Sphincter Of Oddi Manometry Research Articles

Endoscopic sphincter of Oddi manometry in patients with postcholecystectomy syndrome and persisting biliary pain despite previous endoscopic sphincterotomy

Endoscopic sphincter of Oddi manometry in patients with postcholecystectomy syndrome and persisting biliary pain despite previous endoscopic sphincterotomy

Prospective Trial Comparing Solid State Catheter (SSC) and Water Perfusion Triple Lumen Catheter (TLC) for Sphincter of Oddi Manometry (SOM)

Introduction: SOM is the gold standard for diagnosis of Sphincter of Oddi dysfunction (SOD). Numerous studies have established ranges of normal values as well as typical readings in pathologic conditions. All these studies are done using the water perfused TLC. A recently developed SSC can have potential advantages. It is simpler and easier to use, has fewer components and is less prone to artifact. One can also speculate that using the SSC may lead to decreased risk of post-ERCP pancreatitis since no water is infused into the pancreatic duct during pressure measurements. To date no data exist on the accuracy of the measurements with the SSC. Concerns have been raised whether the pressures obtained by TLC are reproducible by SSC. The two catheters have different diameter (TLC 4.5 mm, SSC 4.0 mm). Water is infused via the TLC into the biliary and/or pancreatic duct and that may lead to increased intraductal pressure and therefore increased SOM pressure readings. The manufacturer of the SSC did not conduct clinical studies to establish equivalence with previously marketed devices. The goal of this study was to evaluate the accuracy of the SSC using TLC as gold standard. Methods: This is prospective crossover trial. Each patient, serving as their own control, underwent SOM with TLC and SSC during the same procedure. The order of catheter use alternated in sequential patients. The basal sphincter pressure was measured in the biliary, pancreatic or both sphincter segments as clinically indicated. In each sphincter segment 6 sustained (>30 sec) basal pressure measurements with each of the two sensors (distal and proximal) were obtained (total of 12 measurements per sphincter segment). The manometry was then repeated in the same fashion with the alternative catheter. Results: A total of 378 pressure measurements in 47 sphincter segments (24 biliary, 23 pancreatic) in 30 patients (M 4, F 26) were obtained. Manometry was abnormal (basal pressure >40 mm Hg) in 10/24 biliary sphincters and 12/23 pancreatic sphincters. There was complete agreement on the final result of the SOM (normal/abnormal) between the TLC and SSC (accuracy 100%). To evaluate whether there was a catheter effect on the measurements a split-plot analysis was performed. The p-value for this test 0.9966 was extremely insignificant consistent with no catheter effect on the measuring. 20/30 patents received pancreatic stent. 5/30 patients developed mild post ERCP pancreatitis. Conclusion: This prospective crossover trial shows that the solid state manometry catheter accurately measures pressures during SOM.

