[Stenosing papillitis--a problem of miniinvasive surgery]

The results of conduction of endoscopic transpapillary interventions in 976 patients, suffering stenosing papillitis in 2000 - 2014 yrs, were summarized. In 48 (4.9%) patients complications have had occurr, all the patients are alive.

[Effectiveness of treatment of pancreatic disorders in children (based on catamnesis)]

In the article results of supervision of the patients with chronic pancreatitis and dysfunction of Oddi's sphincter, pancreatic type, in polyclinic were presented. Among them: 50 children received in clinic therapeutic complex offered by us which included: phytoenzyme, spasmolytic and antioxidant. 50 children were treated in traditional way. Screening of functional condition of the pancreas revealed decreasing percentage of moderate exocrine insufficiency of pancreas (10% of incidences) in children with recurrent course of pancreatitis. In long-lasting course of pancreatitis in this group percentage of patients with moderate exocrine insufficiency was decreased due to 15%. At the same time, in patients with moderate and severe exocrine insufficiency (55 and 20% subsequently) which improves non complete efficiency of basic therapy.

Modelling of the pathological bile flow in the duct with a calculus

The aim of the present paper is to develop an analytical model for description of the pathological bile flow in the major duodenal papilla duct with a calculus. The problem is separated into two parts. The first part deals with determination of bile behaviour and constitutive relation parameters of the pathological bile. The viscosity vs. shear rate, the viscosity vs. time, and shear stress vs. shear rate dependences are obtained for different types of bile taken from patients of different age and sex. As a result, the approximation of curves described by the Casson equation was obtained. It was shown that the pathological bile is a thixotropic non-Newtonian fluid. The second part is directly related to modelling of the bile flow in the duct with a calculus. As a result of solving the problem, the bile velocity profile, flow rate vs. time, and bile pressure vs. calculus radius were obtained. The dependences obtained may play an important role in the assessment of an indication to operation.

[A modern look at benign stenosing lesions. Etiology and pathogenesis of diagnostic capabilities. A systematic review]

The problem of nonneoplastic stenosis of major duodenal papilla is on joint of gastroenterology and surgery and present a challenge for physicians. This article reviews what is known about the pathogenesis, epidemiology and diagnostics of papillostenosis and sphincter of Oddi dysfunction.

Surgical pancreatic sphincteroplasty. Historic or history ? A review

BACKGROUND

Minimal invasive techniques represent a constantly expanding field of medicine and numerous well-established operative procedures have gradually been replaced. Likewise, surgical pancreatic sphincteroplasty, which has been the cornerstone in the management of pancreatic flow disorders for decades, has been largely replaced by endoscopy. Endoscopic pancreatic sphincterotomy however, is still not widespread and carries a significant risk of complications. In this study we attempt to review the role of the surgical approach in the modern era.

METHODS

Pubmed database was searched for reports concerning surgical pancreatic sphincteroplasty alone or in comparison with endoscopy, without other limitations.

RESULTS

Initially, 44 studies were obtained. Finally, 22 full papers were selected, pertaining review articles, case series or clinical studies. Only four of them were recent (after 2002) series of surgical sphincteroplasty, pertaining 561 patients. No randomized-controlled trials or meta-analyses were revealed.

CONCLUSIONS

Pancreatic sphincterotomy, either surgical or endoscopic offers good to excellent long-term results in several disorders, like Sphincter Oddi dysfunction, especially when underlying parenchymal disease is limited. Surgical sphincteroplasty is nowadays indicated in most cases of endoscopic failure and in cases that the papilla cannot be approached. Bariatric patients with gastric by-pass and sphincter Oddi dysfunction in particular, have reported to show excellent outcome after surgery. Regardless the method, patient selection is still a very important determinant of success.

[Periampullar diverticulum--related to bilio-pancreatic disorders]

Periampullar diverticulum (PAD) represent a particular type of duodenal diverticulum, with important pathological effect on the functionality of both the billiary tree and the pancreas. In our retrospective, randomised study, we analised 204 patients who underwent ERCP. We diagnosed 34 PAD (17%). We performed the endoscopic procedure for several pathological conditions of the biliary tract (cholestasis, jaundice, angiocolitis). Most DPA were identified in patients over 60 years (80%), beeing slightly more frequent in males (59%). We found in 25% of patients (over 65 years) with bile duct stones at least one PAD. Over 50% of patients with PAD had bile duct stones. Fibrous, obstructive papillo-odditis was found in 37% of patients with PAD.

CONCLUSIONS

1. PAD are related to bilio-pancreatic disorders, especially to bile duct stones. 2. The most common physio-pathological mechanism is a alteration of the bile flow, due to angulation, compression and/or obstruction of the final part of the bile duct and Wirsung duct, followed by secondary upper stasis. 3. Papillosphincterotomy has technical particularities, because of difficulties in incision orientation (a deformed papilla, with modified anatomical relationships, being situated profound inside the diverticulum cavity). Sphincterotomy depth was limited, which lead to less succesfull extraction of bile stones (89%, compared to the control group 92%). 4. We did not encounter major accidents. Secondary acute pancreatitis after ERCP was similar in both study groups. There was no significant difference in morbidity and mortality rates in both groups.

Correlation of endoscopic ultrasonography (EUS) for differential diagnostics between inflammatory and neoplastic lesions of the papilla of Vater and the peripapillary region with results of histologic investigation

PURPOSE

There is currently no imaging procedure that allows precise differentiation between inflammatory and malignant lesions of the papilla of Vater (papilla) in a satisfying manner. The aim was to study whether endoscopic ultrasonography (EUS) as an initial diagnostic step 1. may have the potential to distinguish between different tissue characteristics, such as tumor growth or inflammation of the papilla, because of its high resolution capacity and 2. is superior to the accuracy of histologic investigations of mucosal biopsies by means of a prospective collection and retrospective evaluation of the data.

PATIENTS AND METHODS

Between 1995 and 2002, a significant pathologic finding in the papilla and the peripapillary region was revealed using EUS in 311 patients (overall, 4,832 EUS investigations); the comparison of this suspicion with the results of histologic investigation was only possible in 183 subjects. In 133/183 patients, a biopsy for histologic investigation was not able to be obtained prior to the use of EUS. Diagnosis was set up using EUS, which tried to differentiate between benign or malignant lesions of the papilla. Histologic investigation of the 133 tumor lesions of the papilla became possible by taking deep transpapillary biopsies following papillotomy, papillectomy or by obtaining specimens from surgical resections.

