Sphincter Of Oddi Research Articles

Pay attention to endoscopic diagnosis and treatment for confluence disease of pancreaticobiliary ducts

The confluence of pancreaticobiliary ducts refers to the area between the end of common bile duct, the opening of main pancreatic duct and duodenal papilla. Those confluence diseases of pancreaticobiliary ducts will cause obstruction of biliary and pancreatic outflow tract, cholestasis, pancreatic juice deposition or pancreaticobiliary reflux, and thus induce gallstones, cholangitis, pancreatitis and other diseases. Endoscopic ampullary sphincterotomy is an important way to treat biliary and pancreatic diseases, but the length of incision is determined by the anatomy of Oddi sphincter. The endoscopic approach aims to relieve biliary and pancreatic outflow tract obstruction and pancreatic biliary reflux, and avoid enterobiliary reflux.

Video Caso Clínico: Síndrome del muñón del cístico, resección laparoscópica del remanente

BACKGROUND: Laparoscopic cholecystectomy is one of the most frequently performed surgical procedures, which has gradually evolved to become one of the safest surgeries. However, no procedure is without risk; in this context, biliary duct injury (BDI) is the most important intraoperative complication during cholecystectomy. Common bile duct injury reaches a variable incidence between 0.4 to 1.4%, which is associated with significant long-term morbidity, including stenosis and recurrent cholangitis, significant limitations in the life quality of the patient [1]. In order to reduce the incidence of BDI, several alternative procedures can be performed during a difficult cholecystectomy, among which we can list: cholecystostomy, subtotal cholecystectomy and/or conversion to open cholecystectomy. Subtotal cholecystectomy, according to several meta-analyses, minimizes the possibility of bile duct injury, however, it is associated with the persistence or development of symptomatic gallstones in the remnant of the gallbladder or cystic duct; when this occurs, it is necessary to reoperate on symptomatic patients [1,2]. It is estimated that between 5-40% of patients who have previously undergone cholecystectomy, may present episodes of abdominal pain like those that initially motivated the surgical indication, grouped under the term "post-cholecystectomy syndrome" (PCS) [3]. PCS is mainly caused by residual lithiasis, which represents approximately 21.3% of readmissions [4]; other causes of PCS include: stenosis or bile leak, neuroma in the scar tissue, biliary dyskinesia, Oddi sphincter dysfunction. It is also worth highlighting, within the causes, the cystic duct remnant syndrome defined as "presence of a residual cystic duct greater than 1 cm that produces symptoms as a consequence of the lithiasis inside it", with a prevalence of less than 2.5% among patients that underwent cholecystectomy; however, a high index of suspicion will allow us to recognize it in the immediate postoperative period or even several years later [3,4]. The age range of onset of cystic duct remnant syndrome is from 21 to 90 years. The female preponderance of gallstones is the probable reason for greater frequency of the syndrome in this gender. Clinically, the main reason for consultation is abdominal pain in the right hypochondrium and epigastrium, which occurs in 77% of the patients; accompanied by nausea, in 44% of patients; vomiting in 31% and fever in 19% of patients [5]. Magnetic resonance cholangiopancreatography is the non-invasive technique of choice for evaluating the biliary tree, relegating endoscopic retrograde cholangiopancreatography (ERCP) as a strictly therapeutic technique. In addition, ERCP with sphincterotomy and possible placement of a stent to aid drainage of the main bile duct can be performed, along with definitive surgical treatment, by gallbladder and/or cystic remnant resection [3]. This case report details an experience of surgical reintervention in a patient with a remnant gallbladder and cystic duct with lithiasis.

Magnesium Sulfate for Prevention of Post-ERCP-Pancreatitis: A Randomized Controlled Trial.