ERCP/Manometry Findings in 1,343 Idiopathic Pancreatitis Patients

Background: ERCP with sphincter of Oddi manometry can detect abnormalities in patients otherwise classified as idiopathic pancreatitis. Methods: All patients undergoing ERCP at Indiana University Medical Center have data prospectively entered into a database. 1,547 patients from 1994-2006 were classified initially as idiopathic pancreatitis. After review of medical history, non-invasive imaging, prior endoscopies, and blood studies, 204 patients were eliminated for known causes of pancreatitis. This study reviews the findings of ERCP with or without manometry of the remaining 1,343 patients in correlation with the pre-ERCP clinical diagnosis. Results: Clinical categories were based upon the pre-ERCP diagnosis: a single episode of acute pancreatitis in 281 (20.9%), acute recurrent pancreatitis (IARP) in 758 (56.4%), chronic pancreatitis (CP) in 304 (22.6%). Post-procedure diagnoses were: (See table). Biliary manometry findings were the following: elevated biliary sphincter pressures were found in 63 (41.7%) of the 151 attempted manometries in patients with 1 documented episode of pancreatitis, in 153 (32.9%) patients with acute recurrent pancreatitis of the 465 performed manometries, and in 30 (23.6%) of 127 manometries of CP. Elevated major pancreatic sphincter pressures were found in 93/154 (60.4%) with acute pancreatitis x1, in 266/488 (54.5%) with acute recurrent pancreatitis, and in 69/158 (43.7%) with chronic pancreatitis. Summary: In our large case series of idiopathic pancreatitis patients, ERCP and manometry frequently detects abnormalities that may be a cause of pancreatitis or lead to persistence of symptoms. Manometry abnormalities are the most common treatable cause of idiopathic pancreatitis. Long term outcomes of therapy studies are in progress. Conclusion: ERCP with sphincter of Oddi manometry is indicated for most patients with idiopathic pancreatitis. Tabled 1 ERCP findings Number of patients % of total Sphincter of Oddi dysfunction 539 40.1 Pancreas divisum 240 17.9 Periampullary diverticulum 82 6.1 Choledocholithiasis 61 4.6 Intraductal mucinous tumors 55 4.1 Cholelithiasis (alone) 26 1.9 Anomalous pancreatobiliary junction 7 0.5 Choledochocele 5 0.4 Papilla of Vater adenoma/cancer 4 0.3 Annular pancreas 4 0.3 Open table in a new tab

ERCP/Manometry Findings Based Upon Pre-Procedure Diagnosis: A Sub-Group Analysis of 1,343 Idiopathic Pancreatitis Patients

Background: ERCP with sphincter of Oddi manometry can detect abnormalities in patients otherwise classified as idiopathic pancreatitis. Methods: All patients undergoing ERCP at Indiana University Medical Center have data prospectively entered into a database. 1,547 patients from 1994-2006 were classified initially as idiopathic pancreatitis. After review of medical history, non-invasive imaging, prior endoscopies, and blood studies, 204 patients were eliminated for known causes of pancreatitis. This study reviews the findings of ERCP with or without manometry of the remaining 1,343 patients in correlation with the pre-ERCP clinical diagnosis.

Postcholecystectomy Sphincter of Oddi Dyskinesia—A Diagnostic Dilemma—Role of Noninvasive Nuclear and Invasive Manometric and Endoscopic Aspects

Persistent abdominal pain after cholecystectomy is not uncommon. Sphincter of oddi dysfunction (SOD) is one of the causes for this entity. However, diagnosing SOD is often difficult. Sphincter of oddi manometry (SOM) is the gold standard. Because it is invasive and needs experienced person to perform, simple noninvasive imaging techniques are needed. Other invasive endoscopic methods also play an important role in difficult cases and before therapeutic intervention. Retrospective review of the charts of postcholecystectomy patients who presented with persistent abdominal pain and underwent quantitative hepatobiliary studies (QHBS) as per Sostre et al scoring protocol and simultaneous endoscopic retrograde cholangiopancreatography (ERCP) with SOM between 2003 and 2004. Additional 6 studies with SOM data that had routine nonscoring hepatobiliary study (HBS) were later identified and were included in the study. A total of 24 HBS studies (22 patients) were identified, 19 performed with scoring (Sostre) and 5 with nonscoring methods. ERCP results were available for 16 patients. SOM results were available for 10 patients. Of the 19 who had Sostre's QHBS, 3 were positive and 16 were negative. All 3 QHBS positive patents also had ERCP with SOM findings of SOD. Of the 16 negative Sostre's QHBS, 8 had ERCP with SOM of which 6 had SOD, 1 had no SOD, and 1 was inconclusive. Eight patients who had negative QHBS/ HBS did not undergo further invasive gastrointestinal procedures and were followed conservatively. The rest of 5 patients with negative HBS had ERCP with SOM findings of biliary and pancreatic SOD. From our limited retrospective review, when QHBS by Sostre's is positive there is good correlation to ERCP with SOM. When negative, the agreement with ERCP with SOM is less. However, correlation of Sostre's QHBS is slightly better than nonscoring HBS. Hence, QHBS by Sostre protocol is a simple, noninvasive, and easy to use initial procedure in the management of postcholecystectomy pain syndromes and when positive can guide the gastrointestinal physicians to proceed to invasive ERCP with SOM with confidence.