RESULTS

Using EUS, differentiation between inflammatory and neoplastic lesions of the papilla or the peripapillary region was correct in 109 of 133 cases (82%), while suspected EUS-based diagnosis "papillitis stenosans" (inflammatory lesions of the papilla of Vater) in 4 subjects (3%) was corrected to adenoma and carcinoma, respectively (n=2 each) by histologic investigation. In 20 of 133 patients with suspected neoplastic lesions, inflammatory lesion of the papilla of Vater was detected resulting in an overall sensitivity of 92.3% and specificity of 75.3%.

CONCLUSIONS

EUS makes it possible to detect small intraampullary tumors and segmental thickening of the wall of the prepapillary biliary duct, which cannot be revealed by conventional imaging. In patients with biliary symptoms, EUS can reliably visualize and characterize a malignant lesion as a first diagnostic tool (detection rate, 82%) and may be considered the basis for subsequent diagnostic steps for verifying diagnosis correctly, e. g., using histologic investigation.

[The relationship between Oddi's sphincter and bile duct pigment gallstone]

OBJECTIVE

To investigate the relationship between anatomic abnormalities and malfunction of Oddi sphincter with formation of bile duct pigment gallstone.

METHODS

One hundred and twenty-three patients with a T tube after cholecystectomy and choledochotomy were divided into reflux group and control group by measuring the amounts of radioactivity of (99m)Tc-DTPA in the bile. Among them 53 were selected randomly to undergo choledochoscopic manometry. Basal pressure of Oddi's sphincter (SOBP), amplitude of Oddi's sphincter (SOCA), frequency of contraction (SOF), duration of contraction (SOD), duodenal pressure (DP), common bile duct pressure (CBDP) were scored and analyzed. The level of plasma motilin and serum gastrin of 45 patients and 12 healthy volunteers were measured by radioimmunoassay. The incidence rates of duodenal descending part diverticulum in patients with bile duct pigment stones, patients without alimentary tract diseases, patients with gallbladder polyps, patients with gallbladder stones were studied by means of barium meal examination. The incidence rates of intraduodenal peri-ampullary diverticulum in patients with primary bile duct pigment stones, patients with bile duct stone and gallbladder stones, patients with bile duct stones originating from the gallbladder, patients with inflammation and stricture of the extremity of bile duct and papilla, patients with cancer of the extremity of bile duct and papilla, patients with post-cholecystectomy syndrome were detected by duodenoscope.

RESULTS

Of the patients, 44 were detected with duodenal-biliary reflux (35.8%). SOBP, SOCA and CBDP in the reflux group were much lower than those in control group (P < 0.001). The level of serum gastrin and plasma motilin of the reflux group were much lower than those of control group (P < 0.01). Positive correlation was found between level of motilin and SOBP while level of gastrin was positively correlated with SOBP and CBDP. The incidence of duodenal diverticulum in patients with bile duct pigment stone was 36.62%, which was higher than that of the other 3 groups. The incidence rate of intraduodenal peri-ampullary diverticulum in patients with primary bile duct pigment stone was higher than that of patients with inflammation and stricture of the extremity of bile duct and papilla, patients with cancer of the extremity of bile duct and papilla and patients with bile duct stones originating from the gallbladder.

CONCLUSIONS

The patients with bile duct pigment stone have apparent duodenal-biliary reflux and infection of the bile duct. The state of structure and function of Oddi's sphincter is correlated significantly with bile duct pigment stone. The anatomic abnormalities and malfunction of Oddi's sphincter played an important role in the formation of bile duct pigment stone.

[Bile duct infections as a late complication after endoscopic sphincterotomy]

Nowadays endoscopic sphincterotomy (SE) is considered to be a "gold standard" in the treatment of residual choledocholithiasis and biliary pancreatitis. Nevertheless patients after invasive procedures concerning bile ducts with destruction of Oddi's sphincter often have increased succeptibility to chronic infections of bile ducts.

AIM

Assessment of the influence of SE on bacterial colonization, development of main bile duct chronic inflammation and recurrent choledocholithiasis.

MATERIAL AND METHODS

We included to the study 50 patients with main bile duct lithiasis, who underwent endoscopic cholangiopancreatography (ERCP). Among them there were 32 women in age from 45 to 87 (mean 69.7 +/- 12.3) and 18 men in age from 39 to 84 (mean 59.8 +/- 11.56). The studied group was divided into 3 subgroups: In I (control) group were included 10 patients diagnosed with ERCP techniques because of jaundice of unknown origin. Those patients did't have ERCP or operative revision of bile ducts before, but all of them underwent cholecystectomy in the past. Each II and III group consisted of 20 patients, who underwent SE before 12-24 and 25-36 months earlier respectively. Sterile uodenoscope was inserted to the region of major duodenal papilla, and then a sterile brush was used to collect material to cytological smear (brushing) from main bile duct. In all groups 2 ml of bile were taken by a catheter to a syringe. On the basis of radiograms from ERCP findings, the width of main bile duct was assessed. In all patients blood cell count, aspartate and alanine aminotransferases, gammaglutamyltranspeptidase, alkaline phosphatase, amylase, bilirubin, C-reactive protein and procalcitonine levels were measured.

RESULTS

In our study all 40 patients with previously performed endoscopic sphincterotomy (SE) had bacterial colonization in bile ducts, mostly with Gramm negative pathogens. The most virulent pathogens vere cultured from bile duct swabs from patients after two or more revisions of common bile duct, and after a longer time from sphincterotomy. Those patients had multibacterial bile duct infections (Escherichia coli + Pseudomonas aeruginosa; P. aeruginosa + Enterococcus faecalis; E. faecalis + Enterobacter cloacae + Candida albicans; P. aeruginosa + E. cloacae). E. coil and E. faecalis were most frequently cultured (20 and 16 cases respectively). It was observed that with length of time from endoscopic sphincterotomy, the width of main bile duct and also amount of cultured pathogens and their virulency grow. Elevated transaminases activity and serum procalcitonine levels were observed in studied groups. 9 patients after previous sphincterotomy had recurrent lithiasis.

CONCLUSIONS

Sphincterotomy contributes to colonization of main bile duct with pathogenic bacteria. With length of time from endoscopic sphincterotomy, and amount of performed endoscopic sphincterotomies the amount of cultured pathogens, their virulency and drug resistance grow. Chronic infection of bile ducts after endoscopic sphincterotomy causes higher risk of recurrent lithiasis.

Randomized trial comparing needle-knife and pull-sphincterotome techniques for pancreatic sphincterotomy in high-risk patients

BACKGROUND

Accepted techniques for pancreatic sphincterotomy include use of a needle knife or a pull sphincterotome to ablate the sphincter. There are no prospective studies comparing outcomes between both techniques.

