胆囊切除术后奥狄括约肌功能障碍的内镜治疗

目的 探讨内镜下乳头括约肌切开术对胆囊切除术后Oddi括约肌功能障碍的治疗价值。方法 胆囊切除术后综合征患者行B超、经内镜逆行胰胆管造影检查，测定Oddi括约肌基础压，排除胆管残留或再生结石、胆管狭窄及肿瘤等病变，对最后诊断为Oddi括约肌功能障碍的28例患者行内镜下乳头括约肌切开术。结果 18例患者术后症状基本消失，5例症状明显缓解，2例2次行内镜下乳头括约肌切开术后症状得到缓解，3例术后症状无缓解，手术有效率89．3％（25／28），无严重并发症发生。结论 内镜下乳头括约肌切开术对胆囊切除术后Oddi括约肌功能障碍是一种微创、安全、有效的治疗手段。     

经内镜乳头括约肌切开术后的肠胆反流和胰胆反流

经内镜乳头括约肌切开术（ endoscopic sphincterotomy,EST）是在ERCP诊断性技术的基础上发展起来的,是一种内镜下高频电切开十二指肠乳头及胆总管末端括约肌的治疗技术。EST经过近40年的临床应用和发展,已经成为胆总管结石、胆源性胰腺炎、急性梗阻性化脓性胆管炎及乳头括约肌功能障碍（sphincter of Oddi dysfunction,SOD）等胆胰疾病的内镜下标准治疗方式。但EST需部分或全部切开胆管或胰管括约肌,势必会带来Oddi括约肌结构和功能的损伤。     

Oddi括约肌功能与经内镜乳头括约肌切开术后远期 并发症的关系

胆总管结石是临床常见病,经内镜逆行胰胆管造影术(ERCP)联合经内镜乳头括约肌切开术(EST)是临床首选的治疗方法。然而其术后远期并发症发生率仍然很高,目前较公认的机制是EST术中破坏了Oddi括约肌结构,引发功能障碍,导致肠胆反流,进而出现术后远期并发症。本文就Oddi括约肌功能与EST术后远期并发症的关系及研究现状做如下综述。     

32例Oddi括约肌功能障碍患者临床病理分析

目的提高对Oddi括约肌功能障碍的认识,探讨本病的临床病理特征,以提高对Oddi括约肌功能障碍诊治水平.方法对32例因上腹部疼痛无其他原因解释而行内镜下逆行胰胆管造影或内镜下乳头括约肌切开术患者进行了乳头黏膜组织的活检,对活检标本常规石蜡包埋,HE染色,显微镜下观察,记录其病理改变.同时记录经内镜逆行胰胆管造影（ERCP）下乳头黏膜的病理变化.结果内镜下乳头黏膜主要为充血水肿（90.6%）、糜烂（78.1%）、出血（56.2%）等.ERCP见胆总管扩张,合并十二指肠乳头旁憩室者占59.4%.病理组织学表现为乳头黏膜慢性炎症、急性炎症、腺体增生、黏膜下纤维组织增生等.结论Oddi括约肌功能障碍的病因和病理尚不清楚,其乳头组织的病理改变主要为炎性反应,炎症反应在Odd括约肌功能障碍的发病中具有重要的意义,这可能为诊断和治疗本病提供新的靶点.     

Oddi括约肌狭窄15例临床分析

Oddi括约肌狭窄是一种 Oddi括约肌功能障碍( SOD) [1] ,主要因 Oddi括约肌结构异常所致。胆结石通过十二指肠乳头、手术操作致 Vater壶腹损伤、子宫内膜异位症等继发 Oddi括约肌慢性炎症及纤维化均可导致 Oddi括约肌狭窄。为提高其诊治水平 ,现对 1 5例 Oddi括约肌狭窄患者的临     

Oddi括约肌测压及内镜下十二指肠乳头切开术对Oddi括约肌运动功能障碍诊治的意义

目的：对60例胆囊切除术后复发腹痛患者进行Oddi括约肌测压研究，并探讨内镜下十二指肠乳头切开术（EPT）对Oddi括约肌基础压升高患者疗效。方法：用低顺应性灌注系统，三通道测压导管，观察Oddi括约肌基础压、Oddi括约肌基础收缩幅度、频率和传播方式。对Oddi括约肌基础压＞6．32kPa（35mmHg）者，随机分为两组，一组予以EPT治疗，另一组作为对照，并随访其疗效。结果：Oddi括约肌测压异常发生率为46．7％。Oddi括约肌基础压升高者，EPT治疗后，随访3～18个月，有效率为91．7％，明显高于对照组（P＜0．05）。结论：Oddi括约肌测压对Oddi括约肌运动功能障碍（SO）的诊断具有较高价值。测压发现Oddi括约肌基础压升高患者EPT可获得满意的长期疗效。     