Sphincter of Oddi dysfunction and pancreatitis

Sphincter of Oddi dysfunction (SOD) is a term used to describe a group of heterogenous pain syndromes caused by abnormalities in sphincter contractility. Biliary and pancreatic SOD are each sub-classified as type I, II or III, according to the Milwaukee classification. SOD appears to carry an increased risk of acute pancreatitis as well as rates of post ERCP pancreatitis of over 30%. Various mechanisms have been postulated but the exact role of SOD in the pathophysiology of acute pancreatitis is unknown. There is also an association between SOD and chronic pancreatitis but it is still unclear if this is a cause or effect relationship. Management of SOD is aimed at sphincter ablation, usually by endoscopic sphincterotomy (ES). Patients with type I SOD will benefit from ES in 55%-95% of cases. Sphincter of Oddi manometry is not necessary before ES in type I SOD. For patients with types II and III the benefit of ES is lower. These patients should be more thoroughly evaluated before performing ES. Some researchers have found that manometry and ablation of both the biliary and pancreatic sphincters is required to adequately assess and treat SOD. In pancreatic SOD up to 88% of patients will benefit from sphincterotomy. Therefore, there have been calls from some quarters for the current classification system to be scrapped in favour of an overall system encompassing both biliary and pancreatic types. Future work should be aimed at understanding the mechanisms underlying the relationship between SOD and pancreatitis and identifying patient factors that will help predict benefit from endoscopic therapy.

Randomized trial comparing needle-knife and pull-sphincterotome techniques for pancreatic sphincterotomy in high-risk patients

Accepted techniques for pancreatic sphincterotomy include use of a needle knife or a pull sphincterotome to ablate the sphincter. There are no prospective studies comparing outcomes between both techniques. Compare post-ERCP pancreatitis rates among high-risk patients undergoing pancreatic sphincterotomy with the pull-sphincterotome versus needle-knife technique. Prospective, randomized trial. Patients diagnosed with pancreatic sphincter hypertension at sphincter of Oddi manometry were randomized to undergo pancreatic sphincterotomy with a pull sphincterotome (followed by pancreatic stenting) or a needle knife over a pancreatic stent. To compare post-ERCP pancreatitis rates between the pull-sphincterotome and needle-knife groups. Forty-eight patients were randomized. Patient demographics and the incidence of patient and procedure risk factors for pancreatitis were similar in both treatment groups. The trial was stopped early after an interim analysis showed that post-ERCP pancreatitis was significantly higher among patients undergoing sphincterotomy with a pull sphincterotome than a needle knife (7/24 = 29% [95% CI 13-51] vs 0/24 = 0% [95% CI 0-12]; P = .01). No other complications were encountered. At a mean follow-up of 12 months (range 6-18 months), 60% of patients had complete symptom relief, 15% partial symptom relief, and 25% recurrent symptoms. Reintervention rates and clinical outcomes were not significantly different between the 2 groups. Short duration of follow-up. Pancreatic sphincterotomy is safer in high-risk patients when performed with a needle knife over a pancreatic stent.

Systematic review: sphincter of Oddi dysfunction – non‐invasive diagnostic methods and long‐term outcome after endoscopic sphincterotomy

Sphincter of Oddi dysfunction is a benign, functional gastrointestinal disorder for which invasive endoscopic therapy with potential complications is often recommended. To review the available evidence regarding the diagnostic accuracy of non-invasive methods that have been used to establish the diagnosis and to estimate the long-term outcome after endoscopic sphincterotomy. A systematic review of English language articles and abstracts containing relevant terms was performed. Non-invasive diagnostic methods are limited by their low sensitivity and specificity, especially in patients with Type III sphincter of Oddi dysfunction. Secretin-stimulated magnetic resonance cholangiopancreatography appears to be useful in excluding other potential causes of symptoms, and morphine-provocated hepatobiliary scintigraphy also warrants further study. Approximately 85%, 69% and 37%, of patients with biliary Types I, II and III sphincter of Oddi dysfunction, respectively, experience sustained benefit after endoscopic sphincterotomy. In pancreatic sphincter of Oddi dysfunction, approximately 75% of patients report symptomatic improvement after pancreatic sphincterotomy, but the studies have been non-controlled and heterogeneous. Patients with suspected sphincter of Oddi dysfunction, particularly those with biliary Type III, should be carefully evaluated before considering sphincter of Oddi manometry and endoscopic sphincterotomy. Further controlled trials are needed to justify the invasive management of patients with biliary Type III and pancreatic sphincter of Oddi dysfunction.