AIM

Compare post-ERCP pancreatitis rates among high-risk patients undergoing pancreatic sphincterotomy with the pull-sphincterotome versus needle-knife technique.

STUDY DESIGN

Prospective, randomized trial.

METHODS

Patients diagnosed with pancreatic sphincter hypertension at sphincter of Oddi manometry were randomized to undergo pancreatic sphincterotomy with a pull sphincterotome (followed by pancreatic stenting) or a needle knife over a pancreatic stent.

MAIN OUTCOME MEASUREMENTS

To compare post-ERCP pancreatitis rates between the pull-sphincterotome and needle-knife groups.

RESULTS

Forty-eight patients were randomized. Patient demographics and the incidence of patient and procedure risk factors for pancreatitis were similar in both treatment groups. The trial was stopped early after an interim analysis showed that post-ERCP pancreatitis was significantly higher among patients undergoing sphincterotomy with a pull sphincterotome than a needle knife (7/24 = 29% [95% CI 13-51] vs 0/24 = 0% [95% CI 0-12]; P = .01). No other complications were encountered. At a mean follow-up of 12 months (range 6-18 months), 60% of patients had complete symptom relief, 15% partial symptom relief, and 25% recurrent symptoms. Reintervention rates and clinical outcomes were not significantly different between the 2 groups.

LIMITATIONS

Short duration of follow-up.

CONCLUSIONS

Pancreatic sphincterotomy is safer in high-risk patients when performed with a needle knife over a pancreatic stent.

Effects of structural injure in the bile bacterial contamination after balloon transduodenal sphincteroplasty (papillary dilation) in dogs

PURPOSE

To evaluate, in dogs, the biliary sphincter subjected to dilation by hydrostatic balloon by the point of view of structural alterations of the papilla and the biochemestry and bacterial contamination of the bile.

METHODS

Twenty dogs were submitted to laparotomy, duodenotomy, and enlargement of the major duodenal papilla- GA(n=10) - with balloon of 8mm inflated with pressure of 0,5 atm, during 2 minutes or to the sham procedure - GB(n=10). Blood samples collected on times t(0 day), t(7 days) and t(28 days) were subjected to dosages of alkaline phosphatase (ALP) and gamma-glutamyltransferase (GGT) for cholestasis evaluation. The collected material from the gall bladder at the same times were registered and numbered to be submitted to culture in BHI, blood agar (rich, non-selective element) and Mac Conkey (selective element for Gram-negative bacillus. On the 28th day three fragments of the papilla were tranversally cut by the choledoc axis 3mm from the duodenal papilla and the cuts, stained with hematoxylin-eosin and Masson's tricome, were evaluated according to their inflammatory reaction.

RESULTS

The GGT and ALP averages on the three periods in the groups A and B did not show significant differences, not being characterizes the cholestasis. The bacterian contamination was significantly higher in GA (2,19) than in GB (1,96); the contamination was lower in the initial time compared with 7 and 28 days (t0<t7 and t 28) in GA and GB (t0<t 28). The chronic inflammatory alteration of the mucosa occurred in 60% of the GA animals and in 80% of the GB animals. There was not mural inflammation.

CONCLUSION

The duodenal papilla dilation or its simple manipulation leads to the bacterial contamination of the gall bladder, not associated with cholestasis. The morphologic lesions are more intense in the late phase, not associated with an eventual papilla esthenosis.

Systematic review: sphincter of Oddi dysfunction--non-invasive diagnostic methods and long-term outcome after endoscopic sphincterotomy

BACKGROUND

Sphincter of Oddi dysfunction is a benign, functional gastrointestinal disorder for which invasive endoscopic therapy with potential complications is often recommended.

AIMS

To review the available evidence regarding the diagnostic accuracy of non-invasive methods that have been used to establish the diagnosis and to estimate the long-term outcome after endoscopic sphincterotomy.

METHODS

A systematic review of English language articles and abstracts containing relevant terms was performed.

RESULTS

Non-invasive diagnostic methods are limited by their low sensitivity and specificity, especially in patients with Type III sphincter of Oddi dysfunction. Secretin-stimulated magnetic resonance cholangiopancreatography appears to be useful in excluding other potential causes of symptoms, and morphine-provocated hepatobiliary scintigraphy also warrants further study. Approximately 85%, 69% and 37%, of patients with biliary Types I, II and III sphincter of Oddi dysfunction, respectively, experience sustained benefit after endoscopic sphincterotomy. In pancreatic sphincter of Oddi dysfunction, approximately 75% of patients report symptomatic improvement after pancreatic sphincterotomy, but the studies have been non-controlled and heterogeneous.

CONCLUSIONS

Patients with suspected sphincter of Oddi dysfunction, particularly those with biliary Type III, should be carefully evaluated before considering sphincter of Oddi manometry and endoscopic sphincterotomy. Further controlled trials are needed to justify the invasive management of patients with biliary Type III and pancreatic sphincter of Oddi dysfunction.

Main pancreatic duct, common bile duct and sphincter of Oddi structure visualized by optical coherence tomography: An ex vivo study compared with histology

BACKGROUND

Optical coherence tomography has been proposed to obtain high-resolution imaging of tissue structure of GI tract. Up till now, the optical coherence tomography appearance of the common bile duct, main pancreatic duct and sphincter of Oddi wall structure has not yet been defined.

AIMS

To compare, in a prospective study, optical coherence tomography images of pancreato-biliary ductal system with histology and identify the optical coherence tomography pattern of the normal wall structure of the ducts.

METHODS

Multiple sections of non-neoplastic segments of five consecutive ex vivo human pancreatic specimens were investigated by optical coherence tomography scanning within 1h of resection. Sixty optical coherence tomography images were compared with the corresponding histological findings.

RESULTS

Optical coherence tomography appearance of normal common bile duct, main pancreatic duct and sphincter of Oddi is characterized by a differentiated three-layer architecture with a regular surface and a homogeneous back-scattered signal, corresponding to the single layer of epithelial cells, the connective-muscular layer and the muscular or acinar structure, respectively. Optical coherence tomography and histology findings were concordant in all cases.

CONCLUSIONS

Optical coherence tomography was able to provide in real-time images of wall structure of the normal common bile duct, main pancreatic duct and sphincter of Oddi that are similar to those obtained by histology. These results suggest that optical coherence tomography could enable high-resolution images to be obtained from the pancreato-biliary system during an ERCP procedure.

Esfinterotomía de aguja como técnica de acceso a la vía biliar: estudio prospectivo

OBJECTIVE

Needle-knife sphincterotomy (NKS) is used to achieve biliary access when routine cannulation methods have been unsuccessful. The aim of this study was to analyze the results of NNS in patients with an inaccessible common bile duct (difficult cannulation) using standard techniques in endoscopic retrograde cholangiopancreatography and the factors associated with the success of this procedure and complications.

