Endoscopic manometry of pancreatic and biliary sphincter zones in man

An endoscopic manometric technique was applied to the study of intraductal biliary and pancreatic pressures and sphincter activity in normal subjects. A perfused system using a modified endoscopic retrograde cholangiopancreatography catheter was tested and found to provide reliable ductal and phasic recordings. Twenty-five healthy volunteers aged 19–37, underwent endoscopic manometry under diazepam sedation. Distinct zones of high-pressure phasic activity were identified on pull-through from the pancreatic duct and common bile duct at mean distances of 4.5 and 5.0 mm, respectively, from the papillary orifice with frequencies of 7.0±1.8 (mean±sd) and 5.6±2.4 waves/min, respectively. These were considered to represent separate pancreatic duct and bile duct sphincters. Peak pancreatic duct sphincter pressure (47.6±8.2 mm Hg) and bile duct sphincter pressure (57.2±10.7 mm Hg) were similar. Pancreatic duct pressure was 11.4±3.0. mm Hg and common bile duct pressure was 3.0±2.5 mm Hg. Values were adjusted to duodenal pressure as zero reference. The ductal and sphincteric pressures reported in this study provide a basis for the assessment of physiological, pharmacological, pathophysiological, and surgical effects on this area.This work was supported by grants from the Katherine Gavriluk and Sara Jordan Funds, New England Baptist Hospital, Boston, Massachusetts, and Dr. Carr-Locke is in receipt of grants from the Wellcome Research Travel Fund, London, England, the Leicester Area Health Authority, Leicester, England, and the P and C Hickinbotham Trust, Leicester, England.     

Endoscopic biliary and pancreatic sphincterotomy

Opinion statement Endoscopic sphincterotomy is performed on the biliary and pancreatic sphincters for a variety of indications such as removal of stones, as part of treatment of strictures, to facilitate placement of stents, for closure of ductal leaks, and other indications. Pancreatic sphincterotomy has been increasingly performed for the treatment of papillary stenosis, sphincter of Oddi dysfunction, and for chronic and acute recurrent pancreatitis. Efficacy is clear for more traditional indications, but is not as well defined for some of the latter indications. Minor papillotomy is most often performed for acute recurrent pancreatitis associated with pancreas divisum, sometimes for chronic pancreatitis, and for other indications. Equipment, techniques, and safety of sphincterotomy have improved significantly over the past decades. Success rates are substantially higher when a sphincterotomy is performed by high-volume endoscopists. However, complications such as pancreatitis, bleeding, and perforation can still occur in up to 10% of cases and may occasionally be severe. Patients with the least clear indication or chance of benefit from sphincterotomy, such as those with suspected sphincter of Oddi dysfunction or suspected but absent bile duct stones, are at highest risk of complications. Complications are less frequent, but fully not eliminated, with an experienced endoscopist or an expert in the field. Risk of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) with biliary and/or pancreatic sphincterotomy can be substantially reduced by placement of a small-caliber pancreatic stent. Major challenges include defining the settings in which sphincterotomy is most likely to be effective, selection of appropriate patients for therapeutic ERCP by utilization of alternative imaging techniques such as magnetic resonance cholangiopancreatography and endoscopic ultrasound, and dissemination of newer techniques into practice to ensure optimal safety and efficacy for sphincterotomy.     

ERCP, biliary crystal analysis, and sphincter of Oddi manometry in idiopathic recurrent pancreatitis

