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Walia S, Zaidi MY, McGuire S, Milam C, Fogel EL, Sherman S, Lehman G, Pitt HA, Nakeeb A, Schmidt CM, House MG, Ceppa EP, Timsina L, Zyromski NJ. Contemporary Outcomes of Transduodenal Sphincteroplasty: the Importance of Surgical Quality. J Gastrointest Surg 2023; 27:2885-2892. [PMID: 38062321 DOI: 10.1007/s11605-022-05539-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/04/2022] [Indexed: 02/04/2024]
Abstract
BACKGROUND Sphincter of Oddi dysfunction (SOD) is managed primarily by endoscopic sphincterotomy (ES); however, surgical transduodenal sphincteroplasty (TDS) is a treatment option for select patients. In our high-volume pancreatico-biliary practice, we have observed variable outcomes among TDS patients; therefore, we sought to determine preoperative predictors of durable improvement in quality of life. METHODS SOD patients treated by TDS between January 2006 and December 2015 were studied. The primary outcome measure was long-term changes in quality of life after sphincteroplasty. The secondary outcome measure examined postoperative outcomes, including postoperative complications, need for repeat procedures, and readmission rates. Perioperative data were abstracted, and the SF-36 quality-of-life (QoL) survey was administered. Standard statistical analysis included non-parametric methods to examine bivariate associations. RESULTS Eighty-eight patients had an average follow-up duration of 6.7 (± 2.9) years. Thirty (34%) patients were naïve to endoscopic therapy. Patients with prior endoscopy averaged 2.1 procedures (range 1 to 13) prior to surgery. Perioperative morbidity was 27%; one postoperative death was caused by severe acute pancreatitis. Twenty-nine (33%) patients required subsequent biliary-pancreatic procedures. QoL analysis from available patients showed that 66% were improved or much improved. With multivariable analysis including SOD type and prior endoscopic instrumentation, freedom from surgical complication was the only variable that correlated significantly with a good outcome (p < 0.02). CONCLUSION Surgical transduodenal sphincteroplasty provides durable symptom management for select patients with sphincter of Oddi dysfunction. Minimizing surgical complications optimizes long-term outcomes.
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Affiliation(s)
- Sonal Walia
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Mohammad Y Zaidi
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Sean McGuire
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Claire Milam
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Evan L Fogel
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, 550 N. University Boulevard, UH 4100, Indianapolis, IN, 46202, USA
| | - Stuart Sherman
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, 550 N. University Boulevard, UH 4100, Indianapolis, IN, 46202, USA
| | - Glen Lehman
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, 550 N. University Boulevard, UH 4100, Indianapolis, IN, 46202, USA
| | - Henry A Pitt
- Department of Surgery, Robert Wood Johnson Medical School and Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ, 08903, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Lava Timsina
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA.
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Mortensen GF, Bhutiani N, Brown AN, Davidyuk V, Palin H, Bahr MH, Vitale GC. Long-term Follow-up of Patients Undergoing Endoscopic Intervention for Abdominal Pain with Minimal Biliary Ductal Dilation, Stone Disease, or Malignancy. Am Surg 2021; 87:1426-1430. [PMID: 33393373 DOI: 10.1177/0003134820952823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Safety and efficacy of endoscopic methods in management of biliary colic after cholecystectomy in patients with minimal biliary ductal dilation and no evidence of biliary stones or malignancy have not been clearly demonstrated. This study aimed to assess the efficacy of endoscopic management of such patients. METHODS The University of Louisville database was queried for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for colicky abdominal pain between 1996 and 2016 who had a common bile duct (CBD) diameter of ≤12 mm. All patients had undergone prior cholecystectomy and were free of malignancy. Demographic, serologic, procedural, and outcome variables were assessed. RESULTS A total of 35 patients underwent a total of 99 ERCPs. Median CBD diameter was 10 (range 4-12) mm. A total of 31 patients (89%) underwent sphincterotomy, 28 (80%) underwent stent placement, and 5 (14%) underwent balloon dilation. The median number of ERCPs performed was 2 (range 1-10). Three of the 35 patients (9%) developed post-ERCP pancreatitis at some point during their treatment. At last follow-up since initial ERCP (median 16 months, range 2.4-184 months), 12 (34%) patients endorsed abdominal pain and 11 (31%) reported experiencing nausea. CONCLUSION For select patients with abdominal pain in the setting of minimal CBD dilation and no evidence of stone disease or malignancy, ERCP can safely and effectively be used to manage symptoms. While patients may require multiple interventions, they can derive long-term relief from these procedures.
