chronic Pancreatitis. In such patients who subsequently develop acute episodes, i.e., Acute on Chronic Pancreatitis will further complicate recognition of aetiological factors of RAP. The recognition of possible causes, associated factors, and understanding of pathological progressions are therefore important in the management of such patients. Detailed clinical assessment and clinical reasoning, standard haematological and biochemical workup and basic and advanced imaging studies will help identify patients who can be selected for specific invasive and medical therapy to prevent acute episodes. This brief review is a clinical update to guide clinicians, the best way forward in the management of RAP.

S3022 Hepatic Cerebrospinal Fluid Pseudocyst: A Rare Complication of Ventriculoperitoneal Shunt

Introduction: Ventriculoperitoneal shunts (VPS) are commonly used in the management of hydrocephalus to drain cerebrospinal fluid (CSF) into the peritoneal cavity. The placement of VPS has prolonged the survival of patients with hydrocephalus. Abdominal pseudocysts are long-term complication of VPS that are identified later in life. Hepatic CSF pseudocyst is a rare long-term complication of VPS that should be differentiated from other cystic lesions of liver. Case Description/Methods: A 49-year-old man with intellectual disability from congenital hydrocephalus s/p placement of right and left-sided VPS at age of 3 months and 7 years respectively presented with exertional dyspnea and abdominal distension. On presentation his vitals were unremarkable except tachycardic (115/min)., He had abdominal distention, hepatomegaly but no tenderness. Initial labs showed D-dimer 2.20 mcg/mL, AST 27 u/L, ALT 38 u/L, alkaline phosphate 126 u/L and total bilirubin 0.5 mg/dL. Chest CT with IV contrast was negative for pulmonary embolism, however revealed a large 18x13x13.5 cm cyst in right hepatic lobe. CT abdomen and pelvis demonstrated a 17.5x12.6x12.7 cm cystic lesion in the right hepatic lobe with the tip of VP shunt catheter within cyst cavity. Hepatobiliary nuclear scan was unremarkable for any biliary leak or sphincter of oddi dysfunction. CT head was negative for any acute abnormalities. Shunt series x-rays were negative for disruption of VPS catheter. Robotic laparoscopic cyst fenestration with partial hepatectomy was performed and catheter was repositioned to the right lower quadrant of abdomen. Patient was discharged home two days later with significant reduction of cyst size on follow up imaging. (Figure) Discussion: This case illustrates a rare complication of VPS that result in hepatic CSF pseudocyst. If hydrocephalus is absent, patients with hepatic CSF pseudocyst are asymptomatic at earlier stages., or they may present with abdominal pain, distention, or palpable right upper quadrant abdominal mass. A subset of patients with hepatic CSF pseudocyst are complicated with bacterial or parasitic infection and present with abdominal pain, distention, or right upper quadrant mass. Abdominal ultrasound and CT scan assist in diagnosis by identifying the tip of VPS catheter in the pseudocyst cavity. Asymptomatic patients are managed conservatively while surgical repositioning of VPS catheter with or without cyst fenestration or surgical excision of cyst may be required for complete resolution of symptoms.Figure 1.: CT of abdomen showing a large right hepatic lobe cyst with evidence of tip of right VPS catheter within the cavity of the cyst (arrows) on transverse (A), axial (B) and lateral (C) views. CT scan of the head (D) showing VPS catheters both in right and left lateral ventricles without evidence of ventricular dilation. Shunt series x-ray (E) shows now distortion of VPS catheter. Robotic laparoscopic cyst fenestration (F) shows VPS catheter within cyst cavity containing CSF.