Acute pancreatitis is one of the most common complications of endoscopic retrograde cholangiopancreatography (ERCP). Studies suggest that intrapancreatic calcium has an important role in activating pancreatic enzymes; in addition, elevated intraductal pressure is required for development of pancreatitis. Magnesium sulfate (MS), as a calcium antagonist and a muscle relaxant of the Oddi sphincter, is suggested to reduce the incidence and severity of post-ERCP-pancreatitis (PEP) in this article. We included 270 patients who referred for ERCP between March 2017 and March 2018. They were enrolled into MS (2 g) and placebo (normal saline) groups, administered 1 hour before and 6 hours after the procedure. The ERCPs were done by fellows of gastroenterology under supervision of expert physicians. The incidence and severity of PEP were followed. PEP was seen in 12 (8.9%) patients in the MS group and 17 (12.6%) in the placebo group (P value=0.33). The incidence of PEP in high risk patients group (P value=0.017). Although the usage of MS was not able to prevent PEP in all patients enrolled in this study, but it could significantly reduce the incidence of PEP in high risk patients of intervention group in comparison with placebo group. The median length of hospital stay was also significantly lower in new drug group in contrast to placebo.

Frequency of Clinical Symptoms in Post Cholecystectomy Syndrome Patients our Hospital Experience: A Cross-Sectional Study

Aim: To determine the frequency of different clinical symptoms in (PCS) Post Cholecystectomy Syndrome patients, at a secondary care facility Study Design: A cross-sectional study Place and Duration: This study was conducted at Liaquat University of Medical Health Sciences Jamshoro, Pakistan from May 2020 May 2021. Methodology: For the purpose of this study, 100 patients were selected. Only those individuals were selected who qualified against an inclusion criterion which was set based on the patients’ history of cholecystectomy. For this purpose, a questionnaire was made. The patients that were selected had to go through CT (computed tomography) scans and sonographic tests. Blood testing was also done and sera were prepared for in-depth laboratory tests. Data from the research were analyzed by using SPSS version 19. Results: Most common clinical symptom after post-surgery was right upper quadrant pain (114 patients). Epigastric discomfort was present in 97 patients. Fever was third in line (73 patients) with jaundice being fourth (23 patients). Abdominal tenderness (19 patients) was followed by bile leakage (7 patients), fluid in the peritoneal region (19 patients), CBD dilation (39 patients), recurrent stone in CBD (12 patients), retained stone in CBD (19 patients), dysfunctioning of Oddi sphincter (37 patients) and remnants of the cystic duct stump was present in 41 patients. Conclusion: The results of this study show that post cholecystectomy symptoms and conditions vary among patients and all of them need to be kept in while proposing proper follow-up treatment Keywords: post cholecystectomy syndrome, bile leak, sonography, CT scan

Laparoscopic Management of Common Bile Duct Stones using Semi-rigid Ureteroscope- a Single Centre Prospective Observational Study

Background: Minimally invasive and endoscopic techniques are increasingly being used by surgeons nowadays in the management of patients with cholelithiasis and choledocholithiasis. However, there is a high failure rate in the extraction of large impacted stones using the conventional flexible choledochoscope by the laparoscopic approach. Improvisation of this technique will reduce the failure rate. The present study explored the safety, feasibility, and efficacy of a semirigid ureteroscope (SRUS) in the laparoscopic management of common bile duct (CBD) stones. Methods: A prospective observational clinical study was carried out in an experienced GI surgical unit from January 2020 to December 2021. It included 36 patients diagnosed with radiologically proven gallstone disease with bile duct calculi who underwent Laparoscopic CBD exploration (LCBDE) and stone extraction using SRUS with lap cholecystectomy (LC) as a single-stage procedure. The success rate in terms of complete CBD clearance is the primary outcome measure. Post-procedure complications, 24 hr pain score, in-hospital stay, and patient satisfaction score are the secondary outcome measures. Results: Mean age of the study subjects was 50.45±9.12 years. The most common clinical symptom was biliary colic followed by jaundice. The primary outcome measure of complete CBD clearance was achieved in 94%. A complication following surgery was bile leak in one patient (3%). There were no surgical site infections or T-tube related complications. The average WHO 24-hour pain score was 4.9±1.9. The mean in-hospital stay was 3.3±1.4 and the mean patient satisfaction score was 2.42±0.3. Conclusion: Laparoscopic approach avoids the complications of endoscopic retrograde cholangiopancreatography (ERCP) sphincterotomy/sphinteroplasty and keeps the sphincter of Oddi (SOD) intact. LCBDE with SRUS is a safe and effective single-stage approach without any radiation hazards. The pneumatic lithotripter with its pneumatic ballistic effect is more efficacious, cost-effective, and safe as compared to other lithotripsy techniques. This lithotripter is capable of dealing with different varieties of stones regardless of their composition, size and degree of impaction. However, future comparative studies are needed to prove the superiority of this technique.

