Oddi括约肌功能的电生理研究与启示

上世纪Rugero Oddi对胆总管下端括约肌结构的发现和命名,奠定了Oddi括约肌功能研究的基础.然而时至今日,我们对胆胰结合部的了解仍然不足,特别是Oddi括约肌((sphincter of Oddi,SO)的基础研究仍明显滞后于临床,如何准确评价SO的功能及诊治Oddi括约肌功能障碍(sphincter ofOddi dysfunction,SOD)仍是一个难题.在临床上大部分SOD都发生在胆囊切除术后的病人,缺乏典型的症状和影像学改变,诊断非常困难[1-4].     

ERCP在胆胰结合部疾病中的应用

随着十二指肠镜设备和器械发展,内镜逆行胰胆管造影（ERCP）在胆胰管结合部疾病治疗中占有非常重要地位。ERCP治疗的胆胰管结合部疾病主要包括结石、肿瘤、Oddi括约肌狭窄和胆胰管合流异常。胆胰管结合部结石嵌顿通过括约肌切开术（EST）或电针开窗可迅速缓解; 无法根治性切除的恶性肿瘤可行内镜胆管引流术（ERBD）或内镜胆管金属支架术（EMBE）建立胆汁内引流,严重黄疸术前利用鼻胆导管引流术（ENBD）可有效减黄;Oddi括约肌狭窄行EST优势明显,已经代替传统开腹括约肌成型术;治疗无胆总管扩张的胰胆管合流异常现处于探索阶段。     

胆胰肠结合部外科——一个值得重视和研究的领域

胆胰肠结合部是人体解剖结构和生理调控最复杂的区域之一。胆胰管合流异常、Oddi括约肌(SO)功能障碍、肿瘤等使得这一狭小的区域成为多种疾病的高发地带。然而,迄今对这一人体重要功能结构的生理调控和疾病发生机制尚缺乏足够的认识,胆胰肠结合部外科尚有许多难题有待研究解决。随着有关SO动力学、壶腹部肿瘤生物学行为等研究的深入、保全Oddi括约肌结构和功能完整性治疗理念的更新,胆胰肠结合部外科将成为腹部外科的研究热点之一。     

应重视胆肠结合部外科

应重视胆肠结合部外科解放军总医院普通外科研究所（北京，１００８５３）黄志强胆管、胰管、十二指肠的结合部是消化道中结构和功能最复杂的部位，再没有哪一个部位使研究者注下了那么多的心血。就以胆胰管结合部的括约肌而论，Ｂｏｙｄｅｎ耗费了毕生精力用数十年时间来...     

处理医源性胆胰肠结合部损伤的若干体会

胆胰肠结合部是指远端胆管、胰管与十二指肠交汇之处[1]。该部位的解剖、生理复杂而重要,其损伤可造成严重后果。医源性胆胰肠结合部损伤,常由胆总管探查和内镜十二指肠乳头括约肌切开术(endoscopic sphincterotomy,EST)导致[2-3]。一旦不慎损伤,早期诊断、及时处理,才可使病人转危为安。胆胰肠结合部损伤的原因胆总管探查和EST是最常见的原因。1胆总管探查:     

胆肠结合部外科疾病诊治进展

胆肠结合部外科疾病诊治进展同济医科大学附属同济医院普外科（武汉，４３００３０）袁荣文综述邹声泉审校胆肠结合部（ｃｈｏｌｅｄｏｃｈｏ－ｄｕｏｄｅｎａｌｉｕｎｃｔｉｏｎ，ＣＤＪ）是指十二指肠乳头壶腹部，包括十二指肠壁内的胆总管括约肌段、主胰管括约肌段、共...     

胆胰结合部良性病变的诊断和处理

胆胰结合部的范围包括胆总管下部(3、4段)、胰头、十二指肠三者的毗邻关系[1]。胆胰结合部的良性病变包括该部位的结石,急、慢性炎症,良性肿瘤,胆胰管末段、Oddi乳头狭窄、梗阻和功能障碍等,其中以胆总管下段原发或继发结石最为多见,特别是壶腹结石嵌顿容易并发胆管炎和胰腺炎。反复发作胆管炎、慢性胰腺炎、胰管结石,尤其胰头部肿块型慢性胰腺炎和结石、十二指肠乳头旁或乳头部憩室并发憩室和乳头炎,都是引起胆胰管末段和乳头狭窄、梗阻或Oddi括约肌功能紊乱的原因。胆总管下段、壶腹和乳头部良性肿瘤,如乳头状瘤、腺瘤、息肉、胰头部囊腺…     

男性后尿道横纹括约肌的控尿功能及临床意义

一般认为,男性后尿道的控尿功能由内括约肌和外括约肌来实现.内括肌是一个功能性概念,在解剖形态学上是否真正存在内括约肌,目前尚存有争议.但一般认为内括约肌是平滑肌,位于膀胱颈和后尿道,由膀胱底延续下来的逼尿肌和两侧输尿管延续来的纵行肌以及尿道壁本身的平滑肌构成[1].内括约肌分布有丰富的α-受体,主要受交感神经支配,在控制膀胱排空和尿失禁方面具有重要作用.外括约肌是横纹肌,位于尿生殖膈之中呈环形包绕膜部尿道,由阴部神经(主要是体神经)支配,突然中断排尿由它来实现.在前列腺手术或膀胱颈内切开术后,内括约肌遭受破坏,控尿功能由外括约肌担负,如此时外括约肌也遭受损害或功能不足,即会发生尿失禁.     

胆胰肠结合部损伤延期诊断后的处理原则

目前,学术界对胆胰肠结合部的界限和范围仍存争议。本文中胆胰肠结合部包括十二指肠降部、胰头部、胆总管第3和第4段、胰头部胰管、Vater壶腹部及其外周的Oddi括约肌。胆胰肠结合部损伤与单纯性十二指肠、胆总管下段或主胰管损伤不同,损伤的部位在胆总管、主胰管和十二指肠三者的汇合部,损伤的原因多为医源性因素,损伤后漏出的消化液不单是胆汁或胰液,而是包含胰液、胆汁,甚至还有肠液的强腐蚀性消化液。若胆胰肠结     

医源性胆胰结合部损伤

医源性胆胰结合部损伤指在治疗和检验过程中引起胆总管、主胰管汇合部位的损伤,虽然发生率较低,但其处理不当时常给患者带来极大痛苦,甚至危及患者生命。为此,本文阐述了引起医源性胆胰结合部损伤的原因、早期诊断及防治措施。一、医源性胆胰结合部损伤的原因开腹下胆总管探查术和内镜括约肌切开术(EST)是导致胆胰结合部损伤的两大主要医源性因素。①开腹下胆总管探查术:主要是胆总管探查术时Bakes探条的暴力性操作引起胆胰汇合部损伤,特别是近年来纷纷开展胆道手术的基层医院,在胆总管下端通过受阻时,未经术中胆道造影或胆道镜检查,采用…     

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??Biliary-pancreatic-duodenal junction: the forgotten corner of present day surgery HUANG Zhi-qiang. Research Institute of Hepatobiliary Surgery of PLA, the General Hospital of PLA, Beijing 100853, China
Abstract Junction of the bile duct and the pancreatic duct to the duodenum is a delicate construction in the human body. It is regulated by the combined harmonic action of anatomical configuration, sphincteric action as well as the hormonal regulation and nervous control. Diseases in the location may either be manifested as obstruction or as insufficiency of the sphincter function. Endoscopic manipulation such as sphincterotomy or balloonic dilatation of the sphincter is still the most frequently employed procedure. Surgery in attempt to reconstruct a new and functionally competent junction has been carried on for nearly a century, but still far from success.     

Interaction phenomena between a cuff of an artificial urinary sphincter and a urethral phantom

Male urinary incontinence is highly prevalent, leading to a miserable quality of life. The artificial urinary sphincter (AUS) is the device that closely simulates the function of the biological urinary sphincter. The precise evaluation of occlusion mechanisms and of interaction phenomena occurring between AUS cuff and urethral duct is fundamental for more reliable design. The action induced in the interaction with urethral duct under a specific pressure depends on its constitutive material and structural characteristics. The methods of experimental and computational bioengineering are exploited to investigate mechanical functionality of the coupled system, as AUS and urethral duct. Experimental tests are developed to investigate the response when the AUS is inflated around a urethral phantom. Numerical model of the cuff is developed mimicking the experimental tests for the validation. Subsequently, numerical models are exploited to interpret the interaction of the cuff with urethral phantoms considering the influence of urethral size and of tissues mechanical behavior, mimicking healthy and degraded configurations. The investigation provides useful information on the behavior of AUS cuff with urethral duct evaluating the action induced and represents a support for planning an extension of experimental tests on animal and human urethral samples.     

胆道再手术原因分析：附828例报告

目的:分析导致再次胆道手术的原因，以期减少胆道再手术率。方法:总结1990—1999年间收治的再次胆道手术患者828例的临床资料，对胆道疾病再次手术的原因进行归类分析。结果:再手术的主要原因是结石复发或残留，占65.10%;结石合并Oddi括约肌狭窄占33.82%;单纯Oddi括约肌狭窄占9.54%;胆管损伤性狭窄和胆肠吻合口狭窄占10.39%;胆道系统肿瘤占6.52%。结论:胆道再手术的主要原因仍以结石复发或残留为主，其次为Oddi括约肌狭窄;损伤性胆管狭窄等与手术有关的因素不容忽视。减少胆道再次手术的关键在于初次手术的彻底性和手术方法的合理性。     

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??Consensus and controversies on protection of sphincter of Oddi during biliary surgery YIN Xiao-Yu. Department of Pancreatobiliary Surgery,the First Affiliated Hospital,Sun Yat-Sen University,Guangzhou510080??China
Abstract Sphincter of Oddi is one complicated and finely-regulated apparatus. It consists of common bile duct sphincter, pancreatic duct sphincter and ampulla of Vater sphincter. Recently, with better understanding in the anatomical structure and physiological function of sphincter of Oddi, its pivotal roles in maintaining the intra-ductal pressure within biliary tract and pancreatic duct, hydrodynamics of bile and pancreatic juice, aseptic condition within biliary tract and pancreatic duct, and preventing duodenal reflux have been identified. Hence, the importance in protecting the sphincter of Oddi has been recognized among contemporary biliary surgeons.     

Sphincter of Oddi response to caerulein after endoscopic sphincterotomy for papillary stenosis

Using a percutaneous transhepatic cholangioscopy (PTCS) catheter, sphincter of Oddi motility was measured in a patient with papillary stenosis secondary to bile duct stones. Prior to sphincterotomy, intramuscular injection of 20 micrograms caerulein did not inhibit pathological contraction waves of the sphincter of Oddi or relieve abdominal pain. Endoscopic sphincterotomy of the lower segment of the sphincter of Oddi resulted in recovery of the normal response to caerulein, i.e. relaxation of the sphincter of Oddi. This observation indicates that the pathological contraction and lack of relaxation to cholecystokinin in a patient with papillary stenosis is due to high common bile duct pressure. The measurement of motility of sphincter of Oddi via the PTCS route is useful in diagnosing motor disorders in the sphincter of Oddi and is helpful in deciding to perform endoscopic sphincterotomy.     

Biliopancreatic reflux—pathophysiology and clinical implications

The common bile duct and the main pancreatic duct open into the duodenum, where they frequently form a common channel. The sphincter of Oddi is located at the distal end of the pancreatic and bile ducts; it regulates the outflow of bile and pancreatic juice. In patients with a pancreaticobiliary maljunction, the action of the sphincter does not functionally affect the junction. Therefore, in these patients, two-way regurgitation (pancreatobiliary and biliopancreatic reflux) occurs. This results in various pathological conditions of the biliary tract and the pancreas. Biliopancreatic reflux could be confirmed by: operative or postoperative T-tube cholangiography; CT combined with drip infusion cholangiography; histological detection of gallbladder cancer cells in the main pancreatic duct; and reflux of bile on the cut surface of the pancreas. Biliopancreatic reflux occurs frequently in patients with a long common channel. Although the true prevalence, degree, and pathophysiology of biliopancreatic reflux remain unclear, biliopancreatic reflux is related to the occurrence of acute pancreatitis. Obstruction of a long common channel easily causes bile flow into the pancreas. Even if no obstruction is present, biliopancreatic reflux can still result in acute pancreatitis in some cases.     

