预防性胰管支架在插管困难的胆道型Oddi括约肌狭窄中的应用

目的 探讨预防性胰管支架在减少插管困难的胆道型Oddi括约肌狭窄术后胰腺炎的临床价值及有效性.方法 回顾63例胆道型Oddi括约肌狭窄且插管困难的患者资料,以2009年1月至2010年1月的33例为对照组(仅行单纯内镜治疗而未放置预防性胰管支架),2010年2月至2011年2月的30例为支架组(行内镜治疗的同时成功置入了预防性胰管支架).比较2组术后胰腺炎的发生率.结果 支架组(0/30,0)与对照组(8/33,24.2％)相比,术后胰腺炎发生率差异有统计学意义(P＜0.05).结论 对于明确诊断的胆道型Oddi括约肌狭窄且插管困难的患者而言,预防性胰管支架的置入是安全有效的.     

胆石症患者Oddi括约肌压力表现及其意义

目的探讨胆石症与Oddi括约肌（SO）功能的关系。方法对已行外科胆总管探查术患者术后6周进行胆道镜经T管窦道胆道测压,项目包括s0基础压、s0收缩幅度、sO收缩频率、胆总管压力。探查术原因71例为胆石症,分为胆囊结石组（20例）、胆总管结石组（22例）和肝内胆管结石组（29例）;9例因外伤,作为正常对照。胆道镜先明确有无胆道结石,如有结石在取石前后分别测压,如无结石则直接测压。结果胆道镜检查50例存在胆管结石者取石前后各测压指标均无统计学差异。胆囊结石组、胆总管结石组各指标与对照组无明显差异（P〉0．05）;但肝内胆管结石组的S0基础压、s0收缩幅度、胆总管压力均较对照组明显降低[（8．92±-5．87）mmHg比（16．21±3．27）mmHg、（58．89±26．40）mmHg比（106．30±54．28）mmHg、（8．49±6．89）mmHg比（13．56±2．93）mmHg],差异均有统计学意义（P〈0．05）,SO收缩频率无统计学差异（P〉0．05）。结论胆道测压不能作为判断胆管内有无结石的可靠依据;肝内胆管结石患者存在SO功能异常,其SO基础压和收缩幅度、胆总管压力均明显下降。     

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。     

内镜下乳头括约肌切开术致Oddi括约肌功能损伤的研究现状

Oddi括约肌结构精巧,其功能的完整性对于防止十二指肠内容物反流及细菌等逆行感染,维护肝胆胰内外部生理环境的平衡具有不可替代的作用。内镜下乳头括约肌切开术破坏了Oddi括约肌的完整性,其造成的负效应受到了越来越多的关注。概述了内镜下乳头括约肌切开术致Oddi括约肌功能损伤的研究进展,认为临床医师需正确认识和重视内镜下乳头括约肌切开术致Oddi括约肌功能的损伤,从多角度综合分析,根据患者的具体情况制订合理化诊疗方案。     

奥狄括约肌压力测定:方法及临床应用

奥狄括约肌测压是研究奥狄括约肌运动功能的有效方法,本文综述其方法和正常值。对奥狄括约肌运动功能紊乱诊断和治疗的指导意义以及在研究激素和药物对奥狄括约肌作用方面的应用。     

生长抑素对Oddi括约肌功能的影响

为证实生长抑素对Ｏｄｄｉ括约肌功能的作用，用逆行胰胆管造影下Ｏｄｄｉ括约肌测压研究了生长抑素对２０例患者Ｏｄｄｉ括约肌运动功能的影响。２０例患者中胆总管结石６例，胆总管轻度扩张３例，肝门癌３例，未见明显异常者８例。用低顺应性水灌注系统，三通道测压导管，分别于用药前及静注生长抑素２５０μｇ１分钟后进行Ｏｄｄｉ括约肌测压，以观察Ｏｄｄｉ括约肌的基础压、收缩频率、收缩幅度、收缩间期、传播方式和胆管内压变化。结果显示：用药后Ｏｄｄｉ括约肌基础压降低、收缩频率减慢，其余指标无明显变化。我们认为：生长抑素对Ｏｄｄｉ括约肌有抑制性作用，有利于胆汁和胰液的排出。     

