Postprandial sphincter of Oddi myoelectric activity and gallbladder emptying

Feeding initiates gallbladder emptying and bile delivery into the duodenum. It is not yet defined how the sphincter of Oddi regulates flow of bile into the duodenum during gallbladder emptying. The aim of this study was to assess postprandial spike burst activity in the sphincter of Oddi, while quantitating gallbladder emptying with noninvasive radioisotope imaging. Six adult opossums were prepared with bipolar electrodes in the sphincter of Oddi. After 2 weeks of recovery the animals were fasted overnight and positioned under a gamma camera, and myoelectric recordings were begun. After two cycles of the migrating motor complex (MMC), 2 mCi 99Tc-HIDA was infused intravenously and permitted to concentrate in the gallbladder for a period of 30 min. Subsequently, a 30-ml liquid meal, containing 0.9 g protein, 3.5 g carbohydrate, and 3.3 g fat, was instilled into the stomach. Sphincter of Oddi myoelectric activity (spike bursts/min) and gallbladder emptying (expressed as percentage of original 99Tc counts in the gallbladder) were measured at intervals for 120 min following feeding. Feeding resulted in prompt gallbladder emptying. Sphincter of Oddi spike burst activity was not altered significantly in the first 30 min after feeding, suggesting that motor activity in the sphincter of Oddi does not initially influence bile flow. Subsequently, spike burst activity increased progressively, suggesting that sphincter of Oddi motor activity may accelerate bile delivery into the duodenum during later phases of gallbladder emptying.     

Effect of alcohol on cyclical myoelectric activity of the opossum sphincter of Oddi

Ethyl alcohol may adversely affect pancreatic function by perturbing sphincter of Oddi (SO) or duodenal motor activity. The aim of this study was to identify the effect of ingested alcohol on the SO, duodenal, and gastric myoelectric activity in conscious opossums. In five adult opossums bipolar stranded stainless-steel wire electrodes were implanted on the SO, gastric antrum, and duodenum. After a 2-week recovery period, each animal underwent eight 8-hr recording sessions while fasted and awake. After two fasting cycles of the migrating myoelectric complex, animals were randomly fed either 10 ml of a 30% ethyl alcohol solution or 10 ml of water via an esophageal tube, and recordings continued for 4-6 hr. During the control state, cyclical myoelectric spike activity was recorded from the SO, gastric antrum, and duodenum with a mean +/- SD cycle length of 7.35 +/- 15.0 min, 74.3 +/- 10.1 min, and 94.8 +/- 8.7 min, respectively. With alcohol, SO and duodenal cycle lengths were unchanged while gastric cycle length decreased. However, alcohol effected a significant increase in peak SO spike burst frequency with no corresponding change in gastric or duodenal spike burst frequency. An equivalent volume of water had no influence on sphincter of Oddi myoelectric activity. It is concluded that ingested alcohol induces increased myoelectric activity from the opossum SO, independent of changes in activity of the duodenum or stomach. Since the SO plays a major role in metering bile and pancreatic flow into the duodenum, this may be a factor in alcohol-induced pancreatitis.     

Effect of analgesic drugs on the electromyographic activity of the gastrointestinal tract and sphincter of Oddi and on biliary pressure.

Continuous biliary pressure and electromyographic activity of the sphincter of Oddi and gastrointestinal tract were recorded in conscious opossums following administration of analgesic drugs. Morphine, meperidine, and pentazocin increased significantly the duration of the migrating motor complex (MMC) cycle. Periods of 1-2 minutes of intense burst of spike potentials were seen in the sphincter of Oddi and duodenum following administration of morphine (8 experiments), meperidine (6 experiments), and pentazocin (3 experiments). The biliary pressure in the control studies was similar to that following administration of all analgesics in the animals with gallbladder and following instillation of tramadol, metamizol, and acetylsalicylic acid in animals with no gallbladder. However, the biliary pressure was significantly higher following administration of morphine, meperidine, and pentazocin in the animals with no gallbladder. It is concluded from this study that morphine, meperidine, and pentazocin may cause important disturbances in the motility of the sphincter of Oddi and gastrointestinal tract. These myoelectric disturbances may cause an increase in the biliary pressure in animals that have been subjected to cholecystectomy, but not in animals with intact gallbladder. The gallbladder may accommodate the bile produced by the liver during periods of sphincter of Oddi dysfunction and thus impede an increase in the biliary pressure.     