Evaluation of the opening of the sphincter of Oddi]

Measurement of the activity of the sphincter of Oddi by the method of classical manometry did not reveal any significant difference before and after vagotomy. However, the existence after perfusion of residual pressure greater than initial pressure, suggests that a deformity of the duct during perfusion disturbs measurement of the opening of the sphincter. The mechanical properties of the duct were measured in vitro, as a first approximation it was suggested that the error due to a deformity of the duct, might be eliminated using several perfusion rates and calculating for each rate the opening R of the sphincter using the following formula: R equals (Perfusion pressure-Residual pressure) Flow rate. When the opening of the sphincter is calculated in this way, one may observe that vagotomy leads to definite reduction of the resistance of Oddi's sphincter.     

胆道外科手术中Oddi括约肌保护的共识与争议

Oddi括约肌（sphincter of Oddi）是机体内一个复杂而精细调节的结构,它是由围绕于胆总管末段、胰管末段及胆胰管汇合Vater壶腹的三部分肌束组成。近年来,随着对Oddi括约肌的解剖结构与生理功能研究的不断深入,人们已认识到Oddi括约肌在维护胆道系统与胰管系统的正常压力、胆汁与胰液的流体力学、胆道与胰管系统的无菌状态以及阻止十二指肠液反流等方面均具有不可替代的关键作用;其结构与功能的受损或被废弃可导致一系列胆胰疾病的发生。因此,当代胆道外科医生应该充分认识到保护Oddi括约肌的重要性。     

A new method for correlating pancreatic and biliary duct pressures and sphincter of Oddi electromyography

Myoelectric activity of the sphincter of Oddi and duodenum was correlated with pancreatic and biliary duct pressures in eight opossums, in both the fasted and fed states. Four bipolar electrode pairs were implanted in the sphincter of Oddi and duodenum. A polyethylene T tube was placed in the pancreatic duct. The common duct was cannulated through a small bile duct. This method allowed pressure recording for several weeks and avoided interference with the flow of bile or pancreatic juice into the duodenum. The frequency of slow waves was the same in the sphincter of Oddi and duodenum (19 per minute). The variation in the frequency of spike potentials in the sphincter of Oddi correlated to that of the migrating myoelectric complex in the duodenum. The average frequency of slow waves that have superimposed spike potentials in the sphincter of Oddi and duodenum was 3.0 and 0 in phase 1, 4.7, and 6.2 in phase II, 6.1 and 15.1 in phase III, and 3.4 and 6.3 in phase IV, respectively. The average duration of a migrating myoelectric complex cycle was 92 minutes. After feeding, the interdigestive phases of the migrating myoelectric complex were abolished and substituted by a feeding activity pattern that was characterized by an average number of sphincter of Oddi and duodenum spikes of 6.6 and 10.7, respectively. The mean fasting pressure in the pancreatic and biliary duct was 15 and 13 mmHg, respectively. Pressure changes were of two types--synchronous with respiratory movements and with each sphincter of Oddi spike potential. There was no variation in the baseline pressure during the migrating myoelectric complex phases and the fed state. It is concluded that the sphincter of Oddi of the fasting opossum exhibits cyclic changes in the number of spike potentials that correlate with the migrating myoelectric complex in the duodenum. However, the number and amplitude of spike potentials are different in the sphincter of Oddi and duodenum. There is no change in the baseline pressure during fasting and feeding states, and a temporary pressure elevation synchronic with each sphincter of Oddi spike potential was observed.     

Rhythm abnormalities of the biliary and pancreatic sphincters: diagnosis by endoscopic manometry

Abnormal phasic wave activity was noted in the biliary duct sphincter, pancreatic duct sphincter, or both in 43 patients. This abnormality consisted of a tachyrhythmia in 40 patients and absent phasic wave activity in 3 patients. Tachyrhythmia was encountered in patients with elevated basal sphincter pressures. In four patients with tachyrhythmia, administration of intravenous naloxone failed to modify phasic wave activity. Three patients with normal basal sphincter pressures had absent phasic wave activity. This abnormality occurred in two patients with cirrhosis and in one patient with suspected cirrhosis. In one patient with cirrhosis, administration of intravenous morphine did not induce phasic wave activity.