奥狄括约肌压力测定及临床应用的再评价

奥狄括约肌压力测定（sphincter of Oddi manometry,SOM）是与经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography,ERCP）联合的技术,用于评价胆管及胰管括约肌功能。由于SOM有并发胰腺炎的风险,并对ERCP操作技术要求较高,使其开展受到限制。SOM方法分微型传感器法和灌注法两大类,灌注法中使用可抽吸液体导管或袖套式测压导管能显著降低SOM后胰腺炎发生率。本文就SOM方法的改进和奥狄括约肌功能障碍分型的变迁,以及SOM临床应用价值作一概述。     

奥狄括约肌测压的演进过程及意义

奥狄括约肌测压是诊断奥狄括约肌功能障碍的金标准。但由于奥狄括约肌生理解剖位置的特殊性,人们对其研究仍有一定局限性。本文旨在综述奥狄括约肌和胆胰管测压技术发展演进过程、各种导管的特点及测压相关并发症等。     

乙醇对清醒兔Oddi括约肌运动功能的影响

目的酒精是引起胰腺炎的常见原因.本文观察乙醇是否影响清醒兔Oddi括约肌的运动.方法健康白兔8只,在无菌条件下埋置Oddi括约肌测压管.手术后恢复7d进行实验.将测压管连接于低顺应性毛细血管水灌注系统,记录Oddi括约肌压力变化.经十二指肠分别灌流5%,15%和30%乙醇30min,灌流速度0.5mL/min;静脉则注射同样浓度的乙醇.以生理盐水作为对照.计算灌流乙醇前后Oddi括约肌运动参数变化.结果①经十二指肠灌流15%和30%的乙醇后,Oddi括约肌基础压分别为12.8mmHg±2.5mmHg和8.5mmHg±1.3mmHg,明显低于生理盐水对照组(17.4mmHg±4.3mmHg)(P<0.05和P<0.01),并且呈浓度依赖关系.十二指肠灌流15%和30%的乙醇后Oddi括约肌位相收缩的振幅分别为42.3mmHg±14.6mmHg和27.6mmHg±11.3mmHg、频率分别为(次/min)2.8±1.1和1.9±0.7、动力指数分别为45.5±12.3和33.3±12.7,与生理盐水对照(振幅、频率和动力指数分别为57.6mmHg±18.4mmHg,1.9±0.7次/min和26.7±11.6)比较也明显降低.②经静脉灌流15%和30%的乙醇后,Oddi括约肌基础压力明显低于生理盐水对照(11.7±2.1和8.2±1.6mmHgvs16.7±3.5mmHg)(P<0.05和P<0.01).静脉灌流15%后Oddi括约肌位相收缩的振幅、频率和动力指数分别为47.6mmHg±16.5mmHg,2.7±1.0次/min和37.6±14.5,灌流30%乙醇后三个参数分别为31.6mmHg±13.2mmHg,2.1±0.8次/min和31.4±13.4,与生理盐水对照比较均明显降低(P<0.05和P<0.01).③经十二指肠灌流15%和30%的乙醇后Oddi括约肌位相收缩的周期时间分别为7.4s±2.1s和8.3s±2.5s,经静脉灌流后分别为7.2s+2.3s和8.6s±2.7s.与生理盐水对照组比较,都有明显增加(P<0.01).④比较经十二指肠或经静脉两种途径灌流乙醇对Oddi括约肌运动的影响,发现两者之间无明显差异(P>0.05).结论乙醇减弱Oddi括约肌的运动可能导致十二指肠内容物反流入胆胰管,此可能是酒精引起胰腺炎的主要机制之一.十二指肠和静脉灌流乙醇两者都影响Oddi括约肌运动,提示饮酒后酒精经消化道吸收入血亦可继续干扰Oddi括约肌运动.     