BACKGROUND: This study investigated the role of ERCP, analysis of bile for microcrystals, and sphincter of Oddi manometry in idiopathic recurrent pancreatitis. METHODS: One hundred twenty-six patients met criteria for idiopathic recurrent pancreatitis. Patients with a normal ERCP underwent sphincter of Oddi manometry and analysis of bile. Bile was also collected in patients with papillary stenosis (defined as ductal dilation with delayed drainage of contrast, sphincter basal pressures greater than 40 mm Hg, and positive analysis for cholesterol and/or calcium bilirubinate crystals). RESULTS: ERCP alone identified a cause of idiopathic recurrent pancreatitis in 47 (37%) patients: papillary stenosis in 26 (21%), pancreas divisum in 9 (7%), and choledocholithiasis in 6 (5%). Among patients with a gallbladder, microcrystals were found in 27 (50%) and sphincter dysfunction in 17 (31%). Among patients who have undergone cholecystectomy, sphincter dysfunction was identified in 24 (47%). Minor papilla sphincterotomy was performed in 8 patients (89%) with pancreas divisum. Biliary sphincterotomy was performed in 85 patients and included all patients with choledocholithiasis, choledochocele, microcrystals, papillary stenosis, and sphincter dysfunction except 2 patients with microcrystals who underwent cholecystectomy. Additionally, pancreatic sphincterotomy was performed in 32 (78%) patients with pancreatic sphincter hypertension and in 6 (23%) of 26 patients with papillary stenosis with dilated pancreatic ducts. Thus, among the 126 patients, 93 of the 100 patients with a detected abnormality underwent endoscopic sphincterotomy. Response rates varied from 67% to 100% during follow-up (mean 29.6 months, range 18 to 33 months). CONCLUSION: ERCP techniques including minor papilla cannulation, analysis of bile for microcrystals, and sphincter of Oddi manometry identified a cause of idiopathic recurrent pancreatitis in 79% (endoscopically treatable in 75%) of patients, with or without prior cholecystectomy.     

经内镜微创治疗胆胰疾病的应用价值

目的　探讨经内镜微创治疗胆胰疾病的应用价值。方法　回顾性分析 1995年 7月至 2 0 0 2年 3月经内镜微创治疗胆胰疾病 42 2例次的效果及并发症 ,探讨各种方法的应用价值及优缺点。结果　 42 2例患者分别采取了乳头切开、气囊扩张、机械碎石、取石、鼻胆引流术、胆道放置内支架等治疗 ,其成功率为 94 5 5 %,并发症3 79%。结论　内镜微创治疗胆胰疾病有效、安全且对病人损伤小、可代替部分胆胰疾病的外科手术治疗。     

Recurrence of Common Bile Duct Stones Correlates with Stenosis Following Endoscopic Sphincterotomy

Although stenosis is regarded as one of the causes of recurrence of common bile duct stones after endoscopic sphincterotomy, there is a lack of direct evidence. Endoscopic retrograde cholangiography and manometry were performed in 131 patients 2.2–111.1 months (mean 29.9 months) after sphincterotomy, either for follow-up or at presentation of biliary symptoms. Recurrent stones were found in 33 patients (25%) (recurrent group). The remaining 98 patients (75%) proved not to have recurrence (nonrecurrent group). The common bile duct-to-duodenum pressure gradient in the recurrent group (3.3 ± 1.4 mmHg, mean ±SEM) did not differ from that in the nonrecurrent group (2.9 ±1.5 mmHg) (p=0.85). However, as judged by endoscopic findings, we found a significantly elevated frequency of stenosis of the spincter-otomy orifice in the recurrent group (4 of 33 patients) as compared with the nonrecurrent group (none of 98 patients) (p=0.0035). Recurrence of common bile duct stones appears to correlate with stenosis following sphincterotomy, although manometry does not necessarily indicate the presence of stenosis.     

Nonoperative measurement of pancreatic and common bile duct pressures with a microtransducer catheter and effects of duodenoscopic sphincterotomy

Duodenoscopic manometry of the pancreatic duct (PD_ and common bile duct (CBD) using a microtransducer catheter has distinct advantages over infusion manometry, giving absolute values ofin situ intraluminal pressure. Microtransducer manometry was performed without medication in 49 patients with gallbladder stones (10), common bile duct stones (24), hepatic duct stones (6) and common bile duct dilatation (9), and was successful in 42 (86%) for PD and 36 (73%) for CBD. Ductal pressures showed respiration-synchronized biphasic variations superimposed by the arterial pulsation effect. Considerable postural change of the pressure values suggested that the recording posture should be predetermined. The PD-to-duodenum pressure gradient was higher than the CBD-to-duodenum gradient in most cases. Both were lower than those obtained previously by infusion methods. No significant differences were found in pressure profiles of the four disease groups. Endoscopic sphincterotomy significantly reduced not only CBD pressure but also PD pressure.     

Leaks from laparoscopic cholecystectomy

BACKGROUND/AIMS: Significant postoperative bile leaks occur in approximately 1% of patients. The goal of endoscopic therapy is to eliminate the transpapillary pressure gradient, thereby permitting preferential transpapillary bile flow rather than extravasation at the site of leak. METHODOLOGY: Sixty-four patients were retrospectively evaluated. Endoscopic treatment comprised endoscopic sphincterotomy followed by insertion of a naso-biliary drainage or a stent. Retained stones were extracted by standard procedures. RESULTS: The site of bile extravasation was the cystic duct in 50 cases, ducts of Luschka in 4 cases, common bile duct in 6 cases and common hepatic duct in 4 cases. Retained bile duct stones were detected in 21 cases and papillary stenosis in 4 cases. Endoscopic sphincterotomy was performed in 25 cases, with stones extraction and nasobiliary drainage in 21 cases, and placement of stent in the remainder. Bile leaks resolved in 96.9% of patients, after endoscopic procedure. Two cases of mild pancreatitis were evidenced from endoscopic treatment. CONCLUSIONS: Endoscopic management is the treatment of choice of postcholecystectomy bile leaks.     

Sphincterotomy in the treatment of biliary leakage

BACKGROUND/AIMS: Endoscopic procedures such as sphincterotomy and endobiliary stenting have proved useful to solve postoperative bile leakage. We have assessed the outcome of a series of such patients initially treated with endoscopic sphincterotomy, having reserved stent placement for treatment failures only. METHODOLOGY: Twenty-five consecutive patients referred for endoscopic assessment of postoperative bile leaks and fistulas after cholecystectomy (n = 15), orthotopic liver transplantation (n = 9) and hepatic resection due to cystic hydatid disease (n = 1) underwent endoscopic retrograde cholangiopancreatography and sphincterotomy using a standard papillotome. Sphincterotomy was followed by stone extraction using a Dormia basket if common bile duct lithiasis were present. RESULTS: Bile leaks healed early after endoscopic sphincterotomy in 22 out of 25 patients (88%). Common bile duct stones were also retrieved in 6 of these patients. Bile duct stenosis due to surrounding pancreatic inflammation was demonstrated in two of the patients in which sphincterotomy failed to stop bile leakage. CONCLUSIONS: Endoscopic sphincterotomy alone should at present be considered a highly effective treatment to resolve postsurgical bile leaks unless bile strictures are present.     

Endoscopic balloon dilatation is a safe method in the management of common bile duct stones

BACKGROUNDS AND AIMS: Endoscopic sphincterotomy is a widely accepted treatment for patients with common bile duct stones. Despite improvement in this technique, endoscopic sphincterotomy is still associated with some biliary complications. Endoscopic balloon dilatation is a less traumatic and sphincter preserving method for removal of common bile duct stones. However, the results of controlled studies in comparison with these two methods are contradictory. The aim of this study is to compare the safety and efficacy of endoscopic balloon dilatation and endoscopic sphincterotomy in Chinese patients. PATIENTS AND METHODS: A total of 104 patients with common bile duct stones on endoscopic retrograde cholangiopancreatography were enrolled. They were randomly assigned to endoscopic balloon dilatation or endoscopic sphincterotomy. Endoscopic balloon dilatation was performed by using a balloon dilator to dilate the sphincter for 5 min. The common bile duct stones were then removed by a Dormia basket after endoscopic balloon dilatation or endoscopic sphincterotomy. Mechanical lithotripsy was performed if the stones were difficult to remove by Dormia basket. After discharge, patients were regularly followed up for biliary complications. RESULTS: The successful bile duct stone clearance rate was 94.1% in endoscopic balloon dilatation group and 100% in endoscopic sphincterotomy group. Post-procedural significant haemorrhage was higher in endoscopic sphincterotomy group than in endoscopic balloon dilatation group (14/53 versus 1/48, P < 0.001). The bleeding patient from endoscopic balloon dilatation group was a case of uremia and bleeding occurred 48 h after endoscopic balloon dilatation. All the patients with post-procedural haemorrhage were controlled endoscopically. The post-procedural serum amylase level showed no significant difference in both groups and none of them developed clinical pancreatitis. After a mean 16 months follow-up, three patients (6.3%) in endoscopic balloon dilatation group and four patients (7.5%) in endoscopic sphincterotomy group developed recurrent common bile duct stones. The recurrent common bile duct stones were multiple and muddy in consistency. They were successfully removed endoscopically. CONCLUSION: Both endoscopic balloon dilatation and endoscopic sphincterotomy are safe and effective techniques for the treatment of common bile duct stones. Endoscopic balloon dilatation can be safely applied in patients with coagulopathy and does not increase the incidence of pancreatitis or bleeding.     