A Prospective Study of Complications of Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound in an Ambulatory Endoscopy Center

Our aim was to assess the safety of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in an ambulatory endoscopy center (AEC). Complications occurring in consecutive patients undergoing ERCP or EUS from March 2003 to February 2004 at our AEC were recorded prospectively. Comprehensive complications were defined as consensus criteria plus other adverse events: use of reversal agents, unplanned hospital admission, hospitalization beyond planned 23-hour observation, unplanned emergency department or primary care provider visit, and 30-day mortality. A total of 497 patients (median age, 57 y; 82% American Society of Anesthesiologists class II or III) underwent 685 procedures. Monitored or general anesthesia was used in 25% of EUS and 50% of ERCP procedures. ERCP interventions were as follows: biliary or pancreatic stenting (N = 168), stone extraction (N = 70), sphincterotomy (N = 62), sphincter of Oddi manometry (N = 53), other (N = 66). EUS indications were as follows: known or suspected pancreatic mass (N = 103), upper-gastrointestinal mass/submucosal lesion (N = 71), luminal malignancy staging (N = 40), other (N = 96); 52% had EUS fine-needle aspiration. There was follow-up evaluation in 94% of the patients. There were 43 comprehensive ERCP complications (12.9%), 18 (5.4%) of these fit consensus criteria: pancreatitis (N = 14), cholangitis (N = 2), and perforation (N = 2). There were 9 comprehensive EUS complications (2.9%), 2 (.7%) of these fit consensus criteria: pancreatitis (N = 1) and bleeding (N = 1). Other adverse events for ERCP and EUS were as follows: prolongation of 23-hour observation (N = 14), emergency room visits (N = 3), primary care physician visits (N = 6), use of reversal agents (N = 3), unplanned admissions (N = 2), infection (N = 3), and death (N = 1). ERCP and EUS can be performed in an AEC, provided mechanisms for admission and anesthesia support are in place. The assessment of comprehensive complications is more reflective of adverse events related to ERCP and EUS than consensus criteria alone.

Prospective Evaluation of Impact of Endoscopic Management On Sphincter of Oddi Dysfunction in Children

Background: Data on sphincter of Oddi dysfunction (SOD) in children is scant. Most children diagnosed with SOD are treated by biliary sphincterotomy with suboptimal results. The efficacy and safety of pancreatic and dual sphincterotomy in children with SOD has not been previously reported. Objective: Evaluate the efficacy and safety of pancreatic and dual sphincterotomy in children with SOD. Materials and Methods: Prospective study of all children who underwent ERCP with sphincter of Oddi manometry (SOM) for evaluation of suspected SOD over a 3-yr period. Children diagnosed with SOD underwent pancreatic or dual sphincterotomy with prophylactic pancreatic stenting. Complications were assessed per consensus criteria. Results: Of the 27 children referred for ERCP, 11 underwent SOM for suspected SOD: six were diagnosed with SOD and constitute the study population; five others had normal SOM. Of the 6 children (mean age 11 yrs; range, 5-16; 4 girls) with SOD, 3 presented with recurrent pancreatitis and 3 with post-cholecystectomy pain. All children had >6 hospitalizations/yr and significant loss of school days due to their presenting complaints. Pancreatic sphincter hypertension was noted in all six patients; concomitant biliary sphincter hypertension was noted in the three patients with post-cholecystectomy pain. Patients with recurrent pancreatitis underwent pancreatic sphincterotomy and the three with post-cholecystectomy pain underwent dual sphincterotomy. 3 Fr prophylactic pancreatic stents were placed in all patients. One girl experienced mild post-ERCP pancreatitis that was managed conservatively. At a mean follow-up of 583 days (range, 325-1445), four patients were asymptomatic, one experienced partial symptom relief, and one had recurrent symptoms. Conclusions: As in adults, pancreatic and dual sphincterotomy, in expert hands, is effective and safe in a subgroup of children with SOD. Prospective randomized trials with larger number of patients are required to validate the efficacy of endotherapy in children with SOD.