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Affiliation(s)
| | - Neal Bhutiani
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Amber N Brown
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Vladimir Davidyuk
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Hannah Palin
- Department of Obstetrics and Gynecology, University of Miami, FL, USA
| | - Michael H Bahr
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Gary C Vitale
- Department of Surgery, University of Louisville, Louisville, KY, USA
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Miyatani H, Mashima H, Sekine M, Matsumoto S. Clinical course of biliary-type sphincter of Oddi dysfunction: endoscopic sphincterotomy and functional dyspepsia as affecting factors. Ther Adv Gastrointest Endosc 2019; 12:2631774519867184. [PMID: 31448369 PMCID: PMC6693024 DOI: 10.1177/2631774519867184] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 07/10/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND STUDY AIMS The objective of this study was to clarify the effectiveness of treatment selection for biliary-type sphincter of Oddi dysfunction by severe pain frequency and the risk factors for recurrence including the history of functional gastrointestinal disorder. PATIENTS AND METHODS Thirty-six sphincter of Oddi dysfunction patients who were confirmed endoscopic retrograde cholangiopancreatography enrolled in this study. Endoscopic sphincterotomy was performed for type I and manometry-confirmed type II sphincter of Oddi dysfunction patients with severe pain (⩾2 times/year; endoscopic sphincterotomy group). Others were treated medically (non-endoscopic sphincterotomy group). RESULTS The short-term effectiveness rate of endoscopic sphincterotomy was 91%. The final remission rates of the endoscopic sphincterotomy and non-endoscopic sphincterotomy groups were 86% and 100%, respectively. Symptoms relapsed after endoscopic sphincterotomy in 32% of patients. Patients in the endoscopic sphincterotomy and non-endoscopic sphincterotomy groups had or developed functional dyspepsia in 41% and 14%, irritable bowel syndrome in 5% and 14%, and gastroesophageal reflux disorder in 14% and 0%, respectively. History or new onset of functional dyspepsia was related to recurrence on multivariate analysis. The frequency of occurrence of post-endoscopic retrograde cholangiopancreatography pancreatitis and post-endoscopic retrograde cholangiopancreatography cholangitis was high in both groups. Two new occurrences of bile duct stone cases were observed in each group. CONCLUSION According to the treatment criteria, endoscopic and medical treatment for biliary-type sphincter of Oddi dysfunction has high effectiveness, but recurrences are common. Recurrences may be related to new onset or a history of functional dyspepsia.
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Affiliation(s)
- Hiroyuki Miyatani
- Department of Gastroenterology, Jichi Medical
University Saitama Medical Center, Saitama, Japan
| | - Hirosato Mashima
- Department of Gastroenterology, Jichi Medical
University Saitama Medical Center, Saitama, Japan
| | - Masanari Sekine
- Department of Gastroenterology, Jichi Medical
University Saitama Medical Center, Saitama, Japan
| | - Satohiro Matsumoto
- Department of Gastroenterology, Jichi Medical
University Saitama Medical Center, Saitama, Japan
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Jagannath S, Garg PK. Recurrent Acute Pancreatitis: Current Concepts in the Diagnosis and Management. ACTA ACUST UNITED AC 2018; 16:449-465. [PMID: 30232693 DOI: 10.1007/s11938-018-0196-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW There have been significant developments in the diagnosis, clinical approach, and management of patients with recurrent acute pancreatitis (RAP) in the last decade. This review systematically summarizes our current understanding of RAP. NEW FINDINGS Gallstones and alcohol are common causes of RAP. Non-alcohol non-biliary RAP (nAnB RAP) is a difficult group of patients after excluding these two causes because extensive workup is required to elucidate the etiology. Idiopathic RAP is diagnosed after excluding all the known causes and recurrence is noted to be higher in such patients. Patients with non-biliary RAP are prone to develop chronic pancreatitis (CP) suggesting a continuum from acute to recurrent to chronic pancreatitis. Often, patients destined to develop CP present at an earlier stage with RAP. Endoscopic ultrasound and magnetic resonance cholangiopancreatography (MRCP) are the investigations of choice to detect microlithiasis, choledocholithiasis, ductal abnormalities, peri-ampullary malignancies, and early changes of chronic pancreatitis. The role of pancreas divisum, sphincter of Oddi dysfunction, and anomalous pancreatobiliary union in causing RAP is controversial. Genetic testing may be advisable in younger patients. CONCLUSION With a focused approach and appropriate investigations, the etiology of RAP can be identified in a significant proportion of patients. Therapeutic options are limited and future research is needed to improve understanding of the disease.