Endoscopic sphincterotomy and endoscopic papillary balloon dilatation for bile duct stones: A prospective randomized controlled multicenter trial

BACKGROUND: Endoscopic papillary balloon dilatation may be an alternative to endoscopic sphincterotomy in the treatment of bile duct stones. However, there is a controversy as to the effectiveness and safety of endoscopic papillary balloon dilatation. METHODS: Two hundred eighty-two patients with bile duct stones were enrolled and randomized to an endoscopic sphincterotomy or endoscopic papillary balloon dilatation group. The success rate for duct clearance as well as the frequency and types of complications were evaluated prospectively. Endoscopic sphincterotomy was performed in a standard manner. Endoscopic papillary balloon dilatation was carried out with gradual inflation of a 4-, 6-, or 8-mm diameter balloon. RESULTS: Complete duct clearance was achieved in 100% in the endoscopic sphincterotomy group and 99.3% in the endoscopic papillary balloon dilatation group (not significant). Complications occurred in 11.8% of patients in the endoscopic sphincterotomy group and 14.5% of those in the endoscopic papillary balloon dilatation group (not significant). No complication was severe; there was no mortality. The frequency of acute pancreatitis was higher in the endoscopic papillary balloon dilatation group than the endoscopic sphincterotomy group (respectively, 10.9% vs. 2.8%; p < 0.045). Hemorrhage occurred only in the endoscopic sphincterotomy group. CONCLUSIONS: Endoscopic sphincterotomy and endoscopic papillary balloon dilatation were approximately equal in terms of successful clearance of bile duct stones. They were also similar with respect to overall complications. Endoscopic papillary balloon dilatation is an alternative to endoscopic sphincterotomy as a treatment of bile duct stones.     

Endoscopic Manometry of the Sphincter of Oddi: Its Usefulness for the Diagnosis and Treatment of Benign Papillary Stenosis

Background: Endoscopic manometry is considered useful to identify dysfunction of the sphincter of Oddi (SO) and to predict in which patients good results can be expected after endoscopic sphincterotomy, but this has not been definitively demonstrated.

Methods: Endoscopic manometry of the SO was used in a group of 30 patients with benign papillary stenosis (BPS), in comparison with 30 control subjects. During endoscopic manometry an intravenous bolus of cholecystokinin octapeptide was given to 12 patients and to 10 controls. In 24 BPS patients endoscopic sphincterotomy was performed.

Results: No significant differences were observed between controls and patients with regard to median values of SO basal (20 and 21.5 mmHg) and peak pressure (123 and 126mmHg), wave amplitude (100mmHg), frequency (4 waves/min), and propagation of the common bile duct/duodenum gradient (12.5 and 12.1 mmHg). In two BPS patients a paradoxic response to CCK-OP was observed. Endoscopic sphincterotomy, performed in 24 BPS patients (17 with SO basal pressure less than 40 mmHg and 7 with more than 40 mmHg), gave good results in 23, without any complication. No differences were observed in the results of the endoscopic sphincterotomy among patients with basal pressure more than 40 mmHg and those with less than 40 mmHg.

Conclusions: On the basis of this study, manometric data do not seem helpful for diagnosis of BPS or to discriminate which patients can be treated with endoscopic sphincterotomy.     

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.     

Manometric activity of the pancreatic duct sphincter in patients with total bile duct sphincterotomy for sphincter of Oddi dyskinesia

Previous anatomical studies have described a distinct sphincteric structure at the entrance of the common bile and pancreatic ducts in the duodenum. However, from an anatomical point of view, the pancreatic duct sphincter is only present in one third of human specimens. The purpose of the present study was therefore to investigate whether sphincteric activity could be demonstrated in patients in whom the common bile duct sphincter was completely transsected during endoscopic sphincterotomy. Twelve patients had a complete bile duct sphincterotomy because of sphincter of Oddi dyskinesia. The sphincterotomy was checked manometrically in all, and neutralization of the choledochoduodenal gradient recognized. In all patients a distinct pancreatic sphincteric zone with base-line elevation and superimposed phasic activity was demonstrated. In six patients the pancreatic duct sphincter was studied before and after bile duct sphincterotomy, and, although a definite sphincter zone still was present in the pancreatic duct, a reduction in phasic wave amplitude was observed. A similar decreased base-line and pancreatic duct pressure was observed, although not statistically significant.     