Oddi括约肌运动功能障碍的诊断和治疗

Oddi括约肌运动功能障碍(SOD)是临床较难诊断和治疗的疾病之一.SOD诊断方法较多,但尚缺乏敏感性及特异性的诊断方法.目前认为Oddi括约肌压力测定(SOM)是诊断Oddi括约肌运动功能障碍的"金标准",但因其数据结果的准确性及测压后并发症等影响,难以在临床广泛开展.极少数SOD患者可通过药物治疗缓解症状,更多的SOD患者依靠内镜下乳头括约肌切开术(EST)治疗,EST是SOD最常用且有效的治疗方法,尚有部分患者需通过经十二指肠Oddi括约肌切开成形术及胆肠吻合等外科手术方法才能达到治疗目的.     

Oddi括约肌测压及内镜下十二指肠乳头切开术对Oddi括约肌运动功能障碍诊治的意义

本文对60例胆囊切除术后复发腹痛患者进行0ddi括约肌测压研究,并探讨内镜下十二指肠乳头切开术(EPT)对Oddi括约肌基础压升高患者疗效。用低顺应性水灌注系统,三通道测压导管,观察Oddi括约肌基翻压、Oddi括约肌基础收缩幅度、频率和传播方式。对Oddi括约肌基础压>35mmHg者,随机分为两组,一组予以EPT治疗,另一组做为对照,并随访其疗效。结果发现:Oddi括约肌测压异常发生率为46.7％。Oddi括约肌基础压升高者,EPT治疗后,随访3～18月,有效率为91.7％,明显高于对照组(P<0.05)。结论:Oddi括约肌测压对Oddi括约肌运动功能障碍(SOD)的诊断具有较高价值。测压发现Oddi括约肌基础压升高患者EPT可获得满意的长期疗效。     

Oddi括约肌功能障碍患者乳头局部组织中血管活性肠肽和一氧化氮的改变及其意义

目的　探讨血管活性肠肽 (VIP)和一氧化氮 (NOS)在Oddi括约肌功能障碍发病机制中的作用。方法　选择 68例因不明原因的上腹痛、黄疸而进行逆行胰胆管造影及乳头括约肌切开术的患者 ,采用内镜下活检 ,钳取乳头黏膜、Oddi括约肌及胆管内壁组织各 1块。标本常规石蜡包埋 ,连续切片 ,免疫组化链酶亲和素 过氧化物酶法 (SABC法 )观察乳头组织内VIP及NOS的变化。将 68例患者分为Oddi括约肌功能障碍组 (SOD组 )与非Oddi括约肌功能障碍组 (非SOD组 )。结果　SOD患者乳头黏膜及Oddi括约肌内VIP和NOS含量明显减少 (P <0 .0 5 ) ,VIP和NOS含量呈正相关关系 (r =0 .87,P <0 .0 1)。结论　乳头局部组织中VIP和NOS的表达明显降低。VIP和NOS的减少可能在SOD的发生机制中具有一定的作用     

内镜止血夹预防乳头括约肌切开术后出血的临床观察

内镜下乳头括约肌切开术(EST)后出血是限制其临床应用的一个主要并发症。我们常规应用内镜止血夹预防ERCP乳头括约肌切开术后出血，现总结如下。     

Complications of endoscopic sphincterotomy. A prospective series with emphasis on the increased risk associated with sphincter of Oddi dysfunction and nondilated bile ducts

