Problems with repairing gut sphincters malfunctions

Correcting a gut sphincter malfunction is a difficult problem.Because each sphincter has two opposite functions,that of closure and opening,repairing one there is a risk of damaging the other.Indeed,widening a narrow sphincter,such as lower esophageal sphincter(LES)and anal sphincter,may cause gastroeso-phageal reflux and fecal incontinence,respectively,whereas narrowing a wide sphincter,may cause a difficult transit.All the corrective treatments for difficult or retrograde transit concerning LES and anal sphincter with their unwanted consequences have been analyzed and discussed.To overcome the drawbacks of sphincter surgical repairs,researchers have devised devices capable of closing and opening the gut lumen,named artificial sphincters(ASs).Their function is based on various mechanisms,e.g.,hydraulic,magnetic,mechanical etc,operating through many complicated components,such as plastic cuffs,balloons,micro-pumps,micromotors,connecting tubes and wires,electromechanical clamps,rechargeable batteries,magnetic devices,elastic bands,etc.Unfortunately,these structures may facilitate the onset of infections and induce a local fibrotic reaction,which may cause device malfunctioning,whereas the compression of the gut wall to occlude the lumen may give rise to ischemia with erosions and other lesions.Some ASs are already being used in clinical practice,despite their considerable limits,while others are still at the research stage.In view of the adverse events of the ASs mentioned above,we considered applying bioengineering methods to analyze and resolve biomechanical and biological interaction problems with the aim to conceive and build efficient and safe biomimetic ASs.

Urinary Sphincter Disorders of Neurological Origin: Prognostic Aspects in the Neurology Department of the Ignace Deen National Hospital

Introduction: Complications of Urinary sphincter disorders of neurological origin can be life threatening. The objective of this study was to describe the prognosis of urinary sphincter disorders during neurological conditions. Methods: This was a six-month analytical study conducted at the neurological unit of the Hôpital national Ignace Deen. Including patients with urinary sphincter disorders following a neurological condition;Chi-square, Fischer, and Student’s t-tests were used for variables with a p value less than 0.10 and then included in a logistic model with a significance level set at 0.05 and a 95% confidence interval. Results: We collected 1081 patients among whom, 324 presented, that is to say a frequency of 30%, which concerned subjects aged 57.3 ± 16.4 years with a slight female predominance 50.3%. Urinary incontinence (80.6%) was associated with complications such as urinary tract infection with a high proportion of cerebral damage (92.3%). HIV infection (P = 0.015), bedsores (P = 0.049), and inhalation pneumonia (P = 0.001) were the main poor prognostic factors. Conclusion: Urinary sphincter disorders are elements of poor prognosis, both vital and functional, concerning elderly subjects with a predominance of urinary incontinence. HIV infection, bedsores, pneumopathy are poor prognostic factors.

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 typeⅠ,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 typeⅠSOD will benefit from ES in 55%-95% of cases. Sphincter of Oddi manometry is not necessary before ES in typeⅠ 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.

Selective sphincteroplasty of the papilla in cases at risk due to atypical anatomy

AIM： To analyze the indications, efficacy and safety of sphincteroplasty in our centre.METHODS： A retrospective study of sphincteroplasty in 53 cases of papilla at high risk was performed in 2004-2006. The procedure consisted of duodenoscopy with Olympus TJF 145 Videoduodenoscope, approach to the biliary tract using a catheter with a guidewire, and dilatation of the papilla with a dilatation balloon catheter using a syringe with a manometer for control of the filling pressure.RESULTS： The indications included intradiverticular papilla in 26 patients （49%）, stenosis of a previous sphincterotomy in 19 patients （35.8%）, small size of the papilla in 4 patients （7.5%）, Billroth R gastrectomy in 3 patients （5.6%）, and coagulopathy in one patient （1.9%）. The efficacy was 97.8%, with all the calculi extracted from the common bile duct in 84.4% of the patients, even though 21 of the patients （39.6%） had calculi with a diameter equal to or greater than 10 ram. Seven patients （13.2%） presented complications： haemorrhage in 1 patient （1.9%） and mild pancreatitis in 6 patients （11.3%）. The mean hospital stay in case of complications was of 3 ± 0.63 d.CONCLUSION： Sphincteroplasty is highly effective, with a compllcation rate similar to that of sphincterotomy, furthermore, the complications are of low clinical importance. The use of the 10 mm balloon makes it possible to extract calculi with a diameter of over 15 mm and to extract more than 3 calculi without increasing the rate of complications and reduces the need to resort to lithotripsy or rescue sphincterotomy.

Sphincter of Oddi dysfunction Type Ⅲ: New studies suggest new approaches are needed

Sphincter of Oddi dysfunction(SOD) has been classified into three types based upon the presence or absence of objective findings including liver test abnormalities and bile duct dilatation. Type Ⅲ is the most controversial and is classified as biliary type pain in the absence ofany these objective findings. Many prior studies have shown that the clinical response to endoscopic therapy is higher based upon the presence of these objective criteria. However, there has been variable correlation of the manometry findings to outcome after endoscopic therapy. Nevertheless, manometry and sphincterotomy has been recommended for Type Ⅲ patients given the overall response rate of 33%, although the reported response rates are highly variable. However, all of the prior data was non-blinded and non-randomized with variable follow-up. The evaluating predictors in SOD study- a prospective randomized blinded sham controlled one year outcome study showed no correlation between manometric findings and outcome after sphincterotomy. Furthermore, patients receiving sham therapy had a statistically significantly better outcome than those undergoing biliary or dual sphincterotomy. This study calls into question the whole concept of SOD Type Ⅲ and, based upon prior physiologic studies, one can suggest that SOD Type Ⅲ likely represents a right upper quadrant functional abdominal pain syndrome and should be treated as such.

Characterization of functional biliary pain and dyspeptic symptoms in patients with sphincter of Oddi dysfunction:Effect of papillotomy

AIM： To characterize functional biliary pain and other gastrointestinal （GI） symptoms in postcholecystectomy syndrome （PCS） patients with and without sphincter of Oddi dysfunction （SOD） proved by endoscopic sphincter of Oddi manometry （ESOM）, and to assess the postendoscopic sphincterotomy （EST） outcome. METHODS： We prospectively investigated 85 cholecystectomized patients referred for ERCP because of PCS and suspected SOD. On admission, all patients completed our questionnaire. Physical examination, laboratory tests, abdominal ultrasound, quantitative hepatobiliary scintigraphy （QHBS）, and ERCP were performed in all patients. Based on clinical and ERCP findings 15 patients had unexpected bile duct stone disease and 15 patients had SOD biliary type Ⅰ. ESOM demonstrated an elevated basal pressure in 25 patients with SOD biliary-type Ⅲ. In the remaining 30 cholecystectomized patients without SOD, the liver function tests, ERCP, QHBS and ESOM were all normal. As a control group, 30 ‘asymptomatic＇ cholecystectomized volunteers （attended to our hospital for general cardiovascular screening） completed our questionnaire, which is consisted of 50 separate questions on GI symptoms and abdominal pain characteristics. Severity of the abdominal pain （frequency and intensity） was assessed with a visual analogue scale （VAS）. In 40 of 80 patients having definite SOD （i.e. patients with SOD biliary type Ⅰ and those with elevated SO basal pressure on ESOM）, an EST was performed just afl：er ERCP. In these patients repeated questionnaires were filled at each follow-up visit （at 3 and 6 too） and a second look QHBS was performed 3 mo after the EST to assess the functional response to EST. RESULTS： The analysis of characteristics of the abdominal pain demonstrated that patients with common bile duct stone and definite SOD had a significantly higher score of symptomatic agreement with previously determined biliary-like pain features than patient groups of PCS without SOD and controls. In contrary, no significant differences were found when the pain severity scores were compared in different groups of PCS patients. In patients with definite SOD, EST induced a significant acceleration of the transpapillary bile flow; and based on the comparison of VASs obtained from the pre-and post-EST questionnaires, the severity scores of abdominal pain were significantly improved, however, only 15 of 35 （43%） patients became completely pain free. Post-EST severity of abdominal pain by VASs was significantly higher in patients with predominant dyspepsia at initial presentation as compared to those without dyspeptic symptoms. CONCLUSION： Persistent GI symptoms and general patient dissatisfaction is a rather common finding after EST in patients with SOD, and correlated with the presence of predominant dyspeptic symptoms at the initial presentation, but does not depend on the technical and functional success of EST.

Low rectal cancer:Sphincter preserving techniques-selection of patients,techniques and outcomes

Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal Plan E for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic Micro Surgery(TEM) and Trans Anal Minimally Invasive Surgery(TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery.

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.

Severe acute cholangitis after endoscopic sphincterotomy induced by barium examination:A case report

Endoscopic sphincterotomy (EST) is considered as a possible etiological factor for severe cholangitis. We herein report a case of severe cholangitis after endo-scopic sphincterotomy induced by barium examination. An adult male patient presented with epigastric pain was diagnosed as having choledocholithiasis by ultra-sonography. EST was performed and the stone was completely cleaned. Barium examination was done 3 d after EST and severe cholangitis appeared 4 h later. The patient was recovered after treated with tienam for 4 d. Barium examination may induce severe cholangitis in patients after EST, although rare, barium examination should be chosen cautiously. Cautions should be also used when EST is performed in patients younger than 50 years to avoid the damage to the sphincter of Oddi.

Evaluating the efficacy of endoscopic sphincterotomy on biliary-type sphincter of Oddi dysfunction: A retrospective clinical trial

BACKGROUND Although endoscopic sphincterotomy(EST)has a positive therapeutic effect on biliary-type sphincter of Oddi dysfunction(SOD),some patients still have little relief after EST,which implies that other functional abdominal pain may also be present with biliary-type SOD and interfere with the diagnosis and treatment of it.AIM To retrospectively assess EST as a treatment for biliary-type SOD and analyze the importance of functional gastrointestinal disorder(FGID)in guiding endoscopic treatment of SOD.METHODS Clinical data of 79 patients with biliary-type SOD(type I and type II)treated with EST at Affiliated Hospital of Guizhou Medical University from January 2014 to January 2019 were retrospectively collected to evaluate the clinical therapeutic effect of EST.The significance of relationship between FGID and biliary-type SOD was analyzed.RESULTS Seventy-nine patients with biliary-type SOD received EST,including 29 type 1 patients and 50 type 2 patients.The verbal rating scale-5(VRS-5)scores before EST were all 3 or 4 points,and the scores decreased after EST;the difference was statistically significant(P<0.05).After EST,the serum indexes of alanine aminotransferase,aspartate aminotransferase,alkaline phosphatase and total bilirubin in biliary-type SOD were significantly lower than before(P<0.05).After EST,67(84.8%)and 8(10.1%)of the 79 patients with biliary-type SOD had obviously effective(VRS-5=0 points)and effective treatment(VRS-5=1-2 points),with an overall effectiveness rate of 94.9%(75/79).There was no difference in VRS-5 scores between biliary-type SOD patients with or without FGID before EST(P>0.05).Of 12 biliary-type SOD(with FGID)patients,11 had abdominal pain after EST;of 67 biliary-type SOD(without FGID)patients,0 had abdominal pain after EST.The difference was statistically significant(P<0.05).The 11 biliary-type SOD(with FGID)patients with recurrence of symptoms,the recurrence time was about half a year after the EST,and the symptoms were significantly relieved after regular medical treatment.There were 4 cases of postendoscopic retrograde cholangiopancreatography pancreatitis(5.1%),and no cholangitis,bleeding or perforation occurred.Patients were followed up for 1 year to 5 years after EST,with an average follow-up time of 2.34 years,and there were no long-term adverse events such as sphincter of Oddi restenosis or cholangitis caused by intestinal bile reflux during the follow-up.CONCLUSION EST is a safe and effective treatment for SOD.For patients with type I and II SOD combined with FGID,single EST or medical treatment has limited efficacy.It is recommended that EST and medicine be combined to improve the cure rate of such patients.

Factors influencing lower esophageal sphincter relaxation after deglutition

AIM:To study the relationship between upper esophageal sphincter (UES) relaxation,peristaltic pressure and lower esophageal sphincter (LES) relaxation following deglutition in non-dysphagic subjects.METHODS:Ten non-dysphagic adult subjects had a high-resolution manometry probe passed transnasally and positioned to cover the UES,the esophageal body and the LES.Ten water swallows in each subject were analyzed for time lag between UES relaxation and LES relaxation,LES pressure at time of UES relaxation,duration of LES relaxation,the distance between the transition level (TL) and the LES,time in seconds that the peristaltic wave was before (negative value) or after the TL when the LES became relaxed,and the maximal peristaltic pressure in the body of the esophagus.RESULTS:Relaxation of the LES occurred on average 3.5 s after the bolus had passed the UES and in most cases when the peristaltic wave front had reached the TL.The LES remained relaxed until the peristaltic wave faded away above the LES.CONCLUSION:LES relaxation seemed to be caused by the peristaltic wave pushing the bolus from behind against the LES gate.

Anal Sphincter Function after Intersphincteric Resection for Low Rectal Cancer

Objective： To assess the anal sphincter function after intersphincteric resection for low rectal cancer by questionnaire and vectorial manometry. Methods： twenty five patients underwent intersphincteric resection, the controls contained 25 patients of rectal cancer who underwent low anterior resection and 25 healthy people. The therapeutic responses were evaluated using the Vaizey and Wexner scoring systems and vectorial manometry. Results： The Vaizey and Wexner scores after intersphincteric resection were significantly higher than those of low anterior resection controls at one month, but had no significant difference one year after. On the other hand, the indexes of vectorial manometry still had significant difference one year later. The indexes after intersphincteric resection could not reach the normal level. Conclusion： The anal sphincter function after intersphincteric resection is lower than that after low anterior resection in short term, although the long-term results can be accepted, it still can not reach the normal level.

Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection for circumferential mixed hemorrhoids

AIM:To identify a more effective treatment protocol for circumferential mixed hemorrhoids.METHODS:A total of 192 patients with circumferential mixed hemorrhoids were randomized into the treatment group,where they underwent Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection,or the control group,where traditional external dissection and internal ligation were performed.Postoperative recovery and complications were monitored.RESULTS:The time to wound healing was 12.96 ± 2.25 d in the treatment group shorter than 19.58 ± 2.71 d in the control group.Slight pain rate was 58.3% in the treatment group higher than 22.9% in the control group;moderate pain rate was 33.3% in the treatment group lower than 56.3% in the control group severe pain rate was 8.4% in the treatment group lower than 20.8% in the control group.No edema rate was 70.8% in the treatment group higher than 43.8% in the control group;mild local edema rate was 26% in the treatment group lower than 39.6% in the control group obvious local edema was 3.03% in the treatment group lower than 16.7% in the control group.No stenosis rate was 85.4% in the treatment group higher than 63.5% in the control group;moderate stenosis rate was 14.6% in the treatment group Lower than 27.1% in the control group severe anal stenosis rate was 0% in the treatment group lower than 9.4% in the control group.CONCLUSION:Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection is the optimal treatment for circumferential mixed hemorrhoids and can be widely applied in clinical settings.

Dynamic and ultrastructural study of sphincter of Oddi in early-stage cholelithiasis in rabbits with hypercholesterolemia

AIM To study the relationship between pre-formation of gallstone and the kinetics and ultra-structure of sphincter of Oddi.METHODS Adult female rabbits were used anddivided into 3 groups,and fed with either normalor high cholesterol diet for four or eight weeks.Each group contained eight rabbits.Themanometry of sphincter of Oddi,biliarycineradiography,gallbladder volumemeasurement and ultrastructure observationunder electron microscope were performed.RESULTS In groups Ⅰ and Ⅱ,the basalpressure in low-pressure ampulla or highpressure zone of sphincter of Oddi waselevated,the amplitude of phasic contractionwas decreased and the volume of gallbladderwere increased,with a significant difference(P【0.01)from those of control.Gallstones werefound in group Ⅱ rabbits(7/8).Undercineradiography,low-pressure ampulla showeda spasmodic status without apparent peristalticcontraction.Under electron microscope,insidethe muscular cells of sphincter of Oddi,loosening of microfilament and swelling ofplasmosomes which congregated at the top wereobserved.The amount showed no obviouschange under nitric oxide synthase(NOS)stain.CONCLUSION Twisting of the microfilamentand disarrangement of kink macula densa insidethe muscular ceils suggested that the sphincterof Oddi was under spasmodic status.Theimpaired diastolic function caused andaggravated the stasis of cystic bile.Theswelling plasmosome could be one of theimportant factors in elevating the tonic pressureof sphincter of Oddi.

Effects of sphincter of Oddi motility on the formation of cholesterol gallstones

AIM: To investigate the mechanisms and effects of sphincter of Oddi(SO) motility on cholesterol gallbladder stone formation in guinea pigs.METHODS: Thirty-four adult male Hartley guinea pigs were divided randomly into two groups, the control group(n = 10) and the cholesterol gallstone group(n = 24), which was sequentially divided into four subgroups with six guinea pigs each according to time of sacrifice. The guinea pigs in the cholesterol gallstone group were fed a cholesterol lithogenic diet and sacrificed after 3, 6, 9, and 12 wk. SO manometry and recording of myoelectric activity were obtained by a multifunctional physiograph at each stage. Cholecystokinin-A receptor(CCKAR) expression levels in SO smooth muscle were detected by quantitative real-time PCR(q RT-PCR) and serum vasoactive intestinal peptide(VIP), gastrin, and cholecystokinin octapeptide(CCK-8) were detected by enzyme-linked immunosorbent assay at each stage in the process of cholesterol gallstone formation.RESULTS: The gallstone formation rate was 0%, 0%, 16.7%, and 83.3% in the 3, 6, 9, and 12 wk groups, respectively. The frequency of myoelectric activity in the 9 wk group, the amplitude of myoelectric activity in the 9 and 12 wk groups, and the amplitude and the frequency of SO in the 9 wk group were all significantly decreased compared to the control group. The SO basal pressure and common bile duct pressure increased markedly in the 12 wk group, and the CCKAR expression levels increased in the 6 and 12 wk groups compared to the control group. Serum VIP was elevated significantly in the 9 and 12 wk groups and gastrin decreased significantly in the 3 and 9 wk groups. There was no difference in serum CCK-8 between the groups.CONCLUSION: A cholesterol gallstone-causing diet can induce SO dysfunction. The increasing tension of the SO along with its decreasing activity may play an important role in cholesterol gallstone formation. Expression changes of CCKAR in SO smooth muscle and serum VIP and CCK-8 may be important causes of SO dysfunction.

Roles of sphincter of Oddi motility and serum vasoactive intestinal peptide,gastrin and cholecystokinin octapeptide

AIM: To investigate roles of sphincter of Oddi (SO) motility played in pigment gallbladder stone formation in model of guinea pigs.

Sphincter of Oddi laxity:An important factor in hepatolithiasis

AIM:To evaluate the importance of sphincter of Oddi laxity (SOL) in hepatolithiasis (HL).METHODS:Subjects included 98 patients diagnosed with HL between 2002 and 2007. Detailed histories were taken and the subjects were monitored until July 2008. HL patients were divided into two groups:Group included 45 patients with SOL,and Group included 53 patients without. Recurrence and reoperation indices of both groups were calculated and compared.RESULTS:The recurrence index was 0.135 in Group and 0.018 in Group fldex was 0.070 in Group and 0.010 in Group (P <0.001). The mean frequency of biliary operation was 2.07in Group (P = 0.001). Differences between the two groups are significant.CONCLUSION:HL patients with SOL tend to have a higher risk of recurrence and a larger demand for re-operation than those without this condition.

Sphincter of Oddi hypomotility and its relationship with duodenal-biliary reflux,plasma motilin and serum gastrin

AIM: To detect whether patients with a T tube after cholecystectomy and choledochotomy have duodenal-biliary reflux by measuring the radioactivity of Tc99m-labeled diethylene triamine penta-acetic acid (DTPA) in the bile and whether the patients with duodenal-biliary reflux have sphincter of Oddi hypomotility, by mea-suring the level of plasma and serum gastrin of the patients. Finally to if there is close relationship among sphincter of Oddi hypomotility, duodenal-biliary reflux and gastrointestinal peptides. METHODS: Forty-five patients with a T tube after cholecystectomy and choledochotomy were divided into reflux group and control group. The level of plasma and serum gastrin of the patients and of 12 healthy volunteers were measured by radioimmunoas-say. Thirty-four were selected randomly to undergo choledochoscope manometry. Sphincter of Oddi basal pressure (SOBP), amplitude (SOCA), frequency of con-tractions (SOF), duration of contractions (SOD), duo-denal pressure (DP) and common bile duct pressure (CBDP) were scored and analyzed. RESULTS: Sixteen (35.6%) patients were detected to have duodenal-biliary reflux. SOBP, SOCA and CBDP in the reflux group were much lower than the controlgroup (t = 5.254, 3.438 and 3.527, P < 0.001). SOD of the reflux group was shorter than the control group (t = 2.049, P < 0.05). The level of serum gastrin and plasma motilin of the reflux group was much lower than the control group (t = -2.230 and -2.235, P < 0.05). There was positive correlation between the level of plasma motilin and SOBP and between the level of serum gastrin and SOBP and CBDP. CONCLUSION: About 35.9% of the patients with a T tube after cholecystectomy and choledochotomy have duodenal-biliary reflux. Most of them have sphincter of Oddi hypomotility and the decreased level of plasma motilin and serum gastrin. The disorder of gastroin-testinal hormone secretion may result in sphincter of Oddi dysfunction. There is a close relationship between sphincter of Oddi hypomotility and duodenal-biliary re-flux.

Sphincter of Oddi dysfunction and bile duct microlithiasis in acute idiopathic pancreatitis

Although there are numerous causes of acute panc-reatitis, an etiology cannot always be found. Two potential etiologies, microlithiasis and sphincter of Oddi dysfunction, are discussed in this review. Gallbladder microlithiasis, missed on transcutaneous ultrasound, is reported as the cause of idiopathic acute pancreatitis in a wide frequency range of 6%-80%. The best diagnostic technique for gallbladder microlithiasis is endoscopic ultrasound although biliary crystal analysis and empiric cholecystectomy remain as reasonable options. In contrast, in patients who are post-cholecystectomy, bile duct microlithiasis does not appear to have a role in the pathogenesis of acute pancreatitis. Sphincter of Oddi dysfunction is present in 30%-65% of patients with idiopathic acute recurrent pancreatitis in whom other diagnoses have been excluded. It is unclear if this sphincter dysfunction was the original etiology of the first episode of pancreatitis although it appears to have a causative role in recurring episodes since sphincter ablation decreases the frequency of recurrent attacks. Unfortunately, this conclusion is primarily based on small retrospective case series; larger prospective studies of the outcome of pancreatic sphincterotomy for SOD-associated acute pancreatitis are sorely needed. Another problem with this diagnosis and its treatment is the concern over potential procedure related complications from endoscopic retrograde cholangiopancreatography (ERCP), manometry and pancreatic sphincterotomy. For these reasons, patients should have recurrent acute pancreatitis, not a single episode, and have a careful informed consent before assessment of the sphincter of Oddi is undertaken.

Oddi sphincter preserved cholangioplasty with hepaticosubcutaneous stoma for hepatolithiasis

AIM: To evaluate the long-term outcomes of Oddi sphincter preserved cholangioplasty with hepaticosubcutaneous stoma(OSPCHS) and risk factors for recurrence in hepatolithiasis.METHODS: From March 1993 to December 2012, 202 consecutive patients with hepatolithiasis underwent OSPCHS at our department. The Oddi sphincter preserved procedure consisted of common hepatic duct exploration, stone extraction, hilar bile duct plasty, establishment of subcutaneous stoma to the bile duct. Patients with recurrent stones can undergo stone extraction and/or biliary drainage via the subcutaneous stoma which can be incised under local anesthesia. The long-term results were reviewed. Cox regression model was employed to analyze the risk factors for stone recurrence.RESULTS: Ninety-seven(48.0%) OSPCHS patients underwent hepatic resection concomitantly. The rate of surgical complications was 10.4%. There was no perioperative death. The immediate stone clearance rate was 72.8%. Postoperative cholangioscopic lithotomy raised the clearance rate to 97.0%. With a median follow-up period of 78.5 mo(range: 2-233 mo), 24.8% of patients had recurrent stones, 2.5% had late development of cholangiocarcinoma, and the mortality rate was 5.4%. Removal of recurrent stones and/or drainage of inflammatory bile via subcutaneous stoma were conducted in 44(21.8%) patients. The clearance rate of recurrent stones was 84.0% after subsequent choledochoscopic lithotripsy via subcutaneous stoma.Cox regression analysis showed that residual stone was an independent prognostic factor for stone recurrence.CONCLUSION: In selected patients with hepatolithiasis, OSPCHS achieves excellent long-term outcomes, and residual stone is an independent prognostic factor for stone recurrence.