十二指肠乳头括约肌切开术对Oddi括约肌功能的影响及与远期并发症的关系

目的探讨十二指肠乳头括约肌切开术（endoscopic sphincterotomy,EST）对Oddi括约肌功能的影响及与远期并发症的关系。方法收集2009年1月至2013年t月因胆总管结石行ERCP取石的患者,随访观察EST后并发症的发生情况,分为并发症组和对照组。在EST术前、术后1年分别采用Oddi括约肌测压术,对比Oddi括约肌基础压、收缩压高峰值的变化。并抽取胆汁,做细菌培养。结果共有68例患者纳入研究,随访13—36个月,有3例患者失访,远期并发症发生率为16．9％（11／65）。EST术后Oddi括约肌收缩高峰值和收缩频率明显低于术前,但并发症组与对照组之间在EST术前、术后差异均无统计学意义。EST术前并发症组胆道细菌阳性率54．5％（6／11）与对照组46．3％（25／54）之间比较差异无统计学意义（P=0．618）,但术后胆道细菌阳性率明显高于对照组[70％（7／10）比31．7％（13／41）,P=0．026]。采用Logistic回归分析表明：合并胆囊结石、胆总管直径（〉1．5cm）、结石数量（〉3）、结石最大直径（〉20mm）、EST大切开是EST术后远期并发症的主要危险因素。结论EST术后远期并发症须加强关注,Oddi括约肌功能下降、存在胆肠反流是其发生的基础因素,同时也受多种危险因素的影响。     

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.     

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.     

Sleeve sphincter of Oddi (SO) manometry: a new method for characterizing the motility of the sphincter of Oddi

Background/Purpose

Perfused multilumen sphincter of Oddi (SO) manometry is accepted as the gold standard for diagnosis of SO dysfunction. However, this technique is associated with a relatively high incidence of post-procedure acute pancreatitis. In addition, triple-lumen manometry recordings may be difficult to interpret, as movement may produce artifacts. We have refined the development of a sleeve sensor for human SO manometry. This assembly aims to overcome the above limitations. In this study the accuracy of sleeve SO manometry (SOM) has been evaluated and compared with standard triple-lumen perfused SOM.

Methods

Patients undergoing SO manometric studies consented to having both standard triple-lumen and sleeve SOM. A total of 32 paired studies were performed in 29 patients. Diagnosis was made only from standard triple-lumen SOM and the patient treated accordingly. For each study, SO basal pressure, contraction, amplitude, and frequency were recorded.

Results

There was no statistically significant difference in the recordings of SO basal pressure, contraction, amplitude, and frequency between the two techniques. A strong correlation was demonstrated between SO basal pressure determined with the two catheters. The accuracy of sleeve SOM is comparable to standard triple-lumen SOM, with less movement artifact. One patient developed mild post-manometric pancreatitis.

Conclusions

The sleeve catheter records SO pressures with comparable values to standard triple-lumen SOM. The sleeve assembly potentially can replace the use of the perfused triple-lumen catheter for the objective diagnosis of SO dysfunction.

     

Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction

Background & Aims: Patients with sphincter of Oddi dysfunction are at high risk of developing pancreatitis after endoscopic biliary sphincterotomy. Impaired pancreatic drainage caused by pancreatic sphincter hypertension is the likely explanation for this increased risk. A prospective, randomized controlled trial was conducted to determine if ductal drainage with pancreatic stenting protects against pancreatitis after biliary sphincterotomy in patients with pancreatic sphincter hypertension. Methods: Eligible patients with pancreatic sphincter hypertension were randomized to groups with pancreatic duct stents (n = 41) or no stents (n = 39) after biliary sphincterotomy. The primary measured outcome was pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). Results: Pancreatic stenting significantly decreased the risk of pancreatitis from 26% to 7% (10 of 39 in the no stent group and 3 of 41 in the stent group; P = 0.03). Only 1 patient in the stent group developed pancreatitis after sphincterotomy, and 2 others developed pancreatitis at the time of stent extraction. Patients in the no stent group were 10 times more likely to develop pancreatitis immediately after sphincterotomy than those in the stent group (relative risk, 10.5; 95% confidence interval, 1.4–78.3). Conclusions: Pancreatic duct stenting protects significantly against post-ERCP pancreatitis in patients with pancreatic sphincter hypertension undergoing biliary sphincterotomy. Stenting of the pancreatic duct should be strongly considered after biliary sphincterotomy for sphincter of Oddi dysfunction; pancreatic sphincter of Oddi manometry identifies which high-risk patients may benefit from pancreatic stenting.GASTROENTEROLOGY 1998;115:1518-1524     

