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     

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。     

《中华消化内镜杂志》2014年可直接使用英文缩写的常用词汇

ERCP（经内镜逆行胰胆管造影术） EST（经内镜乳头括约肌切开术） EUS（内镜超声检查术） EUS-FNA（内镜超声引导下细针抽吸术） EMR（内镜黏膜切除术） ESD（内镜黏膜下剥离术）     

2009年本刊可直接用英文缩写的常用词汇

经内镜逆行胰胆管造影术（ERCP） 经内镜乳头括约肌切开术（EST） 内镜超声检查术（EUS） 内镜黏膜切除术（EMR）     

2009年本刊可直接用英文缩写的常用词汇

经内镜逆行胰胆管造影术（ERCP） 经内镜乳头括约肌切开术（EST） 内镜超声检查术（EUS） 内镜黏膜切除术（EMR）     

《中华消化内镜杂志》2010年可直接使用英文缩写的常用词汇

经内镜逆行胰胆管造影术（ERCP） 经内镜乳头括约肌切开术（EST） 内镜超声检查术（EUS） 内镜超声引导下细针抽吸术（EUS—FNA） 内镜下静脉曲张套扎术（EVL） 内镜黏膜切除术（EMR） 内镜黏膜下剥离术（ESD）     

猪作为胰胆管造影操作模型的实验研究

内镜下逆行性胰胆管造影（endoscopic retrograde cholangiopancreotography．ERCP）是在十二指肠镜直视下经十二指肠乳头注入造影剂作X线胰胆管造影检查，是胰腺、胆道等疾病的重要诊治手段之一。通过ERCP．可以进行乳头括约肌切开术、胆胰管取石、支架植入和狭窄扩张。此项微创技术需要经验丰富的内镜医师操作，初学者操作有一定风险.     

治疗性内镜下逆行胰胆管造影技术治疗胆总管结石216例临床分析

随着内镜下逆行胰胆管造影（ERCP）技术的不断提高,治疗性ERCP技术,如内镜下乳头切开术、针状电刀乳头预切开术、内镜下十二指肠鼻胆管引流术（ENBD）、内镜下乳头括约肌气囊扩张术（EPBD）和机械碎石术（ML）等在胆总管结石患者的治疗中得到广泛应用。我们对我院运用ERCP技术治疗的216例胆总管结石患者的临床资料进行回顾性分析。     

ERCP术后急性胰腺炎并发症的危险因素及预防研究进展

内镜逆行性胰胆管造影(ERCP)以及相关治疗技术已成为胆胰疾病的重要治疗手段,ERCP 术后急性胰腺炎(AP)是常见且严重的并发症之一,目前研究发现．治疗性ERCP、Oddi括约肌运动功能障碍、Oddi括约肌压力检测、内镜下乳头括约肌气囊扩张术、插管困难与多次胰管注射、操作者的经验不足为ERCP术后急性胰腺炎的常见危险因素．关于预防ERCP 术后AP的药物研究被广泛开展,生长抑素和加贝酯被多数学者认为对AP有显著的预防作用．更广泛的药物研究其具体效果尚待进一步的研究证实．在内镜技术方面,选择性插管技术的改进、胰管支架和胆道引流技术被认为可有效地防止ERCP术后AP的发生．     

2009年本刊可直接用英文缩写的常用词汇

经内镜逆行胰胆管造影术（ERCP） 经内镜乳头括约肌切开术（EST） 内镜超声检查术（EUS）     

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.     

Is endoscopic sphincterotomy avoidable in patients with sphincter of Oddi dysfunction?

AIM: Endoscopic sphincterotomy is an efficient means of treating sphincter of Oddi dysfunction (SOD), but it is associated with a morbidity rate of 20%. The aim of this study was to assess how frequently endoscopic sphincterotomy was performed to treat SOD in a group of patients with a 1-year history of medical management. METHODS: A total of 59 patients, who had been cholecystectomized 9.3 years previously on average, were included in this study and they all underwent biliary scintigraphy. Medical treatment was prescribed for 1 year. Endoscopic sphincterotomy was proposed for patients whose medical treatment had been unsuccessful. RESULTS: Eleven patients were rated group 1 on the Milwaukee classification scale, 34 group 2 and 14 group 3. The hile-duodenum transit time (HDTT) was lengthened in 32 patients. The medical treatment was efficient or fairly efficient in 45% of the group 1 patients, 67% of the group 2 patients, and 71.4% of the group 3 patients (P=0.29). Only 14 patients out of the 21 whose medical treatment was unsuccessful agreed to undergo endoscopic sphincterotomy. HDTT was lengthened in 11 of the 14 patients undergoing endoscopic sphincterotomy and in 21 of the 45 non-endoscopic sphincterotomy patients (P=0.03). Twelve of the 14 patients who underwent endoscopic sphincterotomy were cured. CONCLUSION: In this prospective series of patients with a 1-year history of medical management, only 23% of the patients with suspected SOD underwent endoscopic sphincterotomy although 54% had an abnormally long HDTT.     

