Sphincter of Oddi dysfunction in children with recurrent abdominal pain: 5-year follow-up after endoscopic sphincterotomy

BACKGROUND: Sphincter of Oddi (SO) dysfunction has not been reported as a cause of recurrent abdominal pain (RAP) in children. We present a 5-year follow-up of a group of children with RAP and manometry proven SO dysfunction. METHODS: Retrospective chart review of children who underwent SO manometry and endoscopic sphincterotomy (ES) for recurrent abdominal pain. Long-term follow-up was obtained by telephone survey. RESULTS: Eleven of the 12 children had abdominal pain; one had reproducible postprandial discomfort. Five children localized the pain to the upper abdomen. The same number of children had associated nausea or vomiting. On hepatobiliary scintigraphy study, three children had SO dysfunction type curve, four had low ejection fraction and nine had reproduction of symptoms on cholecystokinin (CCK) infusion. SO manometry revealed elevated pressure in 11 children. The remaining child had paradoxical contraction of the SO. On short-term follow-up, eight children had resolution of symptoms after ES, three did not respond and one had recurrence of symptom in 6 months. Children symptomatic for less than 1 year were more likely to respond to ES (P < 0.01). All children with upper abdominal pain with nausea and/or vomiting, postprandial pain and SO type scintiscan curve responded to ES. On long-term follow-up, seven of the eight responders to ES remained symptom free, one recurred with irritable bowel syndrome-like symptoms. One child with recurrent symptoms had resolution after cholecystectomy and another non-responder improved after an appendectomy. CONCLUSION: SO dysfunction is an uncommon but treatable cause of RAP in children. Awareness of this condition may help a segment of children with RAP.     

Nipple Invagination: The Umbrella Effect

The authors present their technique for correction of invaginated nipple, a procedure used for the past 20 years. Most often, this condition is a consequence of a subareolar muscle diastasis associated with short fibrous septa as well as short and fibrotic ducts. The correction technique specifically divides the fibrous tracts and corrects the diastasis of the subareolar muscle. The procedure was performed for healthy patients as well as for patients with mastitis sequel treatment and surgical reduction or augmentation mammaplasty.     

Sphincter of Oddi dysfunction: an evidence-based review

Sphincter of Oddi dysfunction is a painful syndrome that presents as recurrent episodes of right upper quadrant biliary pain, or recurrent idiopathic pancreatitis. It is a disease process that has been a subject of controversy, in part because its natural history, disease course and treatment outcomes have not been clearly defined in large controlled studies with long-term follow-up. This review is aimed at clarifying the state-of-the-art with an evidence-based summary of the current diagnostic and therapeutic approaches and modalities for sphincter of Oddi dysfunction.     

胆胰结合部——外科“遗忘”的角落

胆管、胰管与十二指肠的结合部,是人体内精微的结构,它受解剖学构型、括约肌功能、内分泌调控、神经支配的共同的、和谐的调节。胆-胰-肠结合部疾病可表现为梗阻或括约肌关闭不全。当前最常用的处理方法是内镜下乳头切开术或球囊扩张术。外科的努力重造新的有功能的结合部已有近百年历史,但距离目标仍然很远。     

一种新的手术方法治疗陈旧性会阴Ⅲ度裂伤

目的：评价球海绵体肌替代部分肛门括约肌治疗陈旧性会阴Ⅲ度裂伤的临床效果。方法：以球海绵体肌替代部分肛门括约肌。结果：手术治疗后随访5例，3－20个月，全部患者均恢复阴道，肛门和会阴的正常解剖关系，肛门括约肌功能均得到改善，无排便困难；4例能自主控制正常大便及排气；1例主诉不能控制排气，但能控制解便，恢复阴道的清洁度，能进行正常的性生活。结论：采用球海绵体肌替代部分肛门括约肌治疗陈旧性会阴Ⅲ度裂伤具有明显的临床效果。是一种较为理想的治疗方法。     

A study on motility of sphincter of Oddi in postcholecystectomy syndrome

Endoscop c manometry of sphincter of Oddi(SO)and serumlevels of gastrin,glucagon,and somatostatin were measured in patients withpostcholecystectomy syndrome(n=12),asymptomatic cholecystectomised pa-tients(n=6),and controlled subjects(n=14).Pentagastrin-stimulated gastricacid secretion test was also performed in part of patients who had symptoms orno symptoms after gallbladder resection.The results showed that the patientsof symptomatic group had hypertonic dyskinesia of SO as shown by deep andwide waves superimposed on high basal pressure plateau of SO.The symptoma-tic group also had a higher serum level of gastrin and a greater BAO than tho-se of other two groups.No difference of serum levels of glucagon and soma-tostatin was found among these three groups.The hypertonic dyskinesia of SOand hypergastrinemia are considered as possibly important factors in the patho-genesis of postcholecystectomy syndrome.     

咽腭肌应用解剖学研究

目的　为进一步认识咽腭肌的解剖学形态及腭裂的咽腭肌瓣手术对该肌的影响而进行此应用解剖学研究。方法　对正常成人新鲜尸体头颈部固定标本 17例 ,正常及唇腭裂新生儿新鲜尸体头颈部固定标本各 4例进行解剖学观察。对 6例胎儿头颈部标本进行组织学连续切片观察。结果　咽腭肌起于咽部 ,止于软腭。肌腹位于咽腭弓 ,成人长 (2 7 5 8± 6 73)mm ,截面积 (34 1±10 5 )mm2 。该肌血供主要来源于咽升动脉和扁桃体动脉 ,其次为腭升动脉和舌背动脉 ,呈多源性和节段性。该肌神经支配来源于咽丛神经分支 ,在硬腭水平下 15mm以内均有神经分支进入该肌。结论　咽腭肌是咽侧壁及软腭的主要肌肉之一 ,是咽腭肌瓣的良好供区。其血供呈现多源性和节段性。咽腭肌瓣咽成形术对该肌血供及神经支配造成一定的影响 ,应在手术中予以注意。     

The role of internal sphincter in chronic anal fissures

Changes in anal sphincteric manometric pressures in response to rectal distention were measured in eight patients with chronic anal fissures and were compared with the of ten controls. No statistically different resting pressures were noted between the two groups. Overshoot phenomenon was more commonly seen in patients with fissure. There were no differences in the anal sphincteric pressures after lateral internal sphincterotomy (LIS) or fissurectomy midline sphincterotomy (FMS). All fissures healed postoperatively, irrespective of the surgical technique (LIS or FMS) or the pressure readings. It can be concluded that the therapeutic effect of sphincterotomies might at least in part be due to anatomic widening of the anal canal rather than to decreased resting pressures of the internal sphincter. This study was supported by a grant from the American Society of Colon and Rectal Surgeons Research Foundation and was presented as part of a symposium at the annual meeting of the American Society of Colon and Rectal Surgeons, Colorado Springs, Colorado, June 7 to 11, 1981.     

Fecal Incontinence: Does Age Matter? Characteristics of Older <Emphasis Type="Italic">vs.</Emphasis> Younger Women Presenting for Treatment of Fecal Incontinence

Purpose The etiology of fecal incontinence is multifactorial. We hypothesize that women who seek treatment at different ages differ. We sought to determine which characteristics of women with fecal incontinence patients are associated with younger age at presentation. Methods We reviewed a database of 399 women with complete fecal incontinence evaluations from 2001 to 2006, selecting patients who were aged 49 and younger or aged 65 years and older, for a total of 246 patients. Data were obtained from self-report questionnaires on fecal incontinence frequency and associated symptoms, medical history, and results of anorectal physiology tests. Univariate and multivariate analyses were performed. Results The median ages of the two groups were 42 (range, 23–49) years and 72 (range, 65–89) years. Sphincter defects > 90 degrees and previous sphincteroplasty were associated with the younger age group. Previous hemorrhoid surgery and bilateral pudendal neuropathy were associated with the older age group. Younger women had more frequent incontinence to gas, mucus, and liquid stool. Conclusions In our cohort, fecal incontinence-related symptoms and medical conditions differed in older and younger women presenting with this condition. Younger women may be more likely to seek treatment for any degree of symptoms. The differing characteristics of fecal incontinence by age should be considered when developing a treatment strategy. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006. Reprints are not available.     

Manometry based randomised trial of endoscopic sphincterotomy for sphincter of Oddi dysfunction

BACKGROUND—Endoscopic sphincterotomy for biliary-type pain after cholecystectomy remains controversial despite evidence of efficacy in some patients with a high sphincter of Oddi (SO) basal pressure (SO stenosis).
AIM—To evaluate the effects of sphincterotomy in patients randomised on the basis of results from endoscopic biliary manometry.
METHODS—Endoscopic biliary manometry was performed in 81 patients with biliary-type pain after cholecystectomy who had a dilated bile duct on retrograde cholangiography, transient increases in liver enzymes after episodes of pain, or positive responses to challenge with morphine/neostigmine. The manometric record was categorised as SO stenosis, SO dyskinesia, or normal, after which the patient was randomised in each category to sphincterotomy or to a sham procedure in a prospective double blind study. Symptoms were assessed at intervals of three months for 24 months by an independent observer, and the effects of sphincterotomy on sphincter function were monitored by repeat manometry after three and 24 months.
RESULTS—In the SO stenosis group, symptoms improved in 11 of 13 patients treated by sphincterotomy and in five of 13 subjected to a sham procedure (p = 0.041). When manometric records were categorised as dyskinesia or normal, results from sphincterotomy and sham procedures did not differ. Complications were rare, but included mild pancreatitis in seven patients (14 episodes) and a collection in the right upper quadrant, presumably related to a minor perforation. At three months, the endoscopic incision was extended in 19 patients because of manometric evidence of incomplete division of the sphincter.
CONCLUSION—In patients with presumed SO dysfunction, endoscopic sphincterotomy is helpful in those with manometric features of SO stenosis.


Keywords: sphincter of Oddi; manometry; endoscopic sphincterotomy; motility; bile duct; pancreas