Clinical Review of Weight Loss Surgery, Procedures, Complications and Post Procedure Complications Management

Introduction: Obesity is worldwide epidemic associated with serious complications both physical and psychological.Weight loss can be achieved with either medications or surgery, however the non-surgical options lacks durability more than two years. The weight loss surgical approaches classifies as: restrictive (adjustable gastric banding, vertical band gastroplasty), restrictive/resective (sleeve gastrectomy), restrictive/malabsorptive (Roux-en-Y gastric bypass, biliopancreatic diversion with duodenal switch) and purely malabsorptive (duodenal switch) options. Aim: Clinical review of different weight loss surgeries, mechanism of achieving weight loss, and complications of each procedure. Management of possible complications for each procedure. Results: [I] Gastric bypass (open and laparoscopic): the most commonly performed operation for long-term weight control in United States. Provides longstanding weight loss, better control of comorbidities as well as post procedure nutritional sequelae. Complications are (1) anastomotic leak (1–5.6%) and management either relaproscopy if detected early or radiological guided drainage for contained collection (2) anastomotic stricture (3- 11%) which can be managed by endoscopic dilatation or surgery (3) internal hernia require reoperation and closure of the defect. [II] Laparoscopic adjustable gastric band: the commonest weight loss surgery procedure in UK, complications are: (1) Pouch enlargement, (2) band erosion and (3) Band slip. [III] Sleeve gastrectomy: It is restrictive procedure involve neither anastomosis nor malabsortion and it is irreversible. Produce its clinical effect by early satiety from stomach volume loss and low circulating ghrelin levels. Complications (1) gastric leak: From staple line with incidence of 0.7-5%. If detected early (>4days) requires urgent surgical repair, however late presentation (5-10 day) for conservative management (2) bleeding. [IV] Biliopancreatic Diversion with Duodenal Switch (BPD/DS), components of the procedure are: (1) sleeve gastrectomy. (2) Division of duodenum between pylorus and sphincter of oddi. (3) Bypassing proximal small intestine through alimentary limb; distal 250 cm of the small intestine from ICV anastomosed end to end with post pyloric duodenum, while billiopancreatic limb has blind end proximal to sphincter of oddi anastomosed distally ileo-ileal about75 to 100 cm from ICV. Advantages are morbid obese patient can lose more weight and maintain it comparing with other bariatric procedures also it has a better control of comorbidities. Complications are: anastomotic leak, bleeding and nutritional deficiencies. Conclusion: Many surgical procedures have emerged as an acceptable bariatric surgical option for obese patients. Most of the bariatric procedures available nowadays offer beside weight loss, a better control of the obesity related comorbidities as Biliopancreatic Diversion with Duodenal Switch (BPD/DS), while others as adjustable gastric band have low complications rate which explains its popularity.

Progress and Current Limitations of Materials for Artificial Bile Duct Engineering.

Bile duct injury (BDI) and bile tract diseases are regarded as prominent challenges in hepatobiliary surgery due to the risk of severe complications. Hepatobiliary, pancreatic, and gastrointestinal surgery can inadvertently cause iatrogenic BDI. The commonly utilized clinical treatment of BDI is biliary-enteric anastomosis. However, removal of the Oddi sphincter, which serves as a valve control over the unidirectional flow of bile to the intestine, can result in complications such as reflux cholangitis, restenosis of the bile duct, and cholangiocarcinoma. Tissue engineering and biomaterials offer alternative approaches for BDI treatment. Reconstruction of mechanically functional and biomimetic structures to replace bile ducts aims to promote the ingrowth of bile duct cells and realize tissue regeneration of bile ducts. Current research on artificial bile ducts has remained within preclinical animal model experiments. As more research shows artificial bile duct replacements achieving effective mechanical and functional prevention of biliary peritonitis caused by bile leakage or obstructive jaundice after bile duct reconstruction, clinical translation of tissue-engineered bile ducts has become a theoretical possibility. This literature review provides a comprehensive collection of published works in relation to three tissue engineering approaches for biomimetic bile duct construction: mechanical support from scaffold materials, cell seeding methods, and the incorporation of biologically active factors to identify the advancements and current limitations of materials and methods for the development of effective artificial bile ducts that promote tissue regeneration.