MATERIAL AND METHODS

We performed a prospective study of 72 patients who underwent NKS performed by the same endoscopist (J.E.) because of difficult cannulation of the common bile duct between January 1998 and December 2004. The results were analyzed in terms of successful biliary access, whether this was achieved in one or more sessions, its possible association with the underlying disease, and the incidence and severity of complications.

RESULTS

Seventy-two NKS were performed from a total of 1062 sphincterotomies (6.7%). A total of 77.7% of the patients underwent prior implantation of a pancreatic prosthesis (NKS-PP). The final diagnosis was: choledocholithiasis (31.9%), cancer of the pancreas (16.6%), cholangiocarcinoma (13.8%), benign stenosis (8.3%), dysfunction of the sphincter of Oddi (6.9%), normal (6.9%), and miscellaneous (13.8%). Cannulation was successful in 87.5% (63/72), and was achieved in the first session in 73% (46/63). Biliary access was achieved in 72.7% of patients (16/22) with biliopancreatic neoplasms versus 94% (47/50) of those with other diagnoses (p = 0.03). Eleven patients (15.2%) presented 12 complications (16.6%) (6 pancreatitis, 4 cholangitis, 1 papillary hemorrhage, and 1 portal vein filling). The use of a pancreatic prosthesis was related to a higher success rate and significantly fewer complications (p = 0.03).

CONCLUSIONS

NKS-PP can be a safe procedure in patients with difficult cannulation of the common bile duct. The presence of biliopancreatic neoplasm is a risk factor for failure to achieve biliary access compared with other diagnoses. The complication rate was similar to that found in other studies. No cases of severe pancreatitis or perforations were found.

Decreased distribution of nitric oxide synthase and vasoactive intestinal polypeptide positive nerve cells in the sphincter of Oddi in humans with pancreatobiliary diseases

To better understand the relationship between innervation in the sphincter of Oddi and pancreatobiliary diseases, nerve cells which possess nitric oxide synthase (NOS) and/or vasoactive intestinal polypeptide (VIP) were studied immunohistochemically in the sphincter of Oddi and duodenum of humans. Specimens from autopsies included 11 cases with pancreatobiliary diseases and 7 cases without such diseases. An elaborate nerve network was revealed with an anti-S-100 antibody in the sphincter of Oddi and duodenum of all specimens. In the sphincter of Oddi of the control group, approximately 47% of the myenteric nerve cells were NOS positive, whereas 54% were VIP positive. Of the NOS positive nerve cells, 21% were also VIP positive. In contrast, 11% of the nerve cells in the sphincter of Oddi of the disease group were NOS positive while 32% were VIP positive. Within the duodenal myenteric plexus of the control group, 35% of all nerve cells were NOS positive while 40% was VIP positive; among them, 23% of the NOS positive cells were VIP positive. Similar results were observed in the duodenum of the disease group. These data indicate that abundant NOS and VIP positive innervation is present in the sphincter of Oddi and duodenum in humans. The lower proportion of NOS positive or VIP positive nerve cells of the disease group may suggest an inadequacy of the sphincter of Oddi to relax.

Periampullary Tumors: High-Spatial-Resolution MR Imaging and Histopathologic Findings in Ampullary Region Specimens

PURPOSE

To prospectively determine the magnetic resonance (MR) signal intensity characteristics of structures of the ampullary region and to assess the potential use of MR imaging in evaluation of the extent of periampullary tumors in resected specimens.

MATERIALS AND METHODS

Twenty-five specimens from the ampullary region obtained in four autopsy cases without periampullary tumors and in 21 patients with periampullary tumors were examined with a 1.5-T MR system and a circular surface coil with 5-inch (12.7-cm) diameter. High-spatial-resolution MR images were obtained with field of view of 100 x 100 mm, matrix of 256 x 256 or 512 x 256, and section thickness of 2 mm. MR imaging findings were compared with histopathologic findings. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of high-spatial-resolution MR imaging for assessment of tumor invasion into surrounding tissues were evaluated by two radiologists.

RESULTS

T1- and T2-weighted MR images clearly depicted normal structures in the ampullary region that included Oddi muscle, duodenal wall, common bile duct, and pancreas; these findings corresponded well with histologic findings. In 20 (95%) of 21 tumors, high-spatial-resolution MR imaging depicted location and extension of periampullary tumors precisely. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of high-spatial-resolution MR imaging for assessment of tumor invasion into surrounding tissue were 88%, 100%, 96%, 100%, and 94%, respectively.

CONCLUSION

In this study, MR imaging correctly depicted location, extension, and origin of tumor. High-spatial-resolution MR imaging has potential for presurgical staging of tumors in this region.

[Functional dyskinesis of bile excretory ducts: clinical significance and its correction]

Our study has shown the clinical significance of treating of a gall-bladder hypomotor dyskinesia and hypertone of the Oddi's sphincter. Hypomotor dysfunction of gall bladder occurs in 24% patients with cholelithiasis and after a remote lithotripsy in 62.5%, 50% of patients with stenosis of Oddi's sphincter have microcholelithiasis (MCL) and 100% of patients have "sludge".

Sphincter of Oddi dysfunction

Biliary-like pain alone, or associated with a transient increase in liver or pancreatic enzyme, may be the clinical manifestations of sphincter of Oddi dysfunction. Since it is not always possible to dissociate functional conditions from subtle structural changes, the term sphincter of Oddi dysfunction is used to define motility abnormalities caused by 'sphincter of Oddi stenosis' and 'sphincter of Oddi dyskinesia'. Both sphincter of Oddi stenosis and sphincter of Oddi dyskinesia may account for obstruction to flow through the sphincter of Oddi and may thus induce retention of bile in the biliary tree and pancreatic juice in the pancreatic duct. Most of the clinical information concerning sphincter of Oddi dysfunction refers to post-cholecystectomy patients who have been arbitrarily classified according to clinical presentation, laboratory results and endoscopic retrograde cholangiopancreatography findings in: (a) biliary type I, (b) biliary type II, and (c) biliary type III. Prevalence of biliary-type of pain has been reported to vary from 1 to 1.5% in unselected postcholecystectomy people, to 14% in a selected group of patients complaining of postcholecystectomy symptoms. The frequency of sphincter of Oddi dysfunction, as shown by manometry, differs in the different clinical subgroups: 65-95% in biliary group I, mainly due to sphincter of Oddi stenosis; 50-63% in biliary type II, and 12-28% in biliary type III. In patients with idiopathic recurrent pancreatitis, sphincter of Oddi dysfunction varies from 39 to 90%. Diagnostic work-up of postcholecystectomy patients for suspected sphincter of Oddi dysfunction includes liver biochemistry and pancreatic enzymes, plus negative findings of structural abnormalities. Usually, this would include transabdominal ultrasound and endoscopic retrograde cholangiopancreatography. Depending on the available resources, endoscopic ultrasound and magnetic resonance cholangiography may precede endoscopic retrograde cholangiopancreatography in specific clinical conditions. Quantitative evaluation of bile transit from the hepatic hilum to the duodenum at choledochoscintigraphy appears valuable in the decision to undertake sphincter of Oddi manometry or to treat. Sphincterotomy is the standard treatment for sphincter of Oddi dysfunction. In biliary type I patients, the indication for endoscopic sphincterotomy is straightforward without the need of any additional investigation. Slow bile transit in biliary type II is an indication to undergo endoscopic sphincterotomy without sphincter of Oddi manometry. Slow bile transit in biliary type III patients is an indication to perform sphincter of Oddi manometry. Diagnostic work-up of patients with gallbladder in situ is part of the same diagnostic algorithm that has initially excluded the presence of a gallbladder dysfunction.