A new technique for removal of bile duct stones with an expandable metallic stent

BACKGROUND: Endoscopic sphincterotomy is used routinely for extraction of bile duct stones. Also, endoscopic papillary dilation is a safe and effective technique that significantly reduces the need for papillotomy. However, extraction of large and/or multiple stones after endoscopic papillary dilation can be difficult. A new technique, endoscopic metallic stent-lithotripsy, for treatment of bile duct stones without endoscopic sphincterotomy or endoscopic papillary dilation is described. METHODS: A self-expandable metallic stent was used to dilate the major duodenal papilla to allow lithotripsy and removal of bile duct stones in 38 patients. RESULTS: The bile duct was successfully cleared of stones in 36 cases (95%). Complications included one episode of mild pancreatitis and one of cholangitis. CONCLUSIONS: Although the number of patients who underwent successful expanding metallic stent-lithotripsy was small, the method is promising as an alternative to endoscopic sphincterotomy and endoscopic papillary dilation.     

Sphincterotomy in patients with gallstones, elevated LFTs and a normal CBD on ERCP

BACKGROUND/AIMS: To determine whether an endoscopic sphincterotomy affects outcome in patients with symptomatic gallstones, elevated liver function tests and a normal common bile duct on endoscopic retrograde cholangiopancreatogram. METHODOLOGY: A total of 163 patients with symptomatic gallstones and elevated liver function tests, and found to have a normal common bile duct on endoscopic retrograde cholangiopancreatogram were included in the study. Endoscopic sphincterotomy was performed in 78 (47.8%) patients, while 85 (52.1%) patients did not have an endoscopic sphincterotomy. The two groups were compared for detection of small unseen common bile duct stones/debris, endoscopic retrograde cholangiopancreatogram related complications, and biliary complications after cholecystectomy. RESULTS: Small common bile duct stones/debris were recovered in 11/43 (25.5%) patients who had instrumentation of the common bile duct performed after endoscopic sphincterotomy. Common bile duct instrumentation was not performed in any of the patients without endoscopic sphincterotomy. No patient had any biliary complication after cholecystectomy, both in the immediate postoperative period and on a follow-up of 37.5 +/- 13.6 months (range 17-66). Endoscopic retrograde cholangiopancreatogram related complications occurred in 8 patients who had an endoscopic sphincterotomy and in 2 without endoscopic sphincterotomy (p < 0.05). CONCLUSIONS: Performing an endoscopic sphincterotomy in these patients increases the detection of small unseen common bile duct stones/debris without changing the clinical outcome after cholecystectomy. It also increases the endoscopic retrograde cholangiopancreatogram related complication rate, and therefore may not be necessary.     

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%.     

Endoscopic papillary large balloon dilation for large common bile duct stones

Endoscopic papillary large balloon dilation (EPLBD) involves endoscopic biliary sphincterotomy (EBS) followed by balloon dilation using a 12–20-mm balloon to remove large or difficult stones from the common bile duct. The complications and limitations of endoscopic biliary sphincterotomy (EBS) are well known. Endoscopic papillary balloon dilation (EPBD) with a smaller diameter balloon but without sphincterotomy is widely used in a number of regions of the world for removal of routine bile duct stones and has been investigated as an alternative to EBS. EPBD, however, appears to be associated with an increased risk of pancreatitis. EPLBD differs from EPBD as it involves EBS followed by large balloon dilation. EPLBD would theoretically combine advantages of sphincterotomy and balloon dilation by increasing efficacy at stone extraction while minimizing complications of both EBS and EBD. A review of the available literature for EPBLD shows that it is relatively safe and effective. A high success rate (up to 95%) has been described for stone removal using EPLBD, with a low complication rate. Unlike EPBD, EBLBD does not appear to be associated with a higher risk of post-ERCP pancreatitis, probably because of separation of the biliary and pancreatic sphincters after EBS. EPLBD appears to be a reasonable option for removal of large or difficult common bile duct stones. This technique may be especially helpful in patients with difficult papillary anatomy, such as those with small papillae, intra- or peri-diverticular papilla. Its role in patients with coagulopathy or other risks for bleeding remains to be investigated.     