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Affiliation(s)
- Soumya Jagannath
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
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Cost Effective Therapy for Sphincter of Oddi Dysfunction. Clin Gastroenterol Hepatol 2018; 16:328-330. [PMID: 28711688 DOI: 10.1016/j.cgh.2017.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 07/06/2017] [Accepted: 07/07/2017] [Indexed: 02/07/2023]
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Watson RR, Klapman J, Komanduri S, Shah JN, Wani S, Muthusamy R. Wide disparities in attitudes and practices regarding Type II sphincter of Oddi dysfunction: a survey of expert U.S. endoscopists. Endosc Int Open 2016; 4:E941-6. [PMID: 27652298 PMCID: PMC5025319 DOI: 10.1055/s-0042-110789] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 06/13/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Sphincter of Oddi manometry (SOM) is recommended in the evaluation of suspected Type II sphincter of Oddi dysfunction (SOD2), though its utility is uncertain. Little is known about the practice of expert endoscopists in the United States regarding SOD2. METHODS An anonymous electronic survey was distributed to 128 expert biliary endoscopists identified from U.S. advanced endoscopy training programs. RESULTS The response rate was 46.1 % (59/128). Only 55.6 % received training in SOM, and 49.2 % currently perform SOM. For biliary SOD2, 33.3 % routinely obtain SOM, 33.3 % perform empiric sphincterotomy, and 26.3 % perform single session endoscopic ultrasound/endoscopic retrograde cholangiopancreatography (EUS/ERCP). In contrast, an equal number (35.1 %) favor SOM or single session EUS/ERCP for suspected acute idiopathic recurrent pancreatitis, while 19.3 % would perform empiric sphincterotomy. Those who perform SOM believe it to be important in predicting response to treatment compared with those who do not (71.8 % vs 23.1 %, P = 0.01). Yet only 51.7 % of this group performs SOM for suspected SOD2. Most (78.6 %) believe that < 50 % of patients report improvement in symptoms after sphincterotomy. Common reasons for not obtaining SOM included unreliable results (50 %), and procedure-related risks (39.3 %). Most (59.3 %) believe SOD2 is at least in part a functional disorder; only 3.7 % felt SOD is a legitimate disorder of the sphincter of Oddi. CONCLUSIONS Our survey of U.S. expert endoscopists suggests that SOM is not routinely performed for SOD2 and concerns regarding its associated risks and validity persist. Most endoscopists believe SOD2 is at least in part a functional disorder that will not respond to sphincterotomy in the majority of cases.