Functional Gallbladder and Sphincter of Oddi Disorders

The functional disorder of the gallbladder (GB) is a motility disorder caused initially either by metabolic abnormalities or by a primary motility alteration. The functional disorders of the sphincter of Oddi (SO) encompass motor abnormalities of either the biliary or the pancreatic SO. Dysfunction of the GB and/or biliary SO produce similar patterns of pain. The pain caused by a dysfunction of the pancreatic SO can be similar to that of acute pancreatitis. The symptom-based diagnostic criteria of motility dysfunction of the GB and biliary SO are episodes of moderate to severe steady pain located in the epigastrium and right upper abdominal quadrant that last at least 30 minutes. GB motility disorder is suspected after gallstones and other structural abnormalities have been excluded. This diagnosis should then be confirmed by a decreased GB ejection fraction induced by cholecystokinin at cholescintigraphy and after disappearance of the recurrent biliary pain after cholecystectomy. Symptoms of biliary SO dysfunction may be accompanied by features of transient biliary obstruction, and those of pancreatic SO dysfunction are associated with elevation of pancreatic enzymes and even pancreatitis. Biliary-type SO dysfunction is more frequently recognized in postcholecystectomy patients. SO manometry is valuable to select patients with sphincter dysfunction; however, because of the high incidence of complications, these patients should be referred to an expert unit for such assessment. Thus invasive tests should be performed only in the presence of compelling clinical evidence and after noninvasive testing has yielded negative findings. The committee recommends that division of the biliary or pancreatic sphincters only be considered when the patient has severe symptoms, meets the required criteria, and other diagnoses are excluded.

Bio-sensor system discriminating between the biliary and pancreatic ductal systems

Sphincter of Oddi manometry is the "gold standard" to evaluate the ductal anatomy of patients with suspected sphincter of Oddi dysfunction. During such procedure it can be unclear which duct is being investigated without radiographs. Bilirubin and other pigments in bile strongly absorb blue light, whereas pancreatic fluid is clear and does not absorb blue light. The bio-sensor system incorporates fibre-optic technology to measure blue light absorbance in the ducts. Bench tests and animal tests were conducted utilising possums. In bench and animal experiments the bio-sensor correctly discriminated between bile and pancreatic juice, based on the absorbance of blue light. The mean absorbance of the bile was 3.57+/-1.74 and that of the pancreatic duct fluid was 0.53+/-0.34 (P<0.01) in the animal models. The optical sensing system could be incorporated into a manometry catheter to aid sphincter of Oddi manometry shortening procedure time and reduce radiography exposure.

Sphincter of oddi dysfunction in children

Sphincter of Oddi dysfunction (SOD) is a clinical entity caused by a primary motility alteration of either the biliary or the pancreatic sphincter. SOD is a rare condition that has been scarcely reported in children. Most of the reported literature has been in children with idiopathic recurrent pancreatitis. These children are treated endoscopically by dual sphincterotomy of the pancreatic and common duct sphincters. However, the safety and efficacy of sphincter of Oddi manometry and sphincterotomy in the pediatric population await further study.