Mostly retrospective series with limited use of sphincter of Oddi manometry have indicated that early complications are more common when endoscopic sphincterotomy is performed for sphincter of Oddi dysfunction than for common duct stones. The current study was undertaken to prospectively evaluate the frequency and type of complications of endoscopic sphincterotomy performed for sphincter of Oddi dysfunction compared with endoscopic sphincterotomy performed for other conditions. Four hundred twenty-three patients underwent sphincterotomy for sphincter of Oddi dysfunction (166), common duct stone(s) (163), tumor (60), and miscellaneous reasons (34). Patients were observed in the hospital for at least 24 hours after the procedure, and 30-day follow-up data were obtained. The overall complication rate was 6.9%, but complications were more frequent when sphincterotomy was performed for sphincter of Oddi dysfunction than for all other indications (10.8% vs. 4.3%; P = 0.009). Precut sphincterotomy was more frequently required in the sphincter of Oddi dysfunction group (21.1% vs. 11.7%, P = 0.009) but was no more likely to result in a complication (6.2%) than standard sphincterotomy. The risk of a complication was considerable for a small-diameter common bile duct (less than or equal to 5 mm), particularly when sphincterotomy was performed for sphincter of Oddi dysfunction (37.5%). The overall 30-day mortality rate was 1.7%, but the procedure-related mortality rate was believed to be 0.2%. It is concluded that endoscopic sphincterotomy for sphincter of Oddi dysfunction is more hazardous than for other conditions, particularly when a small common bile duct is present.     

Long-term outcome of endoscopic dual pancreatobiliary sphincterotomy in patients with manometry-documented sphincter of Oddi dysfunction and normal pancreatogram

BACKGROUND: For patients with sphincter of Oddi dysfunction and abnormal pancreatic basal sphincter pressure, additional pancreatic sphincterotomy has been recommended. The outcome of endoscopic dual pancreatobiliary sphincterotomy in patients with manometry-documented sphincter of Oddi dysfunction was evaluated. METHODS: An ERCP database was searched for data entered from January 1995 to November 2000 on patients with sphincter of Oddi dysfunction who met the following parameters: sphincter of Oddi manometry of both ducts, abnormal pressure for at least 1 sphincter (> or =40 mm Hg), no evidence of chronic pancreatitis, and endoscopic dual pancreatobiliary sphincterotomy. Patients were offered reintervention by repeat ERCP if clinical symptoms were not improved. The frequency of reintervention was analyzed according to ducts with abnormal basal sphincter pressure, previous cholecystectomy, sphincter of Oddi dysfunction type, and endoscopic dual pancreatobiliary sphincterotomy method. RESULTS: A total of 313 patients were followed for a mean of 43.1 months (median, 41.0 months; interquartile range: 29.8-60.0 months). Immediate postendoscopic dual pancreatobiliary sphincterotomy complications occurred in 15% of patients. Reintervention was required in 24.6% of patients at a median follow-up (interquartile range) of 8.0 (5.5-22.5) months. The frequency of reintervention was similar irrespective of ducts with abnormal basal sphincter pressure, previous cholecystectomy, or endoscopic dual pancreatobiliary sphincterotomy method. Of patients with type III sphincter of Oddi dysfunction, 28.3% underwent reintervention compared with 20.4% with combined types I and II sphincter of Oddi dysfunction (p = 0.105). When compared with endoscopic biliary sphincterotomy alone in historical control patients from our unit, endoscopic dual pancreatobiliary sphincterotomy had a lower reintervention rate in patients with pancreatic sphincter of Oddi dysfuntion alone and a comparable outcome in those with sphincter of Oddi dysfunction of both ducts. CONCLUSION: Endoscopic dual pancreatobiliary sphincterotomy is useful in patients with pancreatic sphincter of Oddi dysfunction. Prospective randomized trials of endoscopic biliary sphincterotomy alone versus endoscopic dual pancreatobiliary sphincterotomy based on sphincter of Oddi manometry findings are in progress.     

Clinical and scintigraphic assessment of the role of endoscopic sphincterotomy in the treatment of sphincter of Oddi dysfunction.

Postcholecystectomy pain caused by sphincter of Oddi dysfunction remains a difficult condition to treat. Endoscopic sphincterotomy has been recommended for those patients with confirmed sphincter of Oddi motor abnormalities. We have studied sphincter of Oddi dysfunction patients to evaluate the effects of endoscopic sphincterotomy on both clinical symptoms and previously reported scintigraphic parameters to determine the efficacy of this method of treatment. Nine postcholecystectomy patients (seven women: two men, median age 59 years) with clinical and manometric evidence of sphincter of Oddi dysfunction underwent endoscopic sphincterotomy for persisting biliary type pain. Each patient had scintigraphy before and eight weeks after endoscopic sphincterotomy. The patients symptomatic response was assessed independently at three monthly intervals after endoscopic sphincterotomy. Scintigraphic analysis showed that the TMAX (time in minutes to maximum counts) was significantly reduced from 25.0 (20-36) (median [range]) before endoscopic sphincterotomy to 15.0 (13-25) after endoscopic sphincterotomy (p less than 0.01). Seven of nine (78%) sphincter of Oddi dysfunction patients had significant improvement in their symptoms after a mean follow up period of 12 months (range 6-19) although only six of nine were totally pain free. These results suggest that endoscopic sphincterotomy in manometrically confirmed sphincter of Oddi dysfunction improves bile drainage as measured by quantitative cholescintigraphy and is associated with at least short term symptom relief in the majority of patients.     