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Affiliation(s)
- Rabindra R. Watson
- UCLA Medical Center – Digestive Diseases, Los Angeles, California, USA,Corresponding author Rabindra R. Watson, MD UCLA Medical Center – Digestive Diseases200 Medical Plaza 330-33Los AngelesCalifornia 90095USA
| | - Jason Klapman
- Moffitt Cancer Center – Gastrointestinal Oncology, Tampa, Florida, USA
| | | | - Janak N. Shah
- California Pacific Medical Center – Interventional Endoscopy, IES Lab, San Francisco, California, USA
| | - Sachin Wani
- University of Colorado and Veterans Affairs Medical Center – Gastroenterology, Aurora, Colorado, USA
| | - Raman Muthusamy
- UCLA Medical Center – Digestive Diseases, Los Angeles, California, USA
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7
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Suarez AL, Pauls Q, Durkalski-Mauldin V, Cotton PB. Sphincter of Oddi Manometry: Reproducibility of Measurements and Effect of Sphincterotomy in the EPISOD Study. J Neurogastroenterol Motil 2016; 22:477-82. [PMID: 26951046 PMCID: PMC4930303 DOI: 10.5056/jnm15123] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 01/30/2016] [Accepted: 02/10/2016] [Indexed: 12/13/2022] Open
Abstract
Background/Aims The reproducibility of sphincter of Oddi manometry (SOM) measurements and results of SOM after sphincterotomy has not been studied sufficiently. The aim of our study is to evaluate the reproducibility of SOM and completeness of sphincter ablation. Methods The recently published Evaluating Predictors and Interventions in sphincter of Oddi dysfunction (EPISOD) study included 214 subjects with post-cholecystectomy pain, and fit the criteria of sphincter of Oddi dysfunction type III. They were randomized into 3 arms, irrespective of manometric findings: sham (no sphincterotomy), biliary sphincterotomy, and dual (biliary and pancreatic). Thirty-eight subjects had both biliary and pancreatic manometries performed twice, at baseline and at repeat endoscopic retrograde cholangiopancreatography after 1–11 months. Sham arm was examined to assess the reproducibility of manometry, and the treatment arms to assess whether the sphincterotomies were complete (elevated pressures were normalized). Results Biliary and pancreatic measurements were reproduced in 7/14 (50%) untreated subjects. All 12 patients with initially elevated biliary pressures in biliary and dual sphincterotomy groups normalized after biliary sphincterotomy. However, 2 of 8 subjects with elevated pancreatic pressures in the dual sphincterotomy group remained abnormal after pancreatic sphincterotomy. Paradoxically, normal biliary pressures became abnormal in 1 of 15 subjects after biliary sphincterotomy, and normal pancreatic pressures became abnormal in 5 of 15 patients after biliary sphincterotomy, and in 1 of 9 after pancreatic sphincterotomy. Conclusions Our data suggest that SOM measurements are poorly reproducible, and question whether we could adequately perform pancreatic sphincterotomy.
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Affiliation(s)
- Alejandro L Suarez
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Qi Pauls
- Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | | | - Peter B Cotton
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA
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8
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Abstract
Sphincter of Oddi dysfunction (SOD) has long been a controversial topic, starting with whether it even exists, as a sphincterotomy-responsive entity to treat, for either: (1) post-cholecystectomy abdominal pain and/or (2) idiopathic recurrent acute pancreatitis (IRAP). Many of its aspects had required further research to better prove or refute its existence and to provide proper recommendations for physicians to diagnose and treat this condition. Fortunately, there has been major advancement in our knowledge in several areas over the past few years. New studies on challenging the classification, exploring alternative diagnostic methods, and quantifying the role of sphincterotomy in treatment of SOD for post-cholecystectomy pain and for IRAP were recently published, including a randomized trial in each of the two areas. The goal of this paper is to review recent literature on selected important questions and to summarize the results of major trials in this field.
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9
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Abstract
This article reviews the diagnosis and management of sphincter of Oddi dysfunction (SOD), including the various factors to consider before embarking on endoscopic therapy for SOD. Selection starts with patient education to include possible patient misconceptions related to symptoms caused by the pancreaticobiliary sphincter as well as reinforcing the risks associated with the diagnosis and therapy. The likelihood of relief of recurrent abdominal pain attributed to SOD is related to the classification of SOD type and a crucial consideration before considering endoscopic therapy in light of recent evidence.
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10
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Wilcox CM. Sphincter of Oddi dysfunction Type III: New studies suggest new approaches are needed. World J Gastroenterol 2015; 21:5755-5761. [PMID: 26019439 PMCID: PMC4438009 DOI: 10.3748/wjg.v21.i19.5755] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 03/12/2015] [Accepted: 04/17/2015] [Indexed: 02/06/2023] Open
Abstract
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 of any 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.
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Abstract
Symptomatic cholelithiasis and functional disorders of the biliary tract present with similar signs and symptoms. The functional disorders of the biliary tract include functional gallbladder disorder, dyskinesia, and the sphincter of Oddi disorders. Although the diagnosis and treatment of symptomatic cholelithiasis are relatively straightforward, the diagnosis and treatment of functional disorders can be much more challenging. Many aspects of the diagnosis and treatment of functional disorders are in need of further study. This article discusses uncomplicated gallstone disease and the functional disorders of the biliary tract to emphasize and update the essential components of diagnosis and management.