Risk Factors for Post-ERCP Pancreatitis: A Prospective Multicenter Study

Pancreatitis is the most common and serious complication of diagnostic and therapeutic ERCP. The aim of this study is to examine the potential patient- and procedure-related risk factors for post-ERCP pancreatitis in a prospective multicenter study. A 160-variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study evaluating whether prophylactic corticosteroids will reduce the incidence of post-ERCP pancreatitis. Data were collected prior to the procedure, at the time of procedure, and 24-72 h after discharge. Post-ERCP pancreatitis was diagnosed and its severity graded according to consensus criteria. Of the 1,115 patients enrolled, diagnostic ERCP with or without sphincter of Oddi manometry (SOM) was performed in 536 (48.1%) and therapeutic ERCP in 579 (51.9%). Suspected sphincter of Oddi dysfunction (SOD) was the indication for the ERCP in 378 patients (33.9%). Pancreatitis developed in 168 patients (15.1%) and was graded mild in 112 (10%), moderate in 45 (4%), and severe in 11(1%). There was no difference in the incidence of pancreatitis or the frequency of investigated potential pancreatitis risk factors between the corticosteroid and placebo groups. By univariate analysis, the incidence of post-ERCP pancreatitis was significantly higher in 19 of 30 investigated variables. In the multivariate risk model, significant risk factors with adjusted odds ratios (OR) were: minor papilla sphincterotomy (OR: 3.8), suspected SOD (OR: 2.6), history of post-ERCP pancreatitis (OR: 2.0), age <60 yr (OR: 1.6), > or =2 contrast injections into the pancreatic duct (OR: 1.5), and trainee involvement (OR: 1.5). Female gender, history of recurrent idiopathic pancreatitis, pancreas divisum, SOM, difficult cannulation, and major papilla sphincterotomy (either biliary or pancreatic) were not multivariate risk factors for post-ERCP pancreatitis. This study emphasizes the role of patient factors (age, SOD, prior history of post-ERCP pancreatitis) and technical factors (number of PD injections, minor papilla sphincterotomy, and operator experience) as the determining high-risk predictors for post-ERCP pancreatitis.

Serum amylase, pancreatic stents, and pancreatitis after sphincter of Oddi manometry

Serum amylase levels 2 hours after ERCP predict postprocedure pancreatitis. The value of serum amylase measurements after sphincter of Oddi manometry (SOM) and the effect of pancreatic-duct stent placement on serum amylase are unknown. Records were reviewed for 88 SOM patients who had serum amylase measured 2 hours after the procedure. Post-SOM pancreatitis was defined as pain with a >3-fold elevation of serum amylase on the morning after SOM. "Possible pancreatitis" was defined as pain with a <3-fold elevation of serum amylase on the morning after SOM. Post-SOM pancreatitis and possible pancreatitis each occurred in 13% of the study cohort. Post-SOM pancreatitis was associated with the absence of a pancreatic stent and occurred in 0% of patients without a stent who had normal 2-hour serum amylase vs. 67% with elevated 2-hour serum amylase (p < 0.01). Among patients who received a stent, pancreatitis occurred in 6%, regardless of whether the 2-hour serum amylase was elevated. Possible pancreatitis occurred mainly in patients who received stents, and it also was associated with elevation of the 2-hour serum amylase. Elevation of the serum amylase level 2 hours after SOM predicts post-SOM pancreatitis but only in patients who do not receive a pancreatic stent. Among patients who received a stent, elevated 2-hour serum amylase levels predict subsequent findings that may be caused by attenuated pancreatitis.

In vitro Effects of Intravenous Anesthetics on the Sphincter of Oddi Strips of Sheep

Background: Intravenous anesthetics are often used for conscious sedation in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincter of Oddi (SO) manometry. This study was designed to investigate the direct effects of some intravenous anesthetics on SO in sheep. Methods: In sheep SO rings, changes in isometric tension in response to cumulative concentrations of intravenous anesthetics were determined, and values for E_max (mean maximal inhibition) and pD₂ (i.e. the negative logarithm of the concentration for the half-maximal response, EC₅₀) were compared. Results: Meperidine (10^–7 to 3 × 10^–5M), fentanyl (10^–7 to 3 × 10^–5M), midazolam (10^–7 to 3 × 10^–5M) and propofol (10^–7 to 3 × 10^–4M) induced concentration-dependent relaxations on SO precontracted with carbachol (10^–6M). E_max and pD₂values following meperidine, fentanyl and midazolam administration were significantly greater than after propofol (p < 0.05). There were no significant differences in E_max and pD₂values for meperidine, fentanyl and midazolam. Conclusion: These results suggest that meperidine, fentanyl and midazolam are equipotent relaxants in the sheep SO in vitro. The relaxatory effect of propofol was 10 times less potent compared to the above agents, and it can be beneficial during SO manometry in controlled clinical human studies.

