Sphincter of Oddi motility

Cholecystectomy and the risk of alimentary tract cancers: A systematic review

AIM: To investigate the association between cholecystectomy and gastro-intestinal tract (GIT) cancers.

METHODS: We conducted a systematic review according to the PRISMA guidelines. A MEDLINE search was performed with predefined search criteria for English Language articles on the association between cholecystectomy and GIT cancers. Additional articles were retrieved by manual search of references. All relevant articles were accessed in full text. Data on study type; cases; controls; country; effect estimate; adjustments for confounders and quality of publication were extracted. The quality of the publications were scored by adherence to the STROBE checklist. The data for each part of the GIT were presented in separate tables.

RESULTS: Seventy-five studies and 5 meta-analyses satisfied the predefined criteria for inclusion and were included in this review. There were inconsistent reports and no strong evidence of an association between cholecystectomy and cancers of the oesophagus (Adenocarcinoma), pancreas, small bowel and right-sided colon cancers. In squamous cancer of the oesophagus, cancers of the stomach, liver, bile ducts, small bowel and left sided colon cancers, good quality studies suggested a lack of association with cholecystectomy. Equally, distal colon and rectal cancers were found not to be associated with cholecystectomy. Several mechanisms for carcinogenesis/promotion of carcinogensis have been proposed. These have focused on a role for bile salts in carcinogenesis with several potential mutagenic molecular events and gut metabolic hormones signaling cell proliferation or initiation of carcinogenesis.

CONCLUSION: This is a comprehensive review of the association between GIT cancers and cholecystectomy. This review found no clear association between cholecystectomy and GIT cancers.

Gallbladder function and dynamics of bile flow in asymptomatic gallstone disease

AIM: To investigate the effects of gallbladder stones on motor functions of the gallbladder and the dynamics of bile flow in asymptomatic gallstone disease.

METHODS: Quantitative hepatobiliary scintigraphy was performed to detect the parameters of gallbladder motor function [gallbladder ejection fraction (GBEF), gallbladder visualization time (GBVT), gallbladder time to peak activity (GBT_max), gallbladder half emptying time (GBT_1/2), and transit time of bile to duodenum (TTBD)] in 24 patients with asymptomatic cholelithiasis who were diagnosed incidentally during routine abdominal ultrasonographic examination and 20 healthy subjects with normal gallbladder.

RESULTS: Even though there was no significant difference in the clinical and laboratory parameters between the patient and control groups, all parameters of gallbladder function except TTBD were found to differ significantly between the two groups. GBEF in the patient group was decreased (P = 0.000) and GBVT, GBT_max, GBT_1/2 in the patient group were longer (P = 0.000, P = 0.015, P = 0.001, respectively).

CONCLUSION: Our results showed that even if there were not any clinical and laboratory findings, gallbladder filling and emptying could be impaired in patients with gallstone disease.

On the mechanical behavior of the human biliary system

This paper reviews the progress made in understanding the mechanical behaviour of the biliary system. Gallstones and diseases of the biliary tract affect more than 10% of the adult population. The complications of gallstones, i.e. acute pancreatitis and obstructive jandice, can be lethal, and patients with acalculous gallbladder pain often pose diagnostic difficulties and undergo repeated ultrasound scans and oral cholecystograms. Moreover, surgery to remove the gallbladder in these patients, in an attempt to relieve the symptoms, gives variable results. Extensive research has been carried out to understand the physiological and pathological functions of the biliary system, but the mechanism of the pathogenesis of gallstones and pain production still remain poorly understood. It is believed that the mechanical factors play an essential role in the mechanisms of the gallstone formation and biliary diseases. However, despite the extensive literature in clinical studies, only limited work has been carried out to study the biliary system from the mechanical point of view. In this paper, we discuss the state of art knowledge of the fluid dynamics of bile flow in the biliary tract, the solid mechanics of the gallbladder and bile ducts, recent mathematical and numerical modelling of the system, and finally the future challenges in the area.