The utility of liver function test abnormalities concomitant with biliary symptoms in predicting a favorable response to endoscopic sphincterotomy in patients with presumed sphincter of oddi dysfunction

Objectives: We sought to study the utility of liver function test abnormalities concomitant with biliary symptoms in predicting a favorable response to endoscopic sphincterotomy in patients with Geenen class II sphincter of Oddi dysfunction.
Methods: We reviewed the clinical course and liver function test results of 24 Geenen-Hogan class II postcholecystectomy patients with biliary colic secondary to sphincter of Oddi dysfunction who did not undergo sphincter of Oddi manometry before treatment with endoscopic sphincterotomy.
Results: Twenty of the 24 patients had an average of 1.4 episodes of abnormal liver function tests associated with biliary colic; eight patients had dilated common bile duct on cholangiogram. Eighteen of the 20 patients with abnormal liver function tests (90%) were pain-free after sphincterotomy; in contrast, only one of four patients (25%) without liver function test changes responded to sphincterotomy. Fisher exact analysis showed that abnormal liver function tests was a significant predictor for favorable response to sphincterotomy with a two-tail p value of 0.018. Of the eight patients with bile duct dilatation, six (75%) responded favorably to sphincterotomy, whereas 13 of 16 patients (81%) without dilatation also responded to sphincterotomy. Analysis of common bile duct dilatation as a predictive factor showed no significance (   p = 1.00  ).
Conclusions: We conclude that the occurrence of abnormal liver function tests during biliary colic may be used to select patients for endoscopic sphincterotomy. Sphincter of Oddi manometry may not be needed in these cases.     

Sphincter of Oddi dysfunction in children with recurrent pancreatitis and anomalous pancreaticobiliary union: an etiologic concept.

BACKGROUND: The exact cause of recurrent pancreatitis among patients with anomalous pancreaticobiliary union is not known. Sphincter of Oddi dysfunction has been implicated as a mechanism. This study evaluated sphincter of Oddi function in children with anomalous pancreaticobiliary union and recurrent pancreatitis and assessed the results of endoscopic sphincterotomy in the management of this condition. METHODS: We retrospectively reviewed 128 endoscopic retrograde cholangiopancreatographic (ERCP) studies performed on children older than 1 year and adolescents with pancreaticobiliary disease. In 64 instances, ERCP was performed because of recurrent pancreatitis. Nine patients underwent sphincter of Oddi manometry followed by endoscopic sphincterotomy, and these patients were included in this study. A basal pressure greater than 35 mm Hg was considered diagnostic for sphincter of Oddi dysfunction. Follow-up data were obtained retrospectively from the patients' relatives and referring physicians. RESULTS: An anomalous pancreaticobiliary union was found in 18 of 64 (28%) patients with recurrent pancreatitis. The 9 patients who underwent sphincter manometry and endoscopic sphincterotomy were 5 girls and 4 boys 2.9 to 17 years of age (mean 7.8 years). A choledochal cyst was found in 7 of these 9 patients. Two patients had anomalous pancreaticobiliary union without common bile duct dilatation. All 9 patients had sphincter of Oddi dysfunction (mean basal pressure 96 +/- 37.8 mm Hg, range 48 to 156 mm Hg). The length of the common channel was 22.8 +/- 5.5 mm, and the length of the sphincter of Oddi segment was 12.1 +/- 1.9 mm (p < 0.001). In all patients the sphincter of Oddi segment was located within the duodenal wall. The mean follow-up period after endoscopic sphincterotomy was 26.4 months (range 18 to 38 months). Eight patients had excellent results defined as absence of symptoms and no subsequent episodes of acute pancreatitis. Treatment of 1 patient was considered moderately successful because the patient still had occasional pain without pancreatic enzyme elevation but no subsequent episodes of acute pancreatitis. One patient had mild postprocedural pancreatitis. CONCLUSIONS: Recurrent pancreatitis and anomalous pancreaticobiliary union are associated with sphincter of Oddi dysfunction in children and adolescents. Endoscopic sphincterotomy is beneficial to these patients.     