Predictors of outcomes after biliary and pancreatic sphincterotomy for sphincter of oddi dysfunction

BACKGROUND: There are few data on combined pancreatic and biliary sphincterotomy for sphincter of Oddi dysfunction (SOD), especially regarding clinical features that might predict outcomes. We sought to examine the relative importance of various clinical features and the presence or absence of objective biliary abnormalities in determining responses to endoscopic therapy. METHODS: A cohort of consecutive patients with suspected SOD was treated with biliary sphincterotomy, with additional pancreatic sphincterotomy at initial or subsequent endoscopic retrograde cholangiopancreatography if there was abnormal pancreatic manometry in conjunction with pain refractory to biliary sphincterotomy, continuous pain, or a history of amylase elevation. Repeat intervention was offered until response was achieved or complete ablation of all treated sphincters was achieved. Response was assessed by patients using a 5-point Likert scale, and multivariate logistic regression analysis used to identify predictors of response. RESULTS: Of 121 patients, 112 (92%) were female, 105 (87%) postcholecystectomy, and by modified Milwaukee biliary classification 18 (15%) were type I, 53 (44%) type II, and 50 (41%) type III. All patients underwent biliary sphincterotomy and 49 (40%) pancreatic sphincterotomy. Good or excellent response at final follow-up was reported by 83 (69%) of 121 patients, including 37 (61%) of 61 patients requiring repeated intervention. Response was not significantly different between biliary types I, II, and III. Patient characteristics (with adjusted odds ratios) that were significant predictors of poor response were normal pancreatic manometry (4.6), delayed gastric emptying (6.0), daily opioid use (4.0), and age <40 (2.7). Abnormal liver function tests or dilated bile duct were not significant. CONCLUSIONS: For the treatment of SOD incorporating pancreatic and biliary sphincterotomy, patient characteristics and pancreatic sphincter manometry may be more important predictors of outcome than the traditional classification based on liver chemistries and bile duct dilation.     

Manometry based randomised trial of endoscopic sphincterotomy for sphincter of Oddi dysfunction

BACKGROUND—Endoscopic sphincterotomy for biliary-type pain after cholecystectomy remains controversial despite evidence of efficacy in some patients with a high sphincter of Oddi (SO) basal pressure (SO stenosis).
AIM—To evaluate the effects of sphincterotomy in patients randomised on the basis of results from endoscopic biliary manometry.
METHODS—Endoscopic biliary manometry was performed in 81 patients with biliary-type pain after cholecystectomy who had a dilated bile duct on retrograde cholangiography, transient increases in liver enzymes after episodes of pain, or positive responses to challenge with morphine/neostigmine. The manometric record was categorised as SO stenosis, SO dyskinesia, or normal, after which the patient was randomised in each category to sphincterotomy or to a sham procedure in a prospective double blind study. Symptoms were assessed at intervals of three months for 24 months by an independent observer, and the effects of sphincterotomy on sphincter function were monitored by repeat manometry after three and 24 months.
RESULTS—In the SO stenosis group, symptoms improved in 11 of 13 patients treated by sphincterotomy and in five of 13 subjected to a sham procedure (p = 0.041). When manometric records were categorised as dyskinesia or normal, results from sphincterotomy and sham procedures did not differ. Complications were rare, but included mild pancreatitis in seven patients (14 episodes) and a collection in the right upper quadrant, presumably related to a minor perforation. At three months, the endoscopic incision was extended in 19 patients because of manometric evidence of incomplete division of the sphincter.
CONCLUSION—In patients with presumed SO dysfunction, endoscopic sphincterotomy is helpful in those with manometric features of SO stenosis.


Keywords: sphincter of Oddi; manometry; endoscopic sphincterotomy; motility; bile duct; pancreas     

Clinical significance of manometric assessment of both pancreatic duct and bile duct sphincter in the same patient

In this study both pancreatic and bile duct sphincter pressures were measured on the same occasion by means of endoscopic manometry in 42 patients with long-standing upper abdominal pain. Nine (53%) of the 17 patients with abnormal sphincter function had a marked difference between the pancreatic duct sphincter pressure (PSOP) and the bile duct sphincter pressure (BSOP): 6 patients with a clinical diagnosis of biliary dyskinesia showed elevated BSOPs, whereas the PSOPs were normal. The reverse, an abnormal PSOP but normal or only a slightly elevated BSOP, was registered in the three patients with chronic pancreatitis. These findings indicate that a motor abnormality may be restricted to only one of the sphincters. Thus, when the sphincter of Oddi is investigated only from the pancreatic duct, manometry may either fail to show an abnormal BSOP in some patients with biliary dyskinesia, or it may falsely suggest this diagnosis in patients with unrecognized pancreatitis.