Medical treatment for sphincter of oddi dysfunction:Can it replace endoscopic sphincterotomy?

AIM:To report the results of a medical management of sphincter of oddi dysfunction(SOD) after an intermediate follow-up period.METHODS:A total of 59 patients with SOD(2 men and 57 women,mean age 51 years old) were included in this prospective study.After medical treatment for one year,the patients were clinically re-evaluated after an average period of 30 mo.RESULTS:The distribution of the patients according to the Milwaukee's classification was the following:11 patients were type 1,34 were type 2 and 14 were type 3.Fourteen patients underwent an endoscopic sphincterotomy(ES) after one year of medical treatment.The median intermediate follow-up period was 29.8 ± 3 mo(3-72 mo).The initial effectiveness of the medical treatment was complete,partial and poor among 50.8%,13.5% and 35%,respectively,of the patients.At the end of the follow-up period,37 patients(62.7%) showed more than 50% improvement.The rate of improvement in patients who required ES was not significantly different compared with the patients treated conservatively(64.2% vs 62.2%,respectively).CONCLUSION:Our study confirms that conservative medical treatment could be an alternative to endoscopic sphincterotomy because,after an intermediate follow-up period,the two treatments show the same success rates.     

腹腔镜联合骶尾部切口在超低位直肠癌保肛术中的应用

2009年5月-2012年10月,对35例超低位直肠肿瘤经腹腔镜联合骶尾部入路行直肠癌根治术,肿瘤下极距肛门2.6-4.2 cm,平均3.9 cm,瘤体直径2.5-3.7 cm,平均3.2 cm.术中均未发生严重并发症和手术死亡,无中转开腹.手术时间120-220 min,平均185 min.术中出血40-110 ml,平均80 ml.术后肠蠕动恢复时间16-60 h,平均46 h.术后排便次数3-5次/d.无吻合口漏发生.骶尾部切口感染3例.术后病理TNM分期：Ⅰ期2例,ⅡA期9例,ⅡB期15例,Ⅲ期9例.病理类型：高分化腺瘤19例,中分化腺瘤12例,低分化腺瘤4例.下切缘镜下均为阴性,肿瘤距下切缘距离2-4.5 cm,平均3.9 cm.术后随访3-30个月,中位时间20.3月,无吻合口及盆腔复发,排便功能恢复均较满意.     

A multidisciplinary approach to sphincter pharyngoplasty for correction of velopharyngeal dysfunction following repair of cleft palate

BackgroundManagement of severe velopharyngeal dysfunction is best performed by a multispecialty team. This team could include a speech-language pathologist, otolaryngologist, prosthodontist, and a plastic surgeon. The most commonly performed surgical procedures in complicated cases with scarred soft palate are sphincter pharyngoplasty and pharyngeal flaps. In this study, a multidisciplinary approach was applied for proper assessment and surgical intervention using sphincter pharyngoplasty for velopharyngeal insufficiency after cleft palate repair.MethodsTwenty patients underwent sphincter pharyngoplasty. Preoperative diagnosis was performed using auditory perceptual assessment, nasoendoscopy assessment, nasometry, and videofluoroscopy.ResultsThere were statistically significant differences between the preoperative and postoperative assessments. Bleeding occurred in two patients. Obstructive sleep apnea occurred in three patients and was resolved spontaneously within three months, and one patient experienced slight wound dehiscence.ConclusionVelopharyngeal dysfunction after cleft palate repair is best treated by a multidisciplinary team through speech therapy together with sphincter pharyngoplasty.     

Endoscopic papillary balloon dilatation may preserve sphincter of Oddi function after common bile duct stone management: evaluation from the viewpoint of endoscopic manometry

Background—Endoscopic papillary balloondilatation (EPBD) has been reported as a safe and effective alternativeto endoscopic sphincterotomy in the management of common bile duct(CBD) stones; its effect on papillary function has yet to be elucidated.
Aim—To investigate sphincter of Oddi (SO)motility before and after EPBD to determine its effect on SO function.
Patients and methods—The papillary function of 10 patients with CBD stones was studied using endoscopic manometry beforeand one week after EPBD. The manometric studies were repeated one monthafter EPBD in seven patients.
Results—One week after EPBD, CBD pressure, SO peakpressure, SO basal pressure, and SO frequency decreased significantly. One month after EPBD, however, all parameters increased although theincreases in SO basal pressure and CBD pressure were not significant. There was no significant difference in values of any parameter beforeand one month after EPBD. No serious complications occurred.
Conclusion—These data suggest at least partialrecovery of papillary function one month after the procedure. EPBDseems to preserve papillary function in treatment of CBD stones; alonger term follow up study with SO manometry should be performed to clarify the effect of EPBD on SO function.

Keywords:endoscopic papillary balloon dilatation; sphincterof Oddi

     

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     

Overt Rectal Prolapse and Fecal Incontinence

PURPOSE  Rectal prolapse is frequently associated with fecal incontinence; however, the relationship is questionable. The study was designed to evaluate fecal incontinence in a large consecutive series of patients who suffered from rectal prolapse, focusing on both past history, anal physiology, and imaging. METHODS  Eighty-eight consecutive patients who suffered from an overt rectal prolapse (72 women, 16 men; mean age, 51.1 ± 19.5 years) as a main symptom were analyzed; 48 patients also experienced fecal incontinence compared with 40 without incontinence. Logistic regression analyses were performed. RESULTS  The two groups of patients did not differ with respect to parity, weekly stool frequency, main duration of symptoms before referral, occurrence of dyschezia, and digital help to defecate. Patients with prolapse who were older than 45 years (odds ratio (OR), 4.51 (1.49–13.62); P = 0.007) and those with a past history of hemorrhoidectomy (OR, 9.05 (1.68–48.8); P = 0.01) were significantly more incontinent. Incontinent group showed frequent internal anal sphincter defect compared with the continent group (60 vs. 6.2 percent; P = 0.0018). CONCLUSIONS  In patients with overt rectal prolapse, the occurrence of fecal incontinence needs special consideration for age and previous hemorrhoid surgery as causative factors. Anal weakness and sphincter defects are frequently observed.     

Advanced rectal cancer

The best treatment of advanced rectal cancer remains uncertain. The aim of this study was to determine the outcome after palliative procedures in patients with advanced rectal cancer. One hundred and three patients treated over a seven-year period were identified, including 30 with local invasion, 18 with local metastases, and 55 with distant metastases. Patients were grouped into two groups: those who underwent palliative resection (68) and those who were treated without rectal resection (55). The nonresected group included patients who underwent diverting colostomies (28) and those who received multimodality therapy without surgery (7). The average age of all patients was 63.1 years. Patients in the nonresected group had more distant disease (68 percent) than the resected group (46 percent). Significant pelvic pain was a more common problem in the nonresected group (15 percent) than in the resected group (4 percent). Similarly, pelvic sepsis was more common in the nonresected group (14 percent) than in the resected group (9 percent). Postoperative mortality was 4.3 percent after palliative resection and 3.8 percent after diverting colostomy. Survival of the resected group at one year was 65 percent and at two years 20 percent. Survival of the nonresected group at one year was 20 percent and at two years 0 percent. Survival in the resected group was significantly (P<.01) better than the nonresected group but probably can be attributed to the more extensive disease generally present in the patients who did not undergo resection. These results suggest that patients with advanced rectal cancers should undergo palliative resection whenever possible because resection decreases pelvic complications and may improve quality of life. Read at meeting of the American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988.     

Oddi括约肌狭窄的诊断与治疗

本文通过对３７５例胆囊、胆总管结石患者术后有残留症状者，经Ｂ超、ＥＲＣＰ、Ｔ管造影诊断为Ｏｄｄｉ括约肌狭窄者１６７例，均经十二指肠镜乳头括约肌切开（ＥＳＴ）治愈。同时讨论了Ｏｄｄｉ括约肌狭窄的原因、临床表现及诊断治疗中注意事项。     

家兔SO低位中枢NOS阳性神经元的分布及其在急性重症胆管炎时表达的改变

目的 探讨家兔胆道口括约肌(sphincter of Oddi,SO)低位中枢一氧化氮合酶(nitric oxide synthase,NOS)阳性神经元及神经纤维的分布特征及其在急性重症胆管炎时表达的改变.方法 将10只家兔随机分为2组,①正常对照组;②急性重症胆管炎组.经灌注固定后,取材腹腔神经节、胸髓及其相应脊神经节、迷走神经下神经节和延髓.以NADPH-d组织化学染色显示NOS阳性神经元及神经纤维.结果 对照组结果如下,①腹腔神经节内未见NOS阳性神经元胞体.②迷走神经下神经节和脊神经节内有极少量NOS阳性神经元胞体.③胸髓内,NOS阳性神经元主要分布在整个灰质中间带及后角固有核,NOS阳性神经纤维主要分布在后角胶状质,后角内、外侧边缘,中央管周围区,背外侧索和前索沟缘束.④延髓内,NOS阳性神经元主要分布在孤束外侧核、迷走神经背核、疑核、延髓中缝核及网状结构.急性重症胆管炎组与对照组相比可见阳性标记物显著增多、着色加深.结论 ①急性重症胆管炎时,SO低位神经中枢的NOS活性上调;②在SO的阳性纤维中,不包括交感性节后纤维.