Value of intraductal biopsies and intraductal cytology in the etiological diagnosis of biliary stenoses

Endobiliairy tissue specimens were obtained for cytologic and histologic examinations at the site of stenosis after percutaneous biliary drainage or endoscopic retrograde sphincterotomy in 49 patients with benign (10 cases) or malignant (39 cases) biliary stricture. Final etiologic diagnosis was obtained by surgery (18 cases), autopsy (one case), aspiration cytology of metastasis (2 cases), serology (2 cases), and in 26 cases, was determined by the course and outcome of the disease. As the sensitivity of each method, cytology and histology, was weak, it was necessary to associate them to improve results. Accurate etiologic diagnosis was achieved in 77 p. 100 of cases. The specificity of the method was satisfactory and specimen examination allowed to correct and confirm the initial etiologic diagnosis in 12 and 65 p. 100 of cases, respectively. The specificity of the method and its low morbidity prompt us to recommend it during transhepatic or retrograde therapeutic drainage as it can serve as a guide for later treatment. On the other hand, achievement of a transhepatic drainage or an endoscopic sphincterotomy only to obtain endobiliairy tissue specimens means taking into account the poor sensitivity of the method and the complications inherent to transhepatic drainage and endoscopic sphincterotomy. The practice of obtaining specimens by the retrograde technique without sphincterotomy or under cholangioscopy should be developed.     

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.     

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.     

Guidewire technique for endoscopic transpapillary procurement of bile duct biopsy specimens without endoscopic sphincterotomy

BACKGROUND: Endoscopic sphincterotomy may be required when endoscopic transpapillary bile duct biopsy specimens are needed for tissue diagnosis. However, endoscopic sphincterotomy has potential complications. A guidewire technique for obtaining transpapillary biopsy specimens without endoscopic sphincterotomy was evaluated. METHODS: A total of 13 patients (11 men, 2 women; mean age 67.5 years) with biliary stricture or obstruction underwent endoscopic retrograde cholangiography. A guidewire was then inserted across the stricture or obstruction and into an intrahepatic duct. Alongside the guidewire, the biopsy forceps (1.5 mm diameter) was introduced into the papillary orifice with the duodenoscope extremely close to the papilla. OBSERVATIONS: Tissue was obtained in 92.3% of the cases for histopathologic evaluation without difficulty or complication. The single failure occurred in a patient who had undergone a partial gastrectomy with Billroth I anastomosis. CONCLUSIONS: The guidewire technique for endoscopic transpapillary procurement of biopsy specimens of the bile duct obviates the need for endoscopic sphincterotomy.     

Sphincter of Oddi dysfunction in patients addicted to opium: an unrecognized entity

BACKGROUND: Opiate-induced sphincter of Oddi dysfunction (SOD) as a clinical entity has not been described. METHODS: Eight chronic opium addicts (all men, mean age 61.3 years, mean duration of addiction 24.75 years) presenting with pancreatobiliary pain and a dilated bile duct with or without dilated pancreatic duct on abdominal US were studied. All patients underwent ERCP and biliary sphincterotomy. In addition, pancreatic sphincterotomy was performed in 4 patients with a dilated pancreatic duct. OBSERVATIONS: At ERCP, the bile duct was dilated in 8 and pancreatic duct in 4 patients. There was delayed drainage of contrast (>45 minutes) from the bile duct in all 7 patients studied, whereas delayed drainage from the pancreatic duct (>9 minutes) was incidentally observed in 3 patients. In 6 patients followed after sphincterotomy for at least 2 years, there was marked relief of symptoms. Transabdominal US at 2 years follow-up revealed a normal bile duct in 5 and persistent albeit minimal dilatation in 1 patient. Acute pancreatitis developed in 4 patients after ERCP and sphincterotomy, which was fatal in one. No patient had any abnormality in the gallbladder on initial or follow-up transabdominal US. CONCLUSION: SOD in opium addicts is a distinct clinical entity, mainly seen in men in this population, that is characterized by a long history of opium addiction and the absence of prior cholecystectomy or associated gallstone disease. Most patients are seen with the classic clinical picture of SOD with marked long-term improvement in symptoms after endoscopic sphincterotomy.     