Oddi括约肌功能失调的药物与内镜治疗的作用

了解药物与内镜下十二指肠乳头括约肌切开术(EST)对胆囊切除术后Oddi括约肌功能失调(SOD)的疗效.以临床诊断的SOD患者先行药物治疗一周,无效者再行EST治疗,观察其疗效.在45例药物治疗的患者中,有效者仅11例,其有效率为24.4%;而在34例药物治疗无效后经EST治疗的患者中,有效者为31例,其有效率为91.2%,明显优于药物治疗(P＜0.005).EST术中和术后出现并发症4例,其发生率为11.8%.EST是药物治疗SOD无效时的最佳手段.     

Gallbladder ejection fraction and its relationship to sphincter of Oddi dysfunction

Theoretically, relative distal common bile duct obstruction due to sphincter of Oddi dysfunction may be a cause of poor gallbladder evacuation observed on quantitative cholescintigraphy. In this study, the relationship of sphincter of Oddi dysfunction to the gallbladder ejection fraction by quantitative cholescintigraphy was explored. Eighty-one patients with biliary-type pain and otherwise normal evaluations underwent quantitative cholescintigraphy, sphincter of Oddi manometry, and ERCP. Abnormalities of stimulated quantitative cholescintigraphy and/or sphincter of Oddi manometry were present in 70% of this study group. Manometric evidence of sphincter dysfunction was present in patients with similar frequency irrespective of the degree of gallbladder evacuation. In conclusion, abnormalities of quantitative cholescintigraphy and sphincter manometry appear to be independent factors, although frequent findings in this patient population.     

A case of the pathogenesis of choledochocele in relaion to dysfunction of the sphincter of Oddi

A 47-year-old woman was admitted for evaluation of pain in the right upper quadrant of the abdomen. Seventeen years previously, she had undergone cholecystectomy for cholelithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) showed a cystic dilatation of the terminal portion of the common bile duct (CBD) protruding into the duodenal lumen and delaying the drainage of contrast medium. In this patient the CBD and the pancreatic duct had separate openings into the duodenum, so the relaitonship of the CBD to the pancreatic duct appeared to be unimportant in the formation of the cyst. Repeated changes in the radius of the cyst suggested dysfunction of the ampullary component of the sphincter of Oddi, with maintenance of normal function of the common duct component. The pathogenesis of the choledochocele in this patient is discussed in relation to dysfunction of the sphincter of Oddi. In addition, 2 criteria for the diagnosis of choledochocele by ERCP are proposed: [1] cystic dilatation of the terminal portion of the CBD protruding into the duodenal lumen, arrd [2] absence of the narrow segment of the CBD.     

Endoscopic biliary manometry in patients with suspected sphincter of Oddi dysfunction and in patients with cystic dilatation of the bile ducts

We studied the motility of the sphincter of Oddi in 12 patients with suspected sphincter of Oddi dysfunction, in four patients with cystic dilatation of the bile ducts (two Caroli's cases and two fusiform choledochal cyst cases), and in 33 patients with retained common duct stones. In these last 33 patients, the motor activity of the sphincter of Oddi was similar to that recorded in nine control subjects without pancreatic or biliary diseases. In the suspected Oddi dysfunction cases, both the basal sphincteric pressure and the frequency of the phasic contractions were significantly elevated (P<0.001). Patients with biliary cystic dilatation showed an increased basal pressure, but the frequency of the contractions was elevated in only those with choledochal cysts and the amplitude in only one of the two patients with Caroli's disease. Motor disorders of the sphincter of Oddi provide a basis for an alternative etiopathogenesis of cystic disease of the biliary system and a possible explanation for pain and dilatation of the bile duct in patients with suspected sphincter of Oddi dysfunction.