Immediate effects of the endoscopic sphincterotomy on the motility of the sphincter of Oddi

An endoscopic manometric technique was used to determine the CBD-duodenum junction pressure profile before and immediately after endoscopic sphincterotomy in 13 patients with common bile duct stones. Premedication (meperidine, atropine, and diazepam) was given to all patients and endoscopic retrograde cholangiopancreatography was performed before endoscopic sphincterotomy. In the patients with intact papilla the features of the sphincter of Oddi motility were similar to those previously described for patients not given premedication or submitted to cholangiography before endoscopic sphincterotomy. Endoscopic sphincterotomy which was successful for immediate stone removal in 9 of 13 patients caused an immediate reduction of sphincter of Oddi motility in all patients, but abolished it in only 2 of them. The present results show that successful common bile duct stone extraction by means of endoscopic sphincterotomy can be accomplished without total abolition of sphincter of Oddi motility.     

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.     

Sphincter of oddi (pancreatic) hypertension and recurrent pancreatitis

Major papilla pancreatic sphincter dysfunction, a variant of sphincter of Oddi dysfunction, causes pancreatitis and pancreatic-type pain. The gold standard for diagnosis is sphincter of Oddi manometry, most commonly performed at endoscopic retrograde cholangiopancreatography (ERCP). Noninvasive testing, such as secretin-stimulated transabdominal or endoscopic ultrasound assessment of pancreatic duct diameter, is less reliable and has relatively low sensitivity. Two thirds of patients with biliary sphincter of Oddi dysfunction have elevated pancreatic basal sphincter pressure. To maximize the diagnostic yield of sphincter of Oddi dysfunction, both the biliary and pancreatic sphincter pressures should be measured. Patients with sphincter of Oddi dysfunction may respond to biliary sphincterotomy alone, but evaluation of their pancreatic sphincter is warranted if symptoms persist after biliary therapy alone. Whether both biliary and pancreatic sphincters should be treated at the first ERCP session is controversial. Biliary and pancreatic endoscopic sphincterotomies are associated with two-to fourfold increased incidence of pancreatitis following the procedure in patients with pancreatic sphincter hypertension. Prophylactic pancreatic duct stenting reduces the frequency and severity of complications by greater than 50%.     

Outcome of endoscopic sphincterotomy in post cholecystectomy patients with sphincter of Oddi dysfunction as predicted by manometry and quantitative choledochoscintigraphy

BACKGROUND: Sphincter of Oddi dysfunction is diagnosed at manometry and, after cholecystectomy, non-invasively at quantitative choledochoscintigraphy. Patients may benefit from endoscopic sphincterotomy. AIMS: The aim of this study was to assess the usefulness of choledochoscintigraphy compared with manometry in predicting outcome of sphincterotomy in post cholecystectomy patients with sphincter of Oddi dysfunction. PATIENTS AND METHODS: Thirty patients with biliary-type pain complying with the Rome diagnostic criteria of sphincter of Oddi dysfunction and belonging to biliary group I and II were subjected to clinical evaluation, choledochoscintigraphic assessment of the hepatic hilum-duodenum transit time, endoscopic retrograde cholangiopancreatography, and perendoscopic manometry. Twenty two biliary group I and II patients with prolonged hepatic hilum-duodenum transit times were invited to undergo sphincterotomy. Fourteen patients underwent sphincterotomy; eight refused. Clinical and scintigraphic assessments were performed at follow up. RESULTS: Hepatic hilum-duodenum transit time was delayed in all patients with manometric evidence of sphincter of Oddi dysfunction, in all biliary group I patients and in 64% of biliary group II patients. At follow up, all patients who underwent sphincterotomy were symptom free and hepatic hilum-duodenum transit time had either normalised or significantly improved. A favourable post sphincterotomy outcome was predicted in 93% of cases at choledochoscintigraphy and in 57% at manometry. CONCLUSIONS: Quantitative choledochoscintigraphy is a useful and non-invasive test to diagnose sphincter of Oddi dysfunction as well as a reliable predictor of sphincterotomy outcome in post cholecystectomy biliary group I and II patients, irrespective of clinical classification and manometric findings.