Effects of gastrointestinal hormones on Oddi's sphincter and duodenal myoelectric activity and pancreatobiliary pressure. Studies in the opossum

Myoelectric activity of Oddi's sphincter and duodenum was correlated with common duct and pancreatic duct pressures in conscious opossums after infusion of the following substances: cholecystokinin, pentagastrin, glucagon, secretin, and acetylcholine. Cholecystokinin and pentagastrin increased and glucagon and secretin decreased the frequency of spike potentials in Oddi's sphincter and the duodenum. Acetylcholine was associated with the largest increase in spike potentials in both Oddi's sphincter and the duodenum. Although there was variation in the number of pressure elevations related to Oddi's sphincter spike potentials, the baseline pressure remained constant during administration of the hormones. Acetylcholine infusion increased the biliary and pancreatic pressures to 29 and 31 mm Hg, respectively. We conclude that gastrointestinal hormones may have an important role in regulating the excretion of bile and pancreatic juice into the duodenum.     

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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.     

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。     

Human fasting and postprandial sphincter of Oddi motility

Sphincter of Oddi motility was evaluated in post-cholecystectomy patients with indwelling T tubes during fasting and after feeding. A triple-lumen catheter was positioned to record from the sphincter of Oddi and duodenum. The sphincter of Oddi was characterized by phasic contractions independent of duodenal contractions. During fasting duodenal wave frequency exhibited four phases, whereas only two phases could be identified from the sphincter of Oddi. A prolonged phase A in the sphincter of Oddi corresponded to duodenal phases I, II and IV. A short phase B in the sphincter of Oddi just preceded the onset of duodenal phase III and was temporally related to it. Sphincter of Oddi basal pressure increased during duodenal phases III and IV. After ingestion of food, sphincter of Oddi basal pressure, wave amplitude and duration decreased, but the frequency remained unchanged. Conversely, duodenal frequency increased but there was no change in amplitude. Thus, the human sphincter of Oddi and duodenum exhibited independent motility demonstrating distinct phases during the interdigestive period. After food, sphincter of Oddi motility altered in a manner which would facilitate the passive flow of fluid into the duodenum.     

Advances in research and clinical practice in motor disorders of the sphincter of Oddi

Perfusion manometry of the sphincter of Oddi (SO) using a pneumohydraulic capillary infusion system records phasic wave activity superimposed on basal pressure. A triple-lumen catheter allows the recording of propagation of the phasic waves. Microtransducer manometry is an alternative that permits prolonged recording of biliary pressure without the need for infusion. A cyclic change is recognized in SO motility in coordination with the migrating motor complex (MMC) of the duodenum during fasting. SO contractions occur at maximal frequency and amplitude during phase 3 of the duodenal MMC. Using two microtransducer catheters placed by duodenoscopy, a cyclic elevation of biliary pressure can be recorded in concert with phase 3. These findings indicate that human SO contractions impede bile flow. SO dysfunction causing biliary-type pain can be diagnosed by manometry. The pressure elevation during phase 3 may contribute to the development of pain in patients with biliary dyskinesia. Gastrectomy and proximal duodenal transection were proven to affect sphincter motility, as evidenced by the paradoxical response to cholecystokinin. Choledocholithiasis and hepatolithiasis are associated with low basal pressure, presumably due to repeated injury to the sphincter by passing stones. SO and biliary manometry leads to better understanding of biliary dynamics and the pathophysiology of biliary diseases. Received: March 25, 2002 / Accepted: April 14, 2002 Offprint requests to: M. Tanaka     

Cyclic motility of the sphincter of Oddi

The sphincter of Oddi has a cyclic motility that is closely associated with the duodenal migrating motor complex during fasting. This close association affects the bile flow mechanism and may play several roles in keeping the intestine clean and maintaining the migrating motor complex. The cyclic motility of the sphincter of Oddi changes after surgery and abnormal motility causes biliary dyskinesia. In this article, the gastrointestinal migrating motor complex and cyclic motility of the sphincter of Oddi are reviewed for better understanding of biliary and gastrointestinal physiology and the relationship between the two phenomena. Received for publication on May 17, 1999; accepted on Aug 16, 1999     

放射性核素动态扫描计量分析对胆囊切除术后胆汁排泄的评价

目的　探讨胆囊切除术对胆汁排泄的影响,寻找评价奥狄（ Ｏｄｄｉ） 括约肌功能的无创方法。 方法　将４５ 名自愿者病人随机分成３ 组,即术前组、术后组及排泄延迟组。经禁食８ ～１２ 小时后,分别静脉给予９ ９ ｍ Ｔｃ Ｅ Ｈ Ｉ Ｄ Ａ１８５ Ｍ Ｂｑ ,同时进行动态采集。取肝总管、胆总管、胆囊及十二指肠等部位的兴趣区（ｒｅｇｉｏｎ ｏｆｉｎｔｅｒｅｓｔ, Ｒ Ｏ Ｉ） ,通过实时的核素比值,分析单位时间的核素分布,同时比较胆总管兴趣区核素排泄的 Ｔｍａｘ 值。 结果　术前组与术后组比较,十二指肠与胆总管兴趣区的核素比值（ Ｒ２） 及胆总管 Ｒ Ｏ Ｉ的 Ｔｍａｘ 值差异无显著意义（ Ｐ＞ ００５） 。而排泄延迟组虽经 Ｂ 型超声检查证实无胆总管扩张,但其 Ｒ２ 值和胆总管 Ｒ Ｏ Ｉ的 Ｔｍａｘ 值与术前组对比差异有显著意义（ｔ１ ＝ ２１６ ,ｔ２ ＝ ２２９ ,ｔ３ ＝ ２０７ , Ｐ＜ ００５） 。 结论　在没有肝外梗阻,无 Ｏｄｄｉ 括约肌功能失调的病人,其胆汁排泄于术前、术后无明显变化,胆囊切除术后胆总管无代偿性扩张。肝胆放射性核素动态扫描计量分析可作为 Ｏｄｄｉ 括约肌功能失调的诊断和分型的敏感、无创方法。     

犬胆囊、Oddi括约肌电活动和胆囊胆总管压力的同步检测

目的探讨同步检测犬胆囊、Oddi括约肌肌电和胆囊、胆总管压力的实验方法。方法采用多通道生理仪同步记录麻醉后犬的胆囊和Oddi括约肌的肌电图以及胆囊、胆总管压力。剖腹显示肝、胆、胃及十二指肠,用7F静脉深穿管经肝穿刺进入胆囊腔内作为测压通道,再将一对铂金电极缝在胆囊底部浆膜上。把另一条7F静脉深穿管制作成带一对铂金电极的胆总管测压和Oddi括约肌肌电检测通道。结果Oddi括约肌峰电位为0．18～0．20mV,频率为2～5次／min;其慢波电位0．06～0．08mV,频率为8～10次／min,峰电位往往在某次慢波电位的基础上突然出现。胆囊肌电不明显。胆囊的压力为7～9cmH2O,胆总管压力为11～15cmH2O。结论同步检测Oddi括约肌肌电活动与胆囊、胆总管压力的实验方法是可行的,有利于研究Oddi括约肌肌电活动与胆囊及胆总管压力的关系,但是对于记录在体胆囊的肌电活动方法需要进一步改进。     

Biliary sphincter motility after neural isolation of the pancreatoduodenal region in conscious dogs

BACKGROUND: Several neural and hormonal factors are known to affect the motility of the sphincter of Oddi. However, the precise mechanisms of the control of sphincter motility have not been completely explored. We investigated the relationship of canine biliary sphincter motility when it is extrinsically denervated by neural isolation of the pancreatoduodenal region. METHODS: Interdigestive and postprandial sphincter motility in a denervated pancreatoduodenal segment and effects of cholecystokinin-octapeptide were studied in 7 conscious dogs. Data were compared with those of 7 neurally intact control dogs. RESULTS: After extrinsic denervation of the pancreatoduodenal region, sphincter motility exerted a cyclic change in concert with the duodenal myoelectric cycles; this change involved short cyclic bursts of motor activity, which gradually increased in intensity. The increase in the cyclic bursts of motor activity was also cyclic and associated with an increase in the plasma motilin concentration. Neural isolation of the pancreatoduodenal region increased sphincter basal pressure and motility index (integral per minute). In the denervated biliary sphincter, the feeding pattern and temporary inhibitory effect of feeding, as seen in controls, were absent, which suggests the role of extrinsic nerves in delivering bile into the duodenum after feeding. In the denervated dogs, cholecystokinin-octapeptide caused excitation of the sphincter activity, instead of relaxation observed in controls. CONCLUSIONS: Extrinsic innervation to the pancreatoduodenal region has an inhibitory effect on biliary sphincter motility. Abnormalities in extrinsic innervation to the biliary sphincter might increase the resistance of the sphincter to the bile flow and induce bile stagnation.     

Graded effect of protein on regional myoelectric activity of the opossum sphincter of Oddi

Although it is known that the sphincter of Oddi exhibits a myoelectric response to intraluminal nutrients, the effect of specific dietary components has not been well characterized. The aim of this study was to determine the effect of intragastric instillation of a protein meal on regional myoelectric activity of the opossum sphincter of Oddi. Seven adult opossums were chronically prepared with self-retaining bipolar electrodes secured to the proximal and distal parts of the sphincter. After a 2-week recovery period, and with the animals fasted and conscious, myoelectric activity was recorded for two cycles of the migrating myoelectric complex. The animals then received graded calories of protein through an orogastric tube and recordings were continued until return of the fasted cyclic activity. Doses of 60, 120, and 240 kcal of protein elicited increases in myoelectric spike activity of the proximal sphincter of 18.7%, 41.9%, and 66.6%, respectively. Similarly, the length of the fed state was prolonged by increasing caloric loads, with mean (plus or minus standard error of the mean) times of 266 +/- 25, 292 +/- 15, and 375 +/- 42 minutes for each dose. A similar relationship was noted in the distal part of the sphincter. Regression analysis between the proximal and distal parts of the sphincter during the fasted and fed states showed a strong and persistent correlation of gradient of spikeburst frequency. We conclude that myoelectric spike frequency of the opossum sphincter of Oddi exhibits a dose-related response to intragastric protein calories. Furthermore, the proximal and distal parts of the sphincter remain electrically coupled, with the proximal region pacing the distal region during the fasted state and after protein administration.     

Effects of Proximal Duodenal Transection and Anastomosis on Interdigestive Sphincter of Oddi Cyclic Motility in Conscious Dogs

Gallstones formed after gastrectomy are bilirubinate stones probably associated with biliary stasis and infection. Effects of proximal duodenal transection performed during gastrectomy on interdigestive sphincter of Oddi cyclic motility possibly relevant to this phenomenon were investigated in four conscious dogs. Although the cyclic change in sphincter motility was still in concert with the duodenal migrating motor complex after duodenal transection, the mean period was shortened (p < 0.02), and the frequency (p < 0.005) and amplitude (p < 0.001) of sphincter phasic waves during phase III were decreased. The cyclic variation of basal pressure disappeared, and the mean basal pressure throughout the cycle was significantly reduced (p < 0.003). Transient inhibition of sphincter and duodenal contractions normally seen during phase III disappeared. Duodenal transection reversed the response of the sphincter to cholecystokinin-octapeptide from inhibition to stimulation and from reduction of the basal pressure to elevation. These data suggest that duodenal transection produces significant changes in interdigestive sphincter of Oddi motility, possibly contributing to augmented duodenobiliary reflux and then lithogenesis. Myoneural continuity between the stomach and sphincter of Oddi at the proximal duodenum may play an important role in maintaining normal biliary dynamics.     

胃肠道神经肽对胆道Oddi括约肌活动和心血管功能影响的实验研究

为了揭示胆道流体力学和心血管功能相互关系，以及从静脉输注胆囊收缩素八肽（Ｃｈｏｌｅｃｙｓ－ｔｏｋｉｎｉｎ，ＣＣＤ－ＯＰ）、血管活性性肠肽（Ｖａｓｏａｃｔｉｖｅｉｎｔｅｓｔｉｎａｌｐｅｐｔｉｄｅ，ＶＩＰ）和Ｐ物质（ＳｕｂｓｔａｎｃｅＰ，ＳＰ）等胃肠道神经肽对它们相互关系的影响，作者观察了９１只豚鼠在静脉输注ＣＣＤ－ＯＰ、ＶＩＰ、ＳＰ及ＣＣＫ－ＯＰ和ＶＩＰ同时输注时左心室活动，Ｏｄｄｉ约肌活动和胆总管     

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??Two issues of biliary surgery can not be ignored??Protection of the sphincter of Oddi function and bile duct injury in last paragraph LIU Yong-feng, LI Gui-chen. Department of General Surgery, the First Hospital of China Medical University, Shenyang110001, China
Corresponding author: LIU Yong-feng, E-mail:yfliu@mail.cmu.edu.cn
Abstract Sphincter of Oddi (SO) is a complex neuromuscular structure located at the choledocho and pancreatoduodenal junction. SO plays a major role in controlling the flow of bile from the common bile duct into the duodenum and effectively prevents duodenobiliary reflux. The protection of the structure and function of SO should be emphasized in biliary surgery. Oddi sphincterotomy or angioplasty should be carried on strictly. It is very difficult for the diagnosis and treatment of the last part of common bile duct injury with iatrogenic reasons. The key point is to prevent its occurrence. Once the injury occurs, early treatment will be important. Damage control surgery has been proven to have the most benefits for delay found. The basic principles of the management for bile duct injury are the diversion of bile juice, pancreatic juice and gastric juice, reducing the leakage of digestive juices and adequate drainage of retroperitoneal space. Enteral nutrition, anti-infection and supportive therapy should be applied as soon as possible. Restoring the continuity of the biliary tract and gastrointestinal tract should be considered in the second stage operation.     