AM. Tratamento de doença bílio-pancreática em pacientes portadores de divertículo duodenal periampolar

OBJETIVO: Analisar o tratamento da doença bílio-pancreática na presença do divertículo periampolar. MÉTODO: De janeiro de 1999 a julho de 2003, 13 doentes com diagnóstico de divertículo periampolar e doença bílio-pancreática associada foram tratados pelo grupo de vias biliares e pâncreas do Departamento de Cirurgia da Santa Casa de São Paulo. Foram analisados retrospectivamente quanto à idade, sexo, quadro clínico e exames laboratoriais e radiológicos, com intuito diagnóstico. O tratamento endoscópico ou cirúrgico e seus resultados foram avaliados. RESULTADOS: Quatro pacientes eram do sexo masculino (30,8%) e nove (69,2%) do sexo feminino, a maioria com idade superior a 70 anos. Os principais sintomas foram de icterícia (61,5%) e dor abdominal (53,8%). Dois doentes apresentaram-se com pancreatite aguda e um com hemorragia digestiva alta. Onze doentes tinham coledocolitíase e dois, diagnóstico de colangiocarcinoma. Dez doentes foram submetidos a colangio-pancreatografia retrógrada endoscópica com 30% de sucesso no tratamento da coledocolitíase. Os outros doentes foram operados: três coledocoduodenostomias, quatro coledocolitotomias com drenagem em T da via biliar. Três doentes foram submetidos à diverticulectomia (23,1%) e um deles (7,7%) à papiloesfincteroplastia. A mortalidade na amostra foi de 7,7%. CONCLUSÃO: A taxa de sucesso do tratamento endoscópico da coledocolitíase foi baixa na presença de divertículo periampolar e a diverticulectomia com ou sem esfincteroplastia pode elevar a morbidade e a mortalidade nestes doentes.

Chinese medicinal herbs Muh-Shiang Bin-Lang-Wan increases the motility of sphincter of Oddi in anesthetized rabbits through activation of M1 muscarinic receptors

The sphincter of Oddi (SO) plays an important role in regulating the bile flow into the duodenum. This study was designed to investigate the effect of Chinese Medicinal Herbs Muh-Shiang-Bin-Lang-Wan (MSBLW) and their mechanism of action on regulating the motility of SO in rabbits. The activity of SO in anesthetized rabbits was measured by using a continuously perfused open-tip manometric method. The rabbits were administered with different doses of MSBLW through naso-gastric tubes. The SO motility before and after the administration of MSBLW were recorded, and analyzed with a computer equipped with an off line analysis software. The results showed that the SO activity, in terms of tonic pressure and phasic contraction pressure, were significantly changed. A significant lower tonic pressure and a higher phasic contraction pressure were noticed 40-60 min after administration of MSBLW with a peak response at 0.5-1.0 gm range. The responses were blocked by pretreatment of muscarinic receptors (M1) antagonist, pirenzepine (10 mg/kg, orally). We conclude that MSBLW is effective in increasing the SO motility in rabbits through activation of M1 muscarinic receptors. However, potential application of MSBLW in the treatment of human biliary disorders needs further evaluation.

Comparison of the dynamics of bile emptying by quantitative hepatobiliary scintigraphy before and after cholecystectomy in patients with uncomplicated gallstone disease

PURPOSE

Quantitative hepatobiliary scintigraphy, a noninvasive method frequently used to diagnose several biliary tract disorders, shows abnormalities in bile secretion and outflow. It is well known that there are wide variations in the normal pattern of bile emptying, but the effect of cholecystectomy on the bile flow has not yet been investigated. The goal of the current study was to examine the dynamics and normal variations of bile flow by quantitative hepatobiliary scintigraphy before and after cholecystectomy in a group of patients with uncomplicated gallstone disease.