ВЫБОР ОПТИМАЛЬНОГО ВАРИАНТА ЭНДОСКОПИЧЕСКОГО ЛЕЧЕНИЯ ПАЦИЕНТОВ С ХОЛЕДОХОЛИТИАЗОМ

Introduction. When using traditional endoscopic methods of choledocholithiasis treatment, the issues related to the remaining high risk of post manipulative complications remain unsolved. The priority task is the development of new methods of endoscopic treatment, which will prevent the development of postoperative complications. Aim. The aim of the study was to determine the optimal treatment option based on the comparative analysis of different ways of endoscopic interventions in patients with choledocholithiasis. Material and methods. The paper presents the outcomes of endoscopic interventions in 127 patients with choledocholithiasis. Of them 84 patients composed the main group in which choledocholithiasis treatment was performed according to the original method including two operative stages. On the first one we performed partial papillotomy, temporary stenting of common bile duct (in 100%) and main pancreatic duct (in 45%), and papillotomy over the stent to the muscular layer of Oddi sphincter. On the second one after 2–4 days the biliary stent was removed, lithoextraction was performed along with bile duct restenting. Pancreatic and biliary stents were removed after 24 hours and 3–8 weeks respectively. A comparison group was composed of 43 patients who underwent endoscopic surgeries by the classical well-known methods. Results and discussion. The analysis showed that the differences in the groups with classical method of choledocholithiasis endoscopic treatment (CMCLET) and original method of choledocholithiasis endoscopic treatment (OMCLET) between the levels of «Average number of surgeries per patient» (2,05 surgeries ranging from 1 to 4 for CMCLET versus 2,41 surgeries ranging from 2 to 5 for OMCLET; p=0,0176) and «Duration of hospitalization» (10,4 days to 8,95 days; p=0,0377), there was an inverse relationship between the number of surgeries and duration of hospitalization, which was largely due to different levels of the rate of early postoperative complications (p=0,0005). Twenty times higher blood amylase levels in the main group compared to the reference values did not lead to the development of acute pancreatitis, the incidence of which was 7 times lower in the comparison group (p=0,001). Conclusion. Comprehensive study of the outcomes of endoscopic treatment in patients with choledocholithiasis using different variants of interventions has shown convincing superiority of the original method of surgical aid.

Paradoxical Stimulatory Response of Remanent Sphincter of Oddi to Buscapina After Endoscopic Sphincterotomy.

Background/AimsEndoscopic removal of bile duct stones has become the treatment of choice, which includes endoscopic sphincterotomy (EST) in the majority of cases, destroying at least partially the Oddi sphincter (OS). Loss of sphincter function in variable grade has been described, but changes in innervation are not known.MethodsEndoscopic manometry of OS was performed in 14 patients after EST with specialized perfused catheter. Pressure values were registered before and after 10 mg Buscapina injected intravenously.ResultsCholedocho-duodenal pressure gradient was absent in all of 14 patients. Basal OS pressure was zero in 7 and conserved in normal range in the remaining 7. Phasic motor activity was registered in 11 patients and was absent in 3 patients. After 10 mg Buscapina intravenous injection, instead of habitual inhibition, increase in basal OS pressure and in frequency of phasic contractions was observed in 9 patients. This response was not related to age of patients, neither with time elapsed between the EST and manometry, nor the estimated size of papillotomy orifice. Duodenal peristalsis was invariably inhibited in all patients.ConclusionsEST destroys not only the smooth muscle of OS, also alters the innervation interrupting the duodeno-sphincteric nerve circuit. This finding questions the use of Buscapina or other anticholinergic agent as spasmolytic in patients after EST.