Structure and Innervation of the Extrahepatic Biliary System in the Australian Possum,Trichosurus Vulpecula

The morphology, microanatomy and innervation of the biliary tree of the Australian possum, Trichosurus vulpecula, was examined. The gross morphology of the gallbladder, hepatic and cystic ducts, and the course of the common bile duct, conforms to those of other species. The sphincter of Oddi has an extraduodenal segment that extends 15mm from the duodenal wall; within this segment the pancreatic and common bile ducts are ensheathed together by sphincter muscle. Their lumens unite to form a common channel within the terminal intraduodenal segment.Nerve cell bodies of the gallbladder were found in an inter-connecting network of ganglia that were located in the serosa, muscularis and mucosa. Nerve fibres innervated the muscle, arterioles and the mucosa. Few ganglia were found along the supra sphincteric portion of the common bile duct. Nerve trunks followed the duct and a dense nerve fibre plexus was found in the mucosa. In the sphincter most ganglia were located in two plexuses, the first between the layers of the external sphincter muscle, which was continuous with the external muscle of the duodenum, and the second was associated with the internal sphincter muscle. Nerve fibres were numerous in the sphincter muscle, and were also found in the subepithelial and periglandular plexuses of both the pancreatic and common bile ducts.     

Cholecystectomy in the cat damages pericholedochal nerves and impairs reflex regulation of the sphincter of Oddi. A mechanism for postcholecystectomy biliary dyskinesia

A recent study demonstrated the activity of the feline sphincter of Oddi to be regulated by the distending pressure in the biliary tract via inhibitory nerves running along the common bile duct. In the present study this mechanism was investigated in cats previously subjected to cholecystectomy. An increment in the hydrostatic pressure in the biliary tree from 0 to 20 cmH2O did not affect the function of the sphincter of Oddi in cholecystectomized cats, but relaxed the sphincter in controls and in cats with sham operation. Morphologic study of the nerve arrangement in the feline extrahepatic biliary tract revealed that cholecystectomy is likely to damage pericholedochal nerves. These experimental observations may have relevance for the development of biliary dyskinesia following cholecystectomy in some patients, and suggest that when performing biliary-tract surgery it is important to preserve nerve fibers running along the common bile duct.     

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??Significance and measures of the sphincter of oddi preservation in the operation of hepatic bile duct stones LI Gui-chen. Department of General Surgery??the First Hospital of China Medical University??Shenyang110001??China
Abstract Sphincter of Oddi (SO) is a complex neuromuscular structure by neural and humoral control. SO plays a major role in the occurrence and development of hepatic bile duct stones. The damage of sphincter of Oddi can lead to serious reflux cholangitis??recurrence of bile duct stones and bile duct cancer sometimes. Indications of EST for the treatment of extrahepatic bile duct stones must be strictly controlled for the protection of the normal structure and function of the sphincter of Oddi. Surgeons must be careful in the treatment of bile duct stones with biliary enteric anastomosis.     

Biliary manometry in choledochal cyst with abnormal choledochopancreatico ductal junction

Intraoperative manometry of the biliary tract and measurement of amylase levels in choledochal cysts were performed in seven patients, aged 14 months to 5 years, with choledochal cysts, in an investigation of the pathophysiology of the biliary tract. An abnormal choledochopancreatico ductal junction was observed in these seven patients by preoperative endoscopic retrograde cholangiopancreaticography (ERCP) or intraoperative cholangiograms. All six patients examined showed a high amylase level in the choledochal cyst (5,450 to 46,500 Somogyi Units). The intraoperative manometry of the biliary tract showed that a remarkable high pressure zone as was found in the area of sphincter of Oddi was not found in the area of abnormal choledochopancreatico ductal junction. The pressure recordings also demonstrated that the sphincter of Oddi pressure in the patient with choledochal cyst was increased by gastrin stimulation. On the contrary, no pressure reaction to gastrin or secretin was found in the area of abnormal choledochopancreatic ductal junction. From these results it seems that free reflux of pancreatic juice into the biliary system occurs, and the reflux stream depends upon the pressure gradient between pancreatic ductal pressure and common bile duct pressure because of the lack of a sphincter function at the choledochopancreatico ductal junction.