Acute recurrent pancreatitis

History, physical examination, simple laboratory and radiological tests, and endoscopic retrograde cholangiopancreatography (ERCP) are able to establish the cause of recurrent acute pancreatitis in 70% to 90% of patients. Dysfunction of the biliary and/or pancreatic sphincter, as identified by sphincter of Oddi manometry, accounts for the majority of the remaining cases. The diagnosis may be missed if the pancreatic sphincter is not evaluated. Pancreas divisum is a prevalent congenital abnormality that is usually innocuous but can lead to recurrent attacks of acute pancreatitis or abdominal pain. In select cases, endoscopic sphincterotomy of the minor papilla can provide relief of symptoms and prevent further attacks. A small proportion of patients with idiopathic pancreatitis have tiny stones in the common bile duct (microlithiasis). Crystals can be visualized during microscopic analysis of bile that is aspirated at the time of ERCP. Neoplasia is a rare cause of pancreatitis, and the diagnosis can usually be established by computerized tomography or ERCP. A wide variety of medications can also cause recurrent pancreatitis. ERCP, sphincter of Oddi manometry, and microscopy of aspirated bile should be undertaken in patients with recurrent pancreatitis in whom the diagnosis is not obvious.

[Sphincter of Oddi dysfunction--prolonged medical therapy or early endoscopic sphincter ablation]

INTRODUCTION

Sphincter of Oddi dysfunction is a real challenge from both diagnostic and therapeutic point of view.

PATIENTS AND METHODS

In the last two years the authors have performed ERCP and EST in 29 patients with positive evocative test results, who had important enzyme elevations and/or did not respond to prolonged medical treatment.

RESULTS

Endoscopic findings were positive in 25/29 patients (86.2%): 8 adenoma of p. Vateri, 17 papillitis were identified, and in 4 cases the papilla was intact. Histopathology obtained in 12 patients supported the diagnosis. In 6 patients, who underwent a postpapillotomy evocative test, after an average of 10 months follow up the results have been converted from positive to negative response in all but two cases. The two patients continued to have abdominal symptoms with persistent positive provocation tests because of restenosis, were treated with repapillotomy.

CONCLUSIONS

The Debray and Nardi tests are useful screening tests for hypertonic biliary or pancreatic dyskinesia. Structural endoscopic and histological findings are frequent already in the functional cases. Early sphincter ablation should be considered in failure of medical therapy for preventing the transformation of this functional disorder into an organic, potentially precancerous state.

Laparoscopic transcystic sphincter of Oddi manometry is not affected by carbon dioxide pneumoperitoneum

Sphincter of Oddi (SO) dysfunction as a potential cause of chronic acalculous cholecystitis (CAC) has not been studied in cases for which intraoperative SO manometry was used during laparoscopic cholecystectomy. In this study, we evaluated the effects of carbon dioxide pneumoperitoneum on laparoscopic transcystic SO manometry. In 27 patients with CAC, transcystic SO manometry had been attempted during laparoscopic cholecystectomy. The mean age of the patients was 46 years (range, 22-71). Complete manometric data sets were obtained in 18 patients. The mean SO pressure, phasic SO pressure, and phasic frequency were 35.4 +/- 29.1 mm/Hg versus 30.8 +/- 23.8 mm/Hg, 104.8 +/- 63.0 mm/Hg versus 73.6 +/- 34.6 mm/Hg, and 2.1 +/- 1.8 contractions/min versus 2.8 +/- 3.4 contractions/min with and without pneumoperitoneum, respectively. All differences were nonsignificant (P > 0.05). Two complications (7.4%) were observed: pancreatitis and jaundice. SO manometry is not affected by CO2 pneumoperitoneum. It may be used to study SO motility in patients with CAC.

[Clinical difficulties and errors in making a diagnosis of chronic papillo-odditis]

138 patients with chronic papillooditis were investigated, 15 of them in a stage of decompensation. In 83.3% of the cases, the diagnosis was not clinically determined (including 68 of 92 endoscoped before their hospitalization--82.9%). 34 patients were diagnosed as having chronic gastroduodenitis, 15--ulcer, 42--chronic cholecystitis, 11--chronic pancreatitis, 4--cholangitis, 9--postcholecystectomic status. All these diseases developed simultaneously with the papillitis. In a second endoscopic check-up with an examination of papilla Vateri, the patients were in all the cases diagnosed without difficulties and the diagnose was confirmed by biopsy. In 21 patients there was confirmed primary papillooditis and in 127--accompanying disorders: chr. gastroduodenitis--29, chr. atrophic gastritis--18, ulcer--15, chr. cholecystitis--42, postcholecystectomic status--9, choledocholithiasis--14, chr. pancreatitis--11. Most often misdiagnosis occurs if: 1) during the routine endoscopic investigation the endoscopist does not examine papilla of Vater; 2) chr. papillitis exists simultaneously with one of the already mentioned diseases that are easier of approach for diagnostics and explanation of the disorders; 3) the clinical picture of papillitis cannot be differentiated from the one of the basic or accompanying disease; 4) the bile drainage is not prevented; 5) the result of the venous biligraphy does not lead to the diagnosis and ERCP is carried out only in a case of a clinical suspicion.

Sphincter of Oddi function and dysfunction

The sphincter of Oddi (SO) is situated at the junction of the bile and pancreatic ducts where they enter the duodenum, and it serves to regulate the flow of bile and pancreatic juices as well as to prevent the reflux of duodenal contents into the pancreatobiliary system. SO dysfunction relates to either the biliary or pancreatic portions of the sphincter. Distinct clinical syndromes relating to either sphincter segment are recognized. The mechanism of dysfunction remains uncertain, but disruption of neural pathways involved in sphincter function seems likely. SO dysfunction is best diagnosed by manometry, which is able to correctly stratify patient groups and determine therapy. Biliary scintigraphy, which is noninvasive, has shown promise as a screening tool for patients with suspected SO dysfunction. Division of the sphincter is an effective treatment for patients with manometrically proven SO stenosis for either the biliary or pancreatic form of the disorder. Other forms of SO dysfunction may benefit from pharmacotherapy.

Ampulla of Vater. Anatomic, embryologic, and surgical aspects

The region of the ampulla of Vater constitutes a complex anatomic and functional entity, the biliopancreaticoduodenal confluence, of which the essentials of this rapid review are the: Variation in site of implantation of the greater duodenal papilla, whereas the relations between the common bile duct and the main pancreatic duct are relatively constant Presence at this site of a weak point in the duodenal wall, commonly the site of mucosal diverticula Interdependence of the parietal duodenal mucosa and the sphincteric system of Oddi Existence of an extramural zone of this sphincter, which should be the only one involved in sphincterotomy Danger of wide excisions of the papilla, which, apart from the risk for hemorrhage, cause a breach of the digestive barrier The ampulla of Vater corresponds to the dilated junction of the common bile duct and main pancreatic duct, if present. The ampulla is an extensive anatomic and functional region that includes not only the choledochopancreatic junction but also the sphincter of Oddi, the whole traversing the duodenal wall to open at the greater duodenal papilla. The chief anatomic features of this biliopancreaticoduodenal junction have been reviewed, forming the basis of techniques of surgical or endoscopic sphincterotomies and localized excisions of vaterian tumors.

Feasibility of stent placement above the sphincter of Oddi ("inside-stent") for patients with malignant biliary obstruction

BACKGROUND AND STUDY AIMS

Animal studies suggest that placement of endobiliary stents wholly above the papilla (the "inside-stent") prolongs the duration of stent patency. We reviewed the cholangiographic characteristics of patients with malignant obstructive jaundice in order to evaluate the feasibility of this approach and to assist in the design of a new stent.

PATIENTS AND METHODS

A review was conducted of 270 patients who had undergone endoscopic retrograde cholangiopancreatography (ERCP) for malignant obstructive jaundice at our hospital, to determine the relative frequencies of the types of cancers. The ERCP films of 59 relevant consecutive patients with malignant obstructive jaundice were studied to determine the length of the stricture, the distance between the stricture and the papilla, and the angulation of the common duct.

RESULTS

The most frequent primary cancers causing malignant obstructive jaundice were pancreatic cancer (57%), biliary cancer involving the hilum (19%, including metastatic disease), nonhilar biliary cancer (14%), and papillary cancer (10%). The length between the lower end of the stricture and the sphincter was more than 2 cm for all hilar biliary cancer, representing two-thirds of nonhilar biliary cancer cases, while it was less than 1 cm for most pancreatic cancers. There was an average angulation of 30-40 degrees in the axis of the distal common bile duct.

CONCLUSIONS

For most biliary cancers, the stricture is high enough to allow the placement of a stent fully above the papilla, but this is not possible for most pancreatic cancers (or any papillary cancers). An "inside-stent" approach would be possible in about one-third of patients with malignant obstructive jaundice if a clearance length of over 2 cm between the stricture and the sphincter is required, and in about 45% of patients if a minimum clearance of 1 cm is required. A 30-40 degrees flexion in the distal part of the stent would approximate the average angulation in the axis of the common bile duct and help to prevent dislocation.

Two unusual cases of postcholecystectomy pain

I report on two patients who were initially diagnosed with sphincter of Oddi dysfunction (S.O.D.) because of postcholecystectomy pain in the right upper quadrant; both had other causes of pain. One patient had an aberrant hepatic duct that drained into a remnant of the cystic duct resulting in formation of stones. The second patient had adhesions of the stomach to the liver with the ligamentum teres bowing across the antrum. Gastroenterologists and endoscopic surgeons should be aware of causes of postcholecystectomy pain that are unrelated to sphincter of Oddi dysfunction.

Biliary manometry, bacterial characteristics, bile composition, and histologic changes fifteen to seventeen years after endoscopic sphincterotomy

AIM

To evaluate the function of the biliary sphincter 15 to 17 years after endoscopic sphincterotomy and to investigate if loss of sphincter function is associated with bacterial colonization, changes in bile composition, or inflammation of the biliary system.

METHODS

Eight patients who had undergone endoscopic sphincterotomy for bile duct stones 15 to 17 years previously underwent ERCP with biliary manometry, bile sampling, and biopsy. Manometry was performed using a perfused triple-lumen manometry catheter and a station pull-through technique. Bile samples were cultured and analyzed for biliary lipids, bile salts, bacterial beta-glucuronidase, and phospholipase A2. Biopsy specimens were taken from the proximal common heptic duct for histologic examination.

RESULTS

Manometry demonstrated absent basal sphincter pressure and no choledochoduodenal pressure gradient in all patients. Phasic contractions were observed in two patients. Cholangiography showed stones in one patient. Positive cultures were obtained in three patients, including the patient with stones. All bile samples showed a high content of biliary lipids and cholesterol. Some samples contained considerable amounts of hydrophobic bile salts. Five samples contained very high levels of phospholipase A2 activity. Significant bacterial beta-glucuronidase activity was found in one patient, the patient with stones. Biopsy specimens of the proximal common hepatic duct in three patients showed chronic inflammation with fibrosis and reactive epithelial changes.

CONCLUSIONS

After endoscopic sphincterotomy for bile duct stones, the function of the biliary sphincter is permanently lost. This is associated with bacterial colonization, presence of cytotoxic components in the bile, and chronic inflammation of the biliary system.

Long-term clinical outcome of post-cholecystectomy patients with biliary-type pain: results of manometry, non-invasive techniques and endoscopic sphincterotomy

OBJECTIVE

The purpose of the present study was to investigate prospectively the value of manometry, non-invasive techniques and endoscopic sphincterotomy in biliary type II and III patients with suspected sphincter of Oddi dysfunction.

METHODS

All patients (n = 31) had undergone a cholecystectomy from 1 to 45 years before entry into the study, and had a history of biliary-type pain ranging from 4 to 156 months. In a primary diagnostic work-up, including ERCP, other causes of gastrointestinal disease were excluded. The width of the common bile duct, pain induced by the injection of contrast medium into the common bile duct, delayed contrast drainage and the results of a morphine-neostigmine test were analysed. Manometric measurements of basal sphincter of Oddi pressure were performed. Twenty-three patients with an elevated basal pressure (> 40 mmHg) underwent endoscopic sphincterotomy.

RESULTS

During the follow-up period (8-62 months) 83% of the patients became symptom free or experienced an improvement. Basal sphincter of Oddi pressure and long-term clinical outcome of patients correlated to different degrees with the results of non-invasive techniques.

CONCLUSIONS

Our data suggest that endoscopic sphincterotomy may be an effective therapeutic modality in group II and III patients with sphincter of Oddi dysfunction in whom other gastrointestinal disorders have previously been excluded.

Clinicopathological characteristics and surgical procedures for carcinoma of the papilla of Vater

BACKGROUND/AIMS

In the present study, clinicopathological characteristics of carcinoma of the papilla of Vater and suitable operative procedures for treatment were investigated.

MATERIAL AND METHODS

Sixty cases (40 male and 20 female) of resected carcinoma of the papilla of Vater were studied clinicopathologically.

RESULTS

Among the patients, a polypoid type without ulceration and an ulcer-formation type, with regard to the gross appearance, were found in 37 cases and 23 cases, respectively. Submucosal invasion, invasion to the sphincter Oddi, pancreatic parenchymal invasion and lymph node involvement were found more frequently in the ulcer-formation type than in the polypoid type without ulceration. Postoperative survival curves revealed that the prognosis was poor when either lymph node involvement, invasion to pancreatic parenchyma or ulcer formation was found. Local resection was performed in seven cases, in all of whom carcinoma was found histologically in the cut surface of the tumor. This is easily explained by the fact that mucosal spread or interstitial infiltration was frequently found even in cases with carcinoma at a relatively early stage.

CONCLUSIONS

Local resection for carcinoma of the papilla of Vater is inadequate as a curative resection, and pylorus-preserving pancreatoduodenectomy should be the treatment of choice for carcinoma of the papilla of Vater. However, since there were no differences between the postoperative survival curves of patients who underwent pancreatoduodenectomy or local resection, local resection may still be suitable for patients with other major diseases or a poor condition.

Long-term follow-up of endoscopic retrograde cholangiopancreatography sphincterotomy for patients with acquired immune deficiency syndrome papillary stenosis

PURPOSE

To evaluate the long-term effects on biliary-type pain and changes in biochemical parameters in patients with AIDS-associated papillary stenosis who underwent endoscopic retrograde cholangiopancreatography (ERCP) sphincterotomy.

PATIENTS AND METHODS

Twenty-five consecutive patients were diagnosed by cholangiography with AIDS-associated papillary stenosis using standard criteria. Patients underwent ERCP sphincterotomy and were followed prospectively in the Gastrointestinal or Liver Clinics, San Francisco General Hospital, and by their primary physicians. Post-procedure data was prospectively collected by chart review or in-person or telephone interview, and analyzed using statistical software.

RESULTS

All patients presented with severe right upper quadrant and/or mid-epigastric abdominal pain and had marked elevations of serum alkaline phosphatase. Following ERCP sphincterotomy, pain scores decreased significantly for at least 9 months of follow-up. Serum alkaline phosphatase levels, however, remained essentially unchanged. Overall quality of life was difficult to assess, as patients suffered from other AIDS-associated debilitating diseases.

CONCLUSIONS

ERCP sphincterotomy, while not without risks, provided significant reduction in pain in patients with AIDS-associated papillary stenosis.

Sphincter of Oddi dysfunction caused by an ampullary neoplasm

The case of a 50-year-old man with abdominal pain and abnormal liver test results is described. Endoscopic retrograde cholangiopancreatography with manometric studies showed biliary dilatation, poor ductal drainage, and sphincter of Oddi dysfunction. Clinical and radiographic clues suggested the possibility of an ampullary lesion; a small ampullary adenoma was detected after endoscopic sphincterotomy, and ampullary carcinoma was found in the operative specimen. Malignancy can cause sphincter dysfunction not only in the esophagus (as pseudoachalasia) but in the ampulla of Vater as well.

Balloon dilatation of the sphincter of Oddi facilitates passage of glass beads from the canine biliary tract

Laparoscopic management of common duct stones is increasing. The most widely used technique involves trans-cystic duct scope placement and stone extraction. Occasionally, stones cannot be retrieved and are allowed to pass spontaneously after manipulation of the sphincter of Oddi. This study examines a model of sphincter of Oddi dilatation in the dog to facilitate passage of glass beads simulating gallstones. In 24 dogs, glass beads of varying sizes (3-8 mm) were implanted in the gallbladder and allowed to pass spontaneously over 1 month. In three separate groups, these animals underwent (1) sham instrumentation of the sphincter of Oddi (control), (2) sphincter dilatation with balloon catheters, or (3) transduodenal sphincterotomy. At the end of 1 month, all the animals were autopsied, and the glass beads were retrieved. Histologic sections of the pancreas were examined for possible pancreatitis. The results of this study show that no animal experienced pancreatitis from sphincter manipulation or the passage of glass beads. The control animals who underwent sham manipulation of the sphincter passed 10% of their glass beads. In contrast, after sphincter dilatation, 52.5% of the 3-mm glass beads passed or 22% of all size beads. Animals with sphincterotomy passed a similar amount of glass beads as those with balloon dilatation. These studies suggest that balloon dilatation is as efficacious as sphincterotomy in facilitating the passage of glass beads from the canine biliary tract.

Pancreaticobiliary long common channel syndrome and congenital anomalous dilatation of the choledochal duct--study of 46 patients

Retrospectively evaluated clinical, radiological and anatomical findings of 46 patients with tubular or cystic dilated choledochal ducts indicate the following conclusion: Pathological stricture of the sphincter of Oddi system, including a hypertrophic and spastic portion of the sphincter choledochus inferior, called "narrow segment", raises the pressure in the choledochal duct to pathological levels and consequently causes a dilatation of the duct during a specific embryonic phase. Such a pathological sphincter of Oddi system develops if a long common channel persists as the result of a disturbance in the development of the distal choledochal and pancreatic duct. This statement contradicts the classical conception which assumes that a reflux of pancreatic juice into the choledochal duct causes ductal dilatation. Authors who are in favor of this conception propose that pancreatic juice causes weakness of the ductal wall, which may be dilated in the embryonic period. However, the findings of the series evaluated here show that dilatation of the duct may also originate without any reflux of pancreatic juice into the choledochal duct if a "narrow segment" exists above the junction of the pancreatic and choledochal ducts. For this reason, pancreatic juice reflux cannot be the condition sine qua non in the development of choledochal duct dilatation. Similarly the pathologic junction angulation can only be an optional factor in this autogenetic anomaly. With regard to a pathological sphincter of Oddi system the question arises whether a partial or complete myotomy of the muscular sphincter may be able to remedy the dilatation and avoid resection of the choledochal duct.(ABSTRACT TRUNCATED AT 250 WORDS)