METHODS

Twenty patients were evaluated before and after cholecystectomy through cholecystokinin octapeptide-augmented quantitative hepatobiliary scintigraphy, and quantitative parameters of bile emptying (Tmax: time to peak activity, T1/2: half-emptying time before and after cholecystokinin octapeptide and duodenum appearance time) were determined and then compared.

RESULTS

Before operation, the bile outflow displayed wide variations, with a moderately delayed common bile duct emptying time in some patients. After cholecystectomy, the T1/2 of the common bile duct decreased significantly when compared with the preoperative status, with only minor patient-to-patient variation, indicating uniformly faster bile emptying (common bile duct T1/2 before and after operation: 30.5 +/- 14.8 and 18.8 +/- 2.6 min, respectively). Cholecystokinin octapeptide administration caused rapid bile outflow from the common bile duct, with a significant decrease in the T1/2 parameters before and after cholecystectomy.

CONCLUSIONS

In patients with their gallbladders in situ, the bile emptying rate showed wide variations and may be moderately slow without distal common bile duct obstruction. After cholecystectomy, the rate of bile emptying accelerated and showed only minor variations, thereby increasing the sensitivity of quantitative hepatobiliary scintigraphy for showing partial biliary obstruction.

Periampullary diverticula and pancreaticobiliary disease

BACKGROUND

Periampullary diverticula (PAD) are extraluminal outpouchings of the duodenum arising within a radius of 2-3 cm from the ampulla of Vater. They are frequently encountered in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and contribute to failure of ERCP. This review details the relationship of PAD to pancreaticobiliary disease and the influence of PAD on the management of patients.

METHODS

The United States National Library of Medicine Medline database was searched for articles on and related to PAD published in English within the past 15 years. Major earlier works were also reviewed.

RESULTS

The prevalence of PAD increases with age and could be as high as 27 per cent. PAD are associated with an incompetent sphincter of Oddi and colonization of bile duct with beta-glucuronidase-producing organisms. PAD are implicated in the pathogenesis of pigment common bile duct stones, but there is no conclusive evidence to associate them with cholecystolithiasis or pancreatitis. PAD are a major cause of failure of ERCP, but success rates of more than 90 per cent have been achieved in specialist centres.

CONCLUSION

With an ageing population, there will be an increase in elderly patients with PAD and symptomatic pancreaticobiliary disease. Continuing improvements in radiological and endoscopic techniques should enable this vulnerable group to be treated effectively and safely.

Local somatothermal stimulation inhibits the motility of sphincter of Oddi in cats, rabbits and humans through nitrergic neural release of nitric oxide

To examine whether and how local somatothermal stimulation inhibits the function of the sphincter of Oddi (SO) in humans and in animals with different types of SO, we measured the activity of SO in anesthetized cats and rabbits by using continuously perfused open-tip manometric methods. Local somatothermal stimulation was achieved by applying an electroheating rod 0.5 cm away from the skin area near the right subcostal region. A heating pad was applied to the corresponding area in patients undergoing endoscopic retrograde cholangiopancreatography and biliary manometry. The motility of the biliary tract in cats, in terms of gall bladder pressure, tonic and phasic contraction pressure and frequency of SO before and during local heat were significantly different, respectively. The local heat-induced SO relaxation was not inhibited by pretreatment with atropine, propranolol, phentolamine or anti-cholecystokinin-octapeptide, but was almost completely blocked by infiltration of local anesthetics. Pretreatment with a nitric oxide synthesis inhibitor also blocked the relaxation, which was reversed by pretreatment with L-arginine, but not by D-arginine. The inhibition of SO motility by local heat in rabbits was also blocked by pretreatment with L-NAME, and this blockade was reversed by L-arginine. Application of local heat on patients demonstrated obvious inhibitory SO responses. We conclude that local somatothermal stimulation inhibits the SO motility in animals with different types of SO through the activation of heat-sensitive neural release of nitric oxide. This procedure may represent a simplified approach for the treatment of diseases with hypofunction of the L-arginine/NO pathway.