Endoscopic sphincterotomy in patients with stenosis of ampulla of Vater： Three-year follow-up of exocrine pancreatic function and clinical symptoms

AIM: To investigate retrospectively the long-term effect of endoscopic sphincterotomy (ES) including exocrine pancreatic function in patients with stenosis of ampulla of Vater. METHODS: After diagnostic endoscopic retrograde cholangiopancreatography (ERCP) and ES because of stenosis of the ampulla of Vater (SOD Type Ⅰ), follow-up examinations were performed in 60 patients (mean follow-up time 37.7 mo). Patients were asked about clini-cal signs and symptoms at present and before interven-tion using a standard questionnaire. Before and after ES exocrine pancreatic function was assessed by determina-tion of immunoreactive fecal elastase 1. Serum enzymes indicating cholestasis as well as serum lipase and amy-lase were measured. RESULTS: Eighty percent of patients reported an im-provement in their general condition after ES. The fecal elastase 1 concentrations (FEC) in all patients increased significantly after ES. This effect was even more marked in patients with pathologically low concentrations (< 200 μg/g) of fecal elastase prior to ES. The levels of serum lipase and amylase as well as serum alcaline phosphatase (AP) and gamma-glutamyltranspeptidase (GGT) decreased signifi-cantly after ES. CONCLUSION: The results of this study demonstrate that patients with stenosis of the ampulla of Vater can be successfully treated with endoscopic sphincterotomy. The positive effect is not only indicated by sustained improvement of clinical symptoms and cholestasis but also by improvement of exocrine pancreatic function.     

Sphincter of Oddi dysfunction and pancreatitis

Sphincter of Oddi dysfunction （SOD） is a term used to describe a group of heterogenous pain syndromes caused by abnormalities in sphincter contractility. Biliary and pancreatic SOD are each sub-classified as type Ⅰ, Ⅱ or Ⅲ, according to the Milwaukee classification. SOD appears to carry an increased risk of acute pancreatitis as well as rates of post ERCP pancreatitis of over 30%. Various mechanisms have been postulated but the exact role of SOD in the pathophysiology of acute pancreatitis is unknown. There is also an association between SOD and chronic pancreatitis but it is still unclear if this is a cause or effect relationship. Management of SOD is aimed at sphincter ablation, usually by endoscopic sphincterotomy （ES）. Patients with type Ⅰ SOD will benefit from ES in 55%-95% of cases. Sphincter of Oddi manometry is not necessary before ES in type Ⅰ SOD. For patients with types Ⅱ and Ⅲ the benefit of ES is lower. These patients should be more thoroughly evaluated before performing ES. Some researchers have found that manometry and ablation of both the biliary and pancreatic sphincters is required to adequately assess and treat SOD. In pancreatic SOD up to 88% of patients will benefit from sphincterotomy. Therefore, there have been calls from some quarters for the current classification system to be scrapped in favour of an overall system encompassing both biliary and pancreatic types. Future work should be aimed at understanding the mechanisms underlying the relationship between SOD and pancreatitis and identifying patient factors that will help predict benefit from endoscopic therapy.     

内镜下胰管括约肌切开术后早期并发症的前瞻性研究

目的评价内镜下胰管括约肌切开术后早期并发症的发生率及相关危险因素。方法前瞻性观察2006年5月至2007年4月行ERCP的住院患者,将ERCP下行胰管括约肌切开术的患者纳入研究。在ERCP术前及术中分别将患者和操作相关情况记录在统一的观察表上;术后随访并发症的发生情况直至出院;有关数据进行统计学分析。结果在纳入观察的165例行胰管括约肌切开术的患者中,25例发生并发症（15．2％）,其中急性胰腺炎22例（13．3％,轻度15例、中度6例、重度1例）,出血1例（0．6％）,急性胆管炎2例（1．2％）,无穿孔或操作相关的死亡发生。多变量分析提示术后急性胰腺炎危险因素是：女性（OR=3．8,95％CI1．4～10．8）、复发性胰腺炎（OR=3．1,95％CI1．0-9．9）、副乳头切开术（OR=5．9,95％CI1．2—28．8）。结论与常规ERCP操作比较,内镜下胰管括约肌切开术后急性胰腺炎的发生率较高。特别是女性、复发性胰腺炎、行副乳头切开术的患者,术后更易发生急性胰腺炎。