Sphincter of Oddi dysfunction: results of treatment by endoscopic sphincterotomy

From a consecutive series of 451 patients with post-cholecystectomy symptoms referred for endoscopic retrograde cholangiopancreatography (ERCP), 40 (9 per cent) were diagnosed as having sphincter of Oddi dysfunction. Eight patients were excluded from the study because of incomplete data (n = 6) or additional diagnoses (n = 2). Thirty of the patients had successful ERCP and endoscopic sphincterotomy (ES); this failed in the remaining two because of severe papillary stenosis (6.3 per cent). Endoscopic biliary manometry was performed in 23 patients (77 per cent). Immediate post-ES complications occurred in eight patients (25 per cent). At a median follow-up of 46 months (range 10-88 months) 19 patients had a good outcome (63.3 per cent) and 11 patients had a poor outcome (36.7 per cent). Patients with a good outcome tended to have a delay of months or years following cholecystectomy before the development of symptoms (median 6 years versus 0 years, P = 0.0003). At ERCP, patients with a good outcome had greater common bile duct diameters (mean +/- s.d. mm, 12.6 +/- 3.6 versus 8.8 +/- 1.8, P = 0.0003) and delayed drainage from the biliary tree of injected contrast (13 versus 2 patients, P = 0.02). Endoscopic biliary manometry was abnormal in all 15 patients with a good outcome in whom it was performed but in only 3 out of 8 patients with a poor outcome (P = 0.003). Sphincter of Oddi dysfunction is an important, albeit uncommon, cause of post-cholecystectomy symptoms. ES provides symptomatic relief in the majority of patients but improved criteria for predicting outcome are required.

Invasive amoebiasis: an unusual presentation

A 63 year old Asian woman who presented with three week's abdominal pain was found to have a hard right iliac fossa mass and rectal ulceration. Profuse rectal bleeding necessitated a laparotomy. An inflammatory paracaecal mass with fistulae involving appendix, small bowel, and bladder was excised with exteriorisation of the bowel ends. Microscopy showed invasive amoebae. Re-anastomosis was successfully done after treatment with metronidazole and diloxanide. There are no previous reports of a paracaecal amoeboma with fistulae to either the appendix, or urinary bladder.

Role of duodenal bile crystal analysis in the investigation of 'idiopathic' pancreatitis

Duodenal bile crystal analysis for the detection of gallstones was assessed in 26 patients with acute pancreatitis of known aetiology (11 attributable to gallstones and 15 to alcohol) and in 37 patients without a history of acute pancreatitis (21 with gallstones and 16 without). The sensitivity was 64-67 per cent and the specificity was 94-100 per cent in these groups. Analysis of duodenal bile from 14 patients with 'idiopathic' pancreatitis revealed calcium bilirubinate crystals (but not cholesterol crystals) in 5 patients (36 per cent). Gallstones were confirmed at cholecystectomy in three of these patients and also in one other patient who had a gallstone on a 'late' ultrasound examination but was negative for crystals. Thus 29 per cent of the original 'idiopathic' group had gallstones confirmed. Gallstone analysis showed that pigment stones were present in 7 of 31 (23 per cent) non-pancreatitis controls compared with 9 of 13 (69 per cent) pancreatitis patients (P = 0.0048). These results suggest that duodenal bile crystal analysis (involving both calcium bilirubinate and cholesterol crystals) may be a useful technique for the investigation of patients with 'idiopathic' pancreatitis.

Long-term survival after resection of ampullary carcinoma is associated independently with tumor grade and a new staging classification that assesses local invasiveness

Long-term survival characteristics after resection for ampullary carcinoma are documented poorly. We have reviewed the clinical and histopathologic features of 23 long-term survivors who underwent resections between 1972 and 1984 (5-year survival rate, 52.1%). Twenty patients (87%) had intestinal type tumors and only two (9%) had papillary tumors. Associated adenomata were present in eight cases (35%) and distant ductular dