Sphincter of Oddi motility in patients with hepatolithiasis and common bile duct stones

Cyclic Change of Sphincter of Oddi Motility and Its Relationship with Small Bowel Migrating Motor Complex in Humans

BACKGROUND

Several animal and human studies have reported that sphincter of Oddi (SO) motility shows cyclical changes during the fasting state. However, to date, the relationship between the SO motility and the migrating motor complex (MMC) of the small bowel (SB) remains unclear in humans.

AIMS

We observed SO motility over a long study period and evaluated its relationship with the MMC of the SB in humans using percutaneous long-term manometry.

METHODS

Our study included patients with hepatolithiasis who required percutaneous transhepatic catheter placement and subsequently underwent choledochoscopy and stone removal. Long-term percutaneous transhepatic SO manometry was performed after complete stone removal. SO and SB motility were simultaneously recorded.

RESULTS

SO motility showed cyclical phasic changes with periodic high-frequency contractions similar to the MMC contractions of the SB. All high-frequency contractions of the SO coincided with phase III contractions of the MMC of the SB. The proportions of phase III contractions of SO and SB were similar, but the proportions of phase I (P = 0.001) and phase II (P = 0.002) contractions were significantly different. The mean basal SO pressure was observed to significantly increase in phase III compared to phase I (P = 0.001) and phase II (P = 0.001) contractions.

CONCLUSIONS

SO motility in humans showed cyclical phasic changes closely coordinated with the MMC of the SB in a fasting state; however, the proportion of phases differed between the SO and the SB. The basal pressure significantly increased during physiological high-frequency phase III contractions of the SO.

Left-sided hepatic resection for hepatolithiasis: a longitudinal study of 110 patients

BACKGROUND

Hepatolithiasis affecting the left hepatobiliary system is common in the Asia Pacific region. This aim of this study was to describe an experience with the diagnosis and treatment of patients with isolated left-sided hepatolithiasis.

METHODS

One hundred and ten patients with isolated left-sided hepatolithiasis who underwent a left-sided hepatic resection between January 1999 and February 2010 were included for further analysis. The clinical profile, cholangiograms, operative procedures and early and late results were examined.

RESULTS

Analysis of magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) findings revealed left hepatic ductal anatomical details in 101 patients. Three types of left hepatic ductal variations were observed (type 1 in 90.1%, type 2 in 5.9% and type 3 in 4.0% patients). Eighty-four (76.4%) patients had the presence of strictures in the left hepatic ductal system and in 26 (23.6%) patients no strictures could be seen. Out of 84 patients with strictures, 78 could be classified (type I in 89.7% and type II in 10.3%). Of the 110 patients, 75 (68.2%) underwent a left lateral sectionectomy, 33 (30%) a left hepatectomy and 2 (1.8%) patients were treated with a left hepatectomy combined with a caudate lobe resection. Of the patients who underwent a left hepatectomy 11.4% developed a bile leak. Eight per cent of patients who underwent a left lateral sectionectomy had infective complications. During a median follow-up period of 63 (range 3-134) months, 2 (2.1%) patients were discovered to have residual stones and five (5.2%) others possessed recurrent stones.

CONCLUSIONS

This study highlights the impact of the presence or absence of bile duct stricture on the clinical and histological profile of patients as well as their operative and the post-operative behaviour. It is concluded that hepatic resection is an appropriate treatment modality in localized left-sided hepatolithiasis.

Reduced myoelectric activity in the sphincter of Oddi in a new model of chronic cholangitis in rabbits: an in vivo and in vitro study

BACKGROUND

Chronic cholangitis caused by hepatolithiasis is a common disease in Southeast Asia. Few studies have addressed the effects of chronic cholangitis on cyclic activity of the sphincter of Oddi (SO). In this study, we investigated the changes of myoelectric activity in rabbits with chronic cholangitis in vivo and in vitro.

METHODS

Chronic cholangitis was induced in rabbits by initially introducing three pieces of 2-0 silk suture and sequentially injecting E. coli into the choledochus through the tube in ductus cysticus. In in vivo experiments, myoelectric activity of SO was recorded by a circular electrode through the jejunum stump in conscious animals. In in vitro experiments, the SO was completely isolated and the myoelectric activity was recorded by a circular electrode in a 10-mL organ bath filled with Krebs solution, with or without addition of cholecystokinin-8 (CCK-8), KCl, ionomycin or induction of capacitative calcium entry (CCE).

KEY RESULTS

In comparison with control and non-infected rabbits, the rabbits with chronic cholangitis showed higher levels of alkaline phosphatase and gamma-glutamyltransferase and significant pathological changes including increased inflammatory infiltration and collagen deposition in mucosae or muscular layer. Cyclic myoelectric activity of SO at phases 2 and 3 of migrating motor complex and the excitatory response to CCK-8 were dramatically decreased in animals with chronic cholangitis. Myoelectric activity of SO was also significantly decreased in vitro with or without agonists or with induction of CCE.

CONCLUSIONS & INFERENCES

Myoelectric activity of SO and its response to agonists are decreased in rabbits with chronic cholangitis both in vivo and in vitro.

Effects of electroacupuncturing at Zuyangming and Zushaoyang Jingxue on stomach and gallbladder kineses and related brain-gut peptide in rabbits

AIM: To investigate the correlation between the meridians and zang-fu as well as the specific effect of the points on their related zang-fu.

METHODS: Atropine was intravenously injected in the rabbits to inhibit the myoelectric activities of the stomach and the sphincter of oddi (SO). After electroacupuncturing at Zusanli and Yanglingquan points, the myoelectric activities of the stomach and SO were observed, and the levels of motilin (MTL) and cholcystokinin (CCK) in the antrum, SO and plasma were measured.

RESULTS: After atropine injection, the mean amplitudes for the high activity of myoelectric slow wave and fast wave were significantly decreased (P = 0.028, P = 0.001). Moreover, the average frequency of myoelectric slow wave was not significantly changed. The mean amplitudes for the myoelectric slow wave and fast wave were enhanced to some extent after electroacupuncturing at Zusanli and Yanglingquan points. The levels of MTL (P = 0.000) and CCK (P = 0.001) in the antrum, SO and plasma were increased markedly after electroacupuncturing at Zusanli and Yanglingquan points. The levels of MTL in the antrum (P = 0.020) and plasma (P = 0.001) and CCK in plasma (P = 0.001) were obviously increased after electroacupuncturing at Zusanli point, whereas the levels of MTL in SO and CCK in the antrum and SO were notably increased after electroacupuncturing at Yanglingquan point. There was a positive effect on the release of MTL and CCK after electroacupuncturing at the points.

CONCLUSION: The inhibition for the myoelectric activities of the stomach and SO are improved after electroacupuncturing at Zusanli and Yanglingquan points. The possible mechanism may be that the acupuncture influences the release of MTL and CCK, so as to regulate the activity of the alimentary canal.

Surgical therapy for hepatolithiasis: a Western experience

BACKGROUND

Hepatolithiasis is very common in East Asia but infrequent in Western countries, and few reports have been published in European series. In East Asia, the association between cholangiocarcinoma and hepatolithiasis is well recognized, but, on the contrary, hepatolithiasis is uncommon in Europe and the United States, and the relationship with cholangiocarcinoma is not well established. The goal of this study was to analyze the perioperative and longterm results of surgical therapy for hepatolithiasis.

STUDY DESIGN

Record review of 22 patients was done to locate immediate (operative morbidity and mortality) and longterm (stone recurrence and survival) results of patients with hepatolithiasis who underwent surgical treatment.

RESULTS

There were 19 (86.4%) hepatic resections and 10 (45.5%) hepatico-jejuno-anastomoses. Operative mortality was absent and morbidity rate was 27.3%. Right hepatectomy was predictive of postoperative complications at multivariate analysis (p = 0.04). One (4.5%) patient had an unknown associated cholangiocarcinoma at time of surgical intervention. Mean followup was 67.59 +/- 65.67 (range 12 to 215) months. None presented recurrent cholangitis during the followup period.

CONCLUSIONS

Surgical therapy is a safe and effective management for hepatolithiasis. The possibility of developing cholangiocarcinoma in inveterate hepatolithiasis is real, and hepatic resection removes this risk.

Diagnosing and treating Sphincter of Oddi dysfunction: a critical literature review and reevaluation

Sphincter of Oddi dysfunction is a pathologic syndrome, without considering etiology, physiopathology, or anatomic aspects of the condition. The clinical manifestations of the syndrome may be a consequence of an "organic stenosis" of the tract or a consequence of "abnormal motility" of the sphincter. Until some years ago, the gold standard technique for studying and treating this pathologic condition was endoscopic retrograde cholangiopancreatography. Two criteria for defining patients in the Milwaukee classification are related to this procedure. The Milwaukee classification was introduced to use clinical and radiologic criteria to define patients with Sphincter of Oddi dysfunction to choose the best treatment. Subsequently, great emphasis has been placed on manometry of the sphincter performed by endoscopic cannulation. The enormous increase of cholecystectomies by means of laparoscopic technique has increased the number of patients who return to their reference-surgeon with a post-cholecystectomy pain and possible Sphincter of Oddi dysfunction. The aim of this paper is to review the literature and to evaluate an up-to-date flow chart for diagnosing and treating the syndrome by using alternative diagnostic procedures that are less invasive than endoscopic retrograde cholangiopancreatography.

The study between the dynamics and the X-ray anatomy and regularizing effect of gallbladder on bile duct sphincter of the dog

AIM: To study the relationship between the radiological anatomy and the dynamics on bile duct sphincter in bile draining and regulatory effect of gallbladder.

METHODS: Sixteen healthy dogs weighing 18 kg to 25 kg were divided randomly into control group and experimental group (cholecystectomy group). Cineradiography, manometry with perfusion, to effect of endogenous cholecystokinin and change of ultrastructure were employed.

RESULTS: According to finding of the choledochography and manometry, in control group the intraluminal basal pressure of cephalic cyclic smooth muscle of choledochal sphincter cCS was 9.0 ± 2.0 mmHg and that of middle oblique smooth muscle of choledochal sphincter (mOS) was 16.8 ± 0.5 mmHg, the intraluminal basal pressure of cCS segment was obviously lower than that of mOS (P < 0.01) in the interval period of bile draining, but significant difference of intraluminal basal pressure of the mOS segment was not found between the interval period of bile draining (16.8 ± 0.5 mmHg) and the bile flowing period (15.9 ± 0.9 mmHg) (P > 0.05). The motility of cCS was mainly characterized by rhythmically concentric contraction, just as motility of cCS bile juice was pumped into the mOS segment in control group. And motility of mOS segment showed mainly diastolic and systolic activity of autonomically longitudinal peristalsis. There was spasmodic state in cCS and mOS segment and reaction to endogenous cholecystokinin was debased after cholecystectomy. The change of ultrastructure of cCS portion showed mainly that the myofilaments of cell line in derangement and mitochondria is swelling.

CONCLUSION: During fasting, the cCS portion has a function as similar cardiac "pump" and it is main primary power source in bile draining, and mOS segment serves mainly as secondary power in bile draining. The existence of the intact gallbladder is one of the important factors in guaranteeing the functional coordination between the cCS and mOS of bile duct sphincter. There is dysfunction in the cCS and mOS with cholecystectomy.