Functional Biliary-Type Pain

Recurrent biliary-type abdominal pain is a perplexing clinical dilemma that occurs in patients with an acalculous gallbladder in situ or in patients who have undergone a previous cholecystectomy. The pathogenesis of functional biliary-type pain is often unclear; therefore, evaluation and management remain controversial. In patients with an acalculous gallbladder in situ, critical importance has been given to delayed gallbladder emptying using cholescintigraphy (CCK-CS) to determine if gallbladder dysfunction is present. However, several issues remain unresolved, including methodology, definition of delayed emptying, and the absence of high-quality studies to determine if CCK-CS can predict who will do well with cholecystectomy. In patients with previous cholecystectomy, the main area of controversy is the evaluation of patients with sphincter of Oddi Type III, including the role of endoscopic retrograde cholangiopancreatography with SO manometry and sphincterotomy in these patients. Suggested algorithms for management of both clinical scenarios are provided.

Frequent occurance of postprandial antral hypomotility proved by antroduodenal manometry in patients with postcholecystectomy syndrome and normal sphincter of Oddi manometry

Frequent occurance of postprandial antral hypomotility proved by antroduodenal manometry in patients with postcholecystectomy syndrome and normal sphincter of Oddi manometry

Role of the Duodenum on Sphincter of Oddi Motility in Conscious Dogs

目的 通过观察清醒状态下十二指肠切除后狗奥狄氏括约肌(SO)运动的变化,检验十二指肠对SO运动的调节作用.方法对照组(n=6)于十二指肠乳头对侧植入测量用套管.十二指肠切除组(n=6)保留十二指肠乳头切除十二指肠,将近端空肠(重建十二指肠)与胃吻合,原十二指肠乳头与重建十二指肠行端侧吻合,再于吻合后的十二指肠乳头对侧植入测量用套管.经套管插入测压管,通过压力变化来观测SO及十二指肠运动变化.结果十二指肠切除后,SO周期性运动消失,SO呈持续性强收缩状态.结论十二指肠对消化间期SO运动有重要的调节作用。

Influence of juxtapapillary diverticulum on hepatic clearance in patients after endoscopic sphincterotomy

The role of juxtapapillary diverticulum ( JPD) in biliary stone formation is controversial. This study was designed to understand the relationship between the size of JPD, hepatic clearance and recurrent bile duct stones in patients after endoscopic sphincterotomy. Five hundred and twenty patients with choledocholithiasis who had received endoscopic sphincterotomy were enrolled. They were divided into three groups: group A (n = 268) without diverticula; group B (n = 156) with small diverticula; and group C (n = 96) with large diverticula. All patients were regularly followed with interviews, liver function test and sonogram to detect the recurrent bile duct stones. Quantitative cholescintigraphy was performed in 176 cholecystectomized patients to evaluate the hepatic clearance. Sphincter of Oddi manometry was performed to exclude incomplete sphincterotomy if quantitative cholescintigraphy was abnormal. After 9-111 months of follow-up, 76 patients had recurrent bile duct stones. There was a significant higher bile duct stone recurrence in group C than in group A (P < 0.01), but no statistical difference was noted between group B and group A (P = 0.2). Patients with JPD were older than those without (P < 0.05). Of 176 cholecystectomized patients, two were excluded because sphincter of Oddi basal pressure was more than 10 mmHg. In the remaining 174 patients, the E45' was significantly lower in group C than in group A (41.2% +/- 18.6%vs 49.1% +/- 14.1%; P < 0.05), and there was no significant difference between group B and group A. JPD is a predisposing factor of delayed biliary emptying and it increases the chance and incidence of recurrent bile duct stones.