Periampullary carcinoma with special reference to their mucin characteristics--a pathologic study of 53 cases

Histological features and mucin characteristics of 53 cases of periampullary carcinoma, a rare group of epithelial tumors is presented. The cases comprised of 17 resected specimens and 36 endoscopic biopsies. Jaundice was the commonest symptom. The mean tumor size was 2 cms diameter (1-6 cms). Forty cases were characterised as well differentiated adenocarcinoma, 5 as moderately differentiated adenocarcinoma, 5 as mucin secreting adenocarcinoma, 3 as papillary adenocarcinoma and 1 as undifferentiated carcinoma. Desmoplasia and insignificant mitosis were amongst the commonly encountered histological features. Forty four cases (83%) stained positive for mucin (PAS-AB) with a majority of them (66%) predominantly showing acidic mucin. The likely prognostic implication of this feature is discussed.

[Relationship between an involvement of Oddi's sphincter in a choledochopancreatic junction and clinical appearances in 120 patients with anomalous arrangement of the pancreatico-biliary ductal system]

We studied relationship between an involvement of Oddi's sphincter in a choledochopancreatic junction and clinical appearances in 120 patients with anomalous arrangement of the pancreaticobiliary ductal system. The 120 composed of 83 with a sphincteric mechanism at the junction of the common bile and pancreatic duct and 37 without the sphincteric mechanism. We found that influences of sphincteric mechanism at the junction closely related to the length of the common duct between an orifice of the papilla of Vater and a junction of the common bile and pancreatic duct. And in all 83 with a sphincteric mechanism at the junction the length of the common duct showed less than 1.5 cm, and in all 37 without a sphincteric mechanism at the junction the common duct showed more than 1.5 cm in length. There was no correlation between a distribution of the sphincter muscle and clinical appearances, association with congenital choledochal cyst, cholelithiasis and bile duct cancer in the 120 patients.

[A point about obstructive non-neoplastic pathology of the duodeno-biliary-pancreatic junction]

Various benign pathological conditions of Oddi's sphincter may give origin to clinical manifestations due to hindrances to biliary flow into the duodenum; the hypertonic dyskinesia, proper, odditis and fibrosclerotic dystrophies. Such forms develop very big problems from a diagnostic and therapeutical point of view, even if an adequate therapy permits in most cases to reach definite results. Therapy in inflammatory forms (odditis) must be first of all of medical type; only when these are changing into fibrosclerotic forms or are manifest in an acute way it is meet to proceed surgically on the sphincter. The action on the sphincter, either by means of endoscopy or surgery, is performed with caution in the forms of hypertonic dyskinesia (only when such forms are going on and have had a long duration, or even resistant to any pharmacological therapy) because of the high percentage of painful recurrences. The cutting of Oddi's sphincter is on the contrary the first therapeutical choice in the fibrosclerotic forms, with immediate success on the symptoms and the results in the long run are optimal.

[Odditis. Pathologic reality or tactics necessity]

In 14 patients with secondary odditis, a biopsy of the papilla was studied, in one case encountering moderate peri and intrafascicular fibrosis and in another, erosion of the papillary mucosa with impaction of biliary material. In 6 biopsies obtained from patients with perforated liver cysticerocosis, submucosal edema of the biliary tree was observed in only 3. On the basis of these studies an analysis is made of the different percentages published, which are highly variable, and results are compared to those reported in larger series. Papillary affectation in lithiasis was related to trauma produced by impaction or expulsion of calculi and the indications for realization of sphincteroplasty or biliodigestive derivation are listed, showing a tendency toward a progressively greater restriction of surgery. The absence of sphincter disease in hepatic cysticercosis perforated into the biliary tract is signalled, the only alterations being edema, which is reversible with treatment of cysticercosis.

Papillary stenosis

The present state of papillary stenosis is reviewed. ERCP manometry has become the most important means of evaluating sphincter of Oddi dynamics. Pressure measurements in the sphincter segment appear useful to differentiate patients with sphincter of Oddi dysfunction from patients with an organic stenosis. The author's experience with sphincter of Oddi manometry, with endoscopic sphincterotomy and hydrostatic balloon dilation of the sphincter of Oddi, and the results of an international inquiry, are presented.

Manometric measurement of human sphincter of Oddi length

Length of biliary (CBD) and/or pancreatic (PD) sphincter of Oddi (SO) was measured during perendoscopic or intraoperative manometry in 21 control subjects and in 46 patients with biliary disease. When the high resting pressure (HPZ) and the phasic wave zone (PAZ) were considered, SO length was, in the control group, 9.5 +/- 0.5 mm (M +/- SE) and 9.4 +/- 0.6 mm at the level of the CBD-SO, and 7.7 +/- 0.6 mm and 6.9 +/- 0.5 mm at the level of the PD-SO. The physiological sphincter length appeared substantially shorter than the anatomical one, as reported in the literature. No significant differences were found between controls and patients with CBD stones. Endoscopic sphincterotomy without manometry reduced mean sphincter length length of the sphincterotomy was tailored to the manometric findings. Surgical partial sphincterotomy reduced sphincter length by only 46.7 +/- 10.3%.

[Lesions of the area of Oddi's sphincter: incidence and association with biliary and pancreatic lesions in a series of 109 autopsies]

One hundred and nine successive post mortem examinations have been performed with a peculiar attention to the gross and microscopic features of the sphincter of Oddi. Biliary lesions were present in 24 cases and pancreatic lesions in 7 cases. According to previous histologic descriptions, a group of 18 pathologic sphincters of Oddi was selected. Biliary lesions were not more common in this group (28 p. 100) than in the group with a normal sphincter of Oddi (21 p. 100) and inversely, there were no more lesions of the sphincter of Oddi in the group with biliary lesions (21 p. 100) than in the group without biliary lesions (15 p. 100). Chronic pancreatitis was more frequently associated with an abnormal sphincter of Oddi, but in these cases, another associated disease could explain pancreatitis (alcoholism, hemochromatosis). Pathologic lesions of the sphincter of Oddi are frequent and usually latent. These features are not simple anatomic variations because five cases were undoubtedly pathologic with an important thickening of the sphincter and a fibro-adenomatosic pattern. This study shows that sclerosing odditis does exist but is rare.