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12
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Endoscopic approach to the patient with motility disorders of the bile duct and sphincter of Oddi. Gastrointest Endosc Clin N Am 2013; 23:405-34. [PMID: 23540967 DOI: 10.1016/j.giec.2012.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Since its original description by Oddi in 1887, the sphincter of Oddi has been the subject of much study. Furthermore, the clinical syndrome of sphincter of Oddi dysfunction (SOD) and its therapy are controversial areas. Nevertheless, SOD is commonly diagnosed and treated by physicians. This article reviews the epidemiology, clinical manifestations, and current diagnostic and therapeutic modalities of SOD.
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13
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Wilcox CM. Endoscopic therapy for sphincter of Oddi dysfunction in idiopathic pancreatitis: from empiric to scientific. Gastroenterology 2012; 143:1423-6. [PMID: 23089546 DOI: 10.1053/j.gastro.2012.10.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Outcomes of sphincter of oddi manometry when performed in low volumes. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2011; 2011:435806. [PMID: 21747651 PMCID: PMC3130956 DOI: 10.1155/2011/435806] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 04/05/2011] [Indexed: 12/14/2022]
Abstract
Background. Sphincter of Oddi manometry is a highly specialized procedure associated with an increased risk of procedural complications. Published studies have typically been performed in large volume manometry centers. Objective. To examine the outcomes and complication rate of SOM when performed in small volumes. Design. Retrospective analysis at a tertiary care referral hospital that infrequently performs Sphincter of Oddi manometry. Patient records were reviewed for procedural details, patient outcomes, and complications after sphincter of Oddi manometry. Results. 36 patients, 23 (23 type II sphincter of Oddi dysfunction (SOD), 13 type III SOD) underwent sphincter of Oddi manometry and were followed up for mean of 16 months. Nine Type II patients (90%) with elevated basal sphincter pressures noted symptom improvement after sphincterotomy compared with only 3 patients (43%) of the patients with normal basal pressures. In type III SOD, 7 patients had elevated basal SO pressure and underwent sphincterotomy. Three patients (43%) improved. There were six
(16%) procedure-related complications. There were four cases
of post ERCP pancreatitis (11%), all of which were mild.
Conclusion. In low numbers, sphincter of Oddi
manometry can be performed successfully and safely by experienced
biliary endoscopists with results that are comparable to large
volume centers.
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Abstract
Sphincter of Oddi dysfunction (SOD) is a poorly-understood disorder, typically presenting as postcholecystectomy, "biliary-type," right-sided abdominal and/or chest wall pain. Most patients referred to specialist clinics for work-up of presumed SOD do not, in fact, have anything wrong with their bile ducts or biliary sphincter mechanisms. A careful history and focused physical examination will often identify the true source of the pain syndrome, ranging from chest wall costochondritis and nerve injury at surgical trochar sites, to gastroparesis and visceral hypersensitivity ("irritable bowel"). The Rome III classification of functional gallbladder and biliary disorders defines SOD as episodic (not daily) pain lasting more than 30 min, which is disruptive of normal activities and not associated with bowel upset. It is not relieved by gastric acid suppression or antispasmodics. Other causes of abdominal pain must be excluded. Standard work-up includes endoscopic retrograde cholangiopancreatography (ERCP) with biliary manometry, which risks post-ERCP pancreatitis, especially in young women with normal bile ducts and liver serology. Noninvasive tests for SOD, such as timed ("gated") cholecystokinin (CCK)-stimulated hepatobiliary iminodiacetic acid (HIDA) scans and secretin-stimulated magnetic resonance cholangiopancreatography, are imperfect and still evolving. Although many doubt the very existence of SOD, a multidisciplinary approach to the management of pre- and postcholecystectomy abdominal pain syndromes is long overdue.
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Affiliation(s)
- John Baillie
- Section on Gastroenterology, Hepatobiliary and Pancreatic Disorders Service, Wake Forest University Baptist Medical Center, Winston-Salem, NC 27157, USA.
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