Postcholecystectomy syndrome, dynamics of ideas, diagnostics, treatment

This article provides an overview of the data on postcholecystectomy syndrome (PCES). The entire period of study of this frequent complication (up to 40%) can be divided into 2 periods: surgical and therapeutic. Surgical complications of cholecystectomy accounted for 10% and were studied by surgeons. This study led to the correction of surgical treatment, formulated the examination program and reduced and minimized surgical complications. The second part of the complications is made up of functional disorders of the sphincter of Oddi, which today are the leading ones and, apparently, remain so. The article gives an idea of PCES as a dynamic disorder of the sphincter of Oddi, gives the last definition of PCES given by the IV Roman Concensus, suggests an algorithm for diagnosis and treatment. As a clinical illustration, the authors present their own data on the diagnosis and treatment of 60 patients with PCES, which confirmed the point of view proposed by the international gastroenterological community. The authors separated two types of postcholecystectomy syndrome: one with a predominance of sphincter of Oddi (SO) spasm and another with a predominance of sphincter of Oddi hypotension. The drug of choice in the spastic type is the selective antispasmodic gimecromone, in which case a dose is of the essence. In case of a hypotonic type of postcholecystectomy syndrome, motor regulators to increase the SO tone should be used. The therapy should be stepwise with an assessment of the effect and correction of the next step of treatment. This treatment option for patients with postcholecystectomy syndrome we see today as the leading one. The features of treatment associated with the developing syndrome of bacterial overgrowth (SIBO) and chronic biliary insufficiency (CBI), which require constant monitoring (diagnosis) and permanent treatment, are considered.

S3576 Oddity of an Opiated Oddi: A Case of Sphincter of Oddi Dysfunction

Introduction: We present a case of recurrent right upper quadrant (RUQ) pain resulting from Sphincter of Oddi Dysfunction (SOD) in the setting of chronic opioid use. SOD is a functional gastrointestinal disorder that presents similarly to other disorders of the biliary tree. Understanding features of this disorder and its etiologies can streamline evaluation and treatment. Case Description/Methods: Our patient is a 77-year-old male, chronic opioid user, who had multiple Emergency Department (ED) visits and hospital admissions for RUQ pain in the setting of significantly elevated liver associated enzymes (LAEs). However, repeated imaging of the RUQ with CT, Ultrasound, and MRCP remained largely unremarkable. On a subsequent presentation, the patient experienced severe increase in pain after administration of morphine. Lab investigation showed an abrupt increase in LAEs and lipase after administration of morphine. Imaging was obtained, and was again inconsistent with cholecystitis. Interestingly, he attained analgesia with meperidine on admission. During a following ED visit, RUQ imaging showed non-specific gallbladder inflammation, and a Hepatobiliary Iminodiacetic Acid (HIDA) scan showed low gallbladder ejection fraction (GBEF). These findings suggested Functional Gallbladder Disorder and laparoscopic cholecystectomy was performed. Unfortunately, ten days later the patient had worsening RUQ pain with no signs of obstruction. With diagnostic criteria for SOD met and other etiologies ruled out, our patient was referred for sphincterotomy. Discussion: Opiate-induced SOD is theoretically well known, but there have been only few reported cases in literature. Furthermore, SOD is difficult to diagnose, as providers must first rule out other hepatobiliary disease. ROME IV Diagnostic Criteria for Functional Gastrointestinal Disorders was used in review of our case. Biliary pain, absence of bile duct stones or other structural abnormalities, and elevated LAEs fulfilled the criteria for this disorder. This case highlights the clinical evaluation and care of SOD. While all opioids have been shown to contract the Sphincter of Oddi (SO), morphine has been shown to strongly cause this contraction, and is one of the earliest reported causes of SOD in literature. Meperidine has been shown to have minimal effect on the SO contraction and is the ideal opioid to treat pain of biliary or pancreatic source.

S1373 Epidemiology of Ampullary Cancer in the Unites States: A Population-Based Study

Introduction: Ampulla of Vater is a complex structure formed by the union of the pancreatic duct and common bile duct into an opening into the medial wall of duodenum at the sphincter of oddi. Ampullary cancer is defined as cancer arising from ampulla of vater distal to the bifurcation of common bile duct and pancreatic duct. Ampullary cancer is rare and account for 0.2% of gastrointestinal tract tumors with estimated average 5-year survival rate of 40%. There are limited data in the literature regarding the epidemiology of ampullary cancer. Using a large database, we explored the epidemiology of ampullary cancer in US. Methods: We queried a commercial database: Explorys Inc, Cleveland, OH, USA; an aggregate of electronic medical records data from 26 major integrated US healthcare systems consisting of 36 hospitals in the US, between the years 2016 and 2021. After we excluded patients with age < 20, a cohort of patients with Systematized Nomenclature of Medicine ¬ Clinical Terms (SNOMED–CT) of “Primary malignant neoplasm of Ampulla of Vater” were identified and prevalence was calculated. Multivariable model was performed to adjust for cofounding factors. Results: Out of 29,123,520 individuals in the database, 1,170 patients with ampullary cancer were identified. The baseline characteristics of the study population are presented in Table1. Prevalence of Ampullary cancer is 4.01 per 100.000. Using a univariate analysis, the prevalence of ampullary cancer in different age groups is presented in Figure 1 (top), and based on sex and race in Figure 1 (bottom). After adjusting for cofounding factors, patients with ampullary cancer are more likely to be senior adults with age above 65 (OR 5.4, 95% CI: 4.8 - 6.1), males (OR 1.4, 95% CI: 1.3 - 1.6), smokers (OR 1.7, 95% CI: 1.5-1.9), diabetic (OR 2.6, 95% CI: 2.4 - 2.9), and have inflammatory bowel disease (OR 5.6, 95% CI: 4.7 - 7), with family history of gastrointestinal malignancy (OR 4.5, 95% CI: 3.8 - 5.2) Conclusion: Our study is one of the largest US population studies to date evaluating the epidemiology of ampullary cancer. Patients with ampullary cancer were more likely to be elderly, males, asian, smokers, diabetic, and have inflammatory bowel disease and with family history of gastrointestinal malignancy. Being a rare cancer with high mortality rate, the clinician must keep a high index of suspicion of ampullary cancer in patients with the risk factors emphasized in this study for timely diagnosis and better outcomes.Table 1.: BMI, Body mass index - GI, Gastrointestinal.Figure 1.: (Upper panel): Prevalence rate of Ampullary Cancer based on age groups. (Lower Panel): Prevalence rate of Ampullary Cancer based on sex and race.

Морфологічна діагностика ерозивного езофагіту при гастроезофагеальній рефлюксній хворобі

Досліджено біоптати стравоходу 79 хворих із клінічно підтвердженою гастроезофагеальною рефлюксною хворобою. За допомогою комп’ютерної морфометрії виміряно та проаналізовано ширину міжклітинних просторів плоского епітелію стравоходу, а також особливості міграції клітин запалення у випадках розвитку неерозивного, ерозивного й еозинофільного езофагіту залежно від тонуса сфінктера Одді та жовчного міхура.

Our Experience in Single Center Endoscopic Retrograde Cholangiopancreatography

Amaç: Endoskopik retrograd kolanjiopankreatografi (ERCP), safra yolu ve pankreasın benign ve malign patolojilerinin tanı ve tedavisinde etkin bir biçimde kullanılmaktadır. ERCP bilgi, beceri ve pratik gerektiren kompleks bir uygulamadır. Diğer endoskopik uygulamalardan farklı teknik ve ekipmanın kullanımı ve daha fazla komplikasyon görülmesiyle ayrılır. Bu çalışmadaki amacımız bir genel cerrahi ERCP ünitesinin 19 aylık deneyimini paylaşmaktır. Materyal ve metod: Bu çalışmada15 Mayıs 2019-31Aralık 2020 tarihleri arasında klinik, medikal ve radyolojik verilerde kolestaz, obstruktif kolanjit/pankreatit veya safra kaçağı tanısı konulan ve ERCP işlemi yapılan 513 hastanın verileri retrospektif olarak değerlendirmiştir. Bulgular: Çalışmaya alınan hastaların yaş dağılımı 18-109 arasında ve yaş ortalaması 58,54±20,16 idi. Cinsiyet dağılımı; 356 kadın (%69,4), 157 erkek (%30,6) şeklinde idi. En sık safra yolu tıkanıklığına bağlı kolestaz, tıkanma ikteri, akut pankreatit veya kolanjit tanıları konulmuştu. Bu hastaların 452 si koledok taşı, 15’i pankreas başı tümörü, 11’i koledok tümörü ve 10’u papilla tümörü idi.10 hasta Oddi Sfinkter Disfonksiyonu( ODS) nedeniyle işleme alındı. Safra yolu tıkanılığı ile gelen 499 hastanın 63’ü akut biliyer pankreatit, 38 i akut kolanjit tanılarıyla yatırılmıştı. İşlem süresi 20 dakikayla 90 dakika arasında değişti (ortalama işlem süresi 37 dk). Hastaların ERCP sonrası, 56’sında tedavi gerektirmeyen amilazemi, 24‘ünde ortalama 3 günlük medikal tedaviyle gerileyen pankreatit, 5’inde kan transfüzyonu gerektirmeyen ve adrenalin enjeksiyonu ve balon baskısıyla kontrol edilebilen kanama gelişti. Bir hastada taş ekstraksiyonu sırasında basket ve taş papillada sıkışmıştı. Operatif mortalite olmadı. Sonuç; Safra yollarındaki kaçaklar ve fistüller en iyi ERCP ile gösterilir ve endoskopik olarak tedavi edilir. Etkin olduğu kadar bünyesinde perforasyon, sepsis ve mortalite gibi çok ciddi komplikasyonları barındırdığından endoskopistin uygulamanın endikasyonunu doğru belirlemesi, potansiyel komplikasyonlarını bilmesi ve oluşan komplikasyonları erken bir şekilde tanıması ve tadavisini yönetmesi, komplikasyon yaratacak ve gereksiz uygulamalardan mumkun olduğunca kaçınması gerektiği kanaatindeyiz.

Gall stones and hypothyroidism: a double jeopardy

Background: Gall stones are one of the frequent biliary pathologies in the biliary system. Gall stones are deposition of bile pigments, cholesterol and calcium salts in the form of hard crystalline mass in the gall bladder. Saturation of bile in gall bladder, bile stasis due to sphincter of Oddi dysfunction, biliary sludge and change in chemical disproportion of bile are all risk factors for gall stone development. Thyroid disorders are also a very common endocrine pathology. On the Oddi sphincter, thyroid hormone receptors are present, and thyroxine has a strong relaxing effect on the sphincter. Hypothyroidism reduces the gall bladder contractility and causes lipid metabolism alteration which leads to biliary stasis. These promote the gall stone formation.Methods: A single centre cross-sectional study, was done among 86 patients diagnosed with cholelithiasis clinically and confirmed by ultrasonography. All patients were subjected to thyroid profile test, liver function test, fasting lipid profile test. Patients with a history of hypothyroidism were excluded from the study.Results: Among 86 study subjects, 29 (33.7%) of study subjects had hypothyroidism, out of which 21 (24.4%) had subclinical hypothyroidism, 8 (9.3%) had clinical hypothyroidism. Of the remaining subjects 4 (4.7%) were hyperthyroid and 53 (61.6%) were Euthyroid. A total of 24 subjects had dyslipidaemia of which (15) 62.5% had clinical and sub clinical hypothyroidism (p&lt;0.001).Conclusions: In the evolution of Gall stones in hypothyroid patients, decreased liver cholesterol metabolism, decreased bile emptying and decreased Oddi relaxation sphincter play a role. In our study there was a strong association between hypothyroidism and gall stones. Hypothyroid patients also had abnormal total cholesterol, triglycerides and ALP levels.

Possible reasons for the regrettable results of patency of an inside stent in endoscopic transpapillary biliary stenting.

Endoscopic biliary decompression is a minimally invasive procedure for cholestasis since the first endoscopic retrograde cholangiopancreatography-guided biliary stenting performed by Soehendra and Reynders-Frederix. Among the endoscopic biliary decompression, endoscopic transpapillary biliary stenting (EBS), is a mainstream choice and presently has two methods of placement: stenting above the sphincter of Oddi (SO) (suprapapillary) and stenting across the SO (transpapillary). Stent patency is the most important concern for patients, endoscopists and physicians because it can affect both the life prognosis and treatment schedule of patients. Biliary stent occlusion can occur because of several factors. Among them, direct food impaction, biofilm formation, and sludge formation play important roles and are presumed to be theoretically overcome by EBS above the SO. Thus, EBS above the SO is expected to result in a longer patency than EBS across the SO. In the literature, there have been six comparative studies on EBS for distal biliary obstruction in which the stent was placed above or across the SO, including two randomized controlled trials (RCTs) with negative results of stenting above the SO. With respect to EBS for hilar biliary obstruction, there have been no RCTs, whereas four retrospective comparative studies with negative results and four retrospective comparative studies showing positive results of stenting above the SO have been reported. In this review, we focused on EBS above and across the SO, and summarized the positive and negative results of the two types of stenting to promote effective clinical practice and to provide a basis for future studies.

Thyroid function and gallstone disease: is there an association?

Gallstone disease, amounts to a significant amount of disease burden to the medical society, more commonly encountered in the West. Various predisposing factors are associated with the development of cholelithiasis, namely age, gender, dietary food habits and haemolytic conditions, but whether or not thyroid dysfunction is a causative factor, till date, is a subject of dispute. Gallstones can be classified into cholesterol stones and pigment stones which are black or brown (with cholesterol) in colour. Thyroid hormones are said to have a direct effect on the sphincter of oddi, thereby aiding in biliary emptying. They also alter the lipid metabolism which is said to cause supersaturation of cholesterol in bile, and hence result in the formation of cholesterol stones. Several studies have tried to establish this hypothesis and have concluded with diversified results. This review article throws light into the concept of the association between thyroid dysfunction and formation of gallstones by evaluating several articles through a systematic approach in order to arrive at a better consensus.

Efficacy and Safety of Hymecromone Various Doses in Patients Who Have Undergone Cholecystectomy

Laparoscopic cholecystectomy is the leading method of treatment of cholelithiasis. Often, postcholecystectomy syndrome develops after cholecystectomy. In most cases, its manifestations are of a functional nature and are associated with dysfunction of the Oddi sphincter. A study of the effectiveness of the drug Odeston (hymecromone) at doses of 600 mg and 1200 mg per day in patients with postcholecystectomy syndrome was conducted. 36 patients were randomized into two groups: the first group consisted of 18 patients receiving the drug hymecromone at a dosage of 600 mg per day (200 mg three times a day), the second group of 18 patients receiving the drug hymecromone 1200 mg per day (400 mg three times a day). The duration of therapy was 21 days. When assessing the pain syndrome on a visual analog scale, statistically significant dynamics (Chi2; p &lt; 0.01) was observed in both groups after therapy, most pronounced in the second group. In the second group, normalization of the stool was noted (Chi2; p = 0.015) and a decrease in the diameter of the common bile duct (Wilcoxon criterion; p = 0.05). When assessing the dynamics of abdominal pain and its impact on daily activities 90 days after therapy, a statistically significant advantage was revealed in the second group (Chi2; p = 0.014). The data obtained indicate that Odeston is more effective in postcholecystectomy syndrome at a dose of 1200 mg per day.

Dormia catheter trapped in the bile duct: an unknown complication

Conventional treatment of lithiasis of the main biliary tract (MBT) is based on endoscopic sphincterotomy followed by extraction of the stone(s) using a balloon catheter and/or Dormia catheter. Several risk factors associated with failure to remove a stone in the main biliary tract have been reported. The most important factor is probably a stone volume greater than 15 mm or an initial diameter of the MBT smaller than that of the stone. Care must be taken not to impact the stone in the Oddi sphincter or in the Dormia in order not to compromise stone removal. Complications associated with the use of the Dormia catheter include bile duct injuries, which are a well-known surgical problem. Injuries specifically related to the use of catheter have been less reported and seem to be underestimated. We here display an image showing Dormia catheter trapped in the bile duct around a fixed stone which couldn´t be removed after endoscopic exploration in a 60-year-old patient with cholangitis caused by lithiasis. Choledochotomy for removal of stone was performed.

Oddi Sphincter Repair for Biliary Complications after Endoscopic Papillectomy

Introduction: Endoscopic papillectomy (EST) is widely used in the treatment of benign biliary diseases. However, EST can permanently disrupt the function of the Oddi sphincter, resulting in an increased risk of cholangitis, choledocholithiasis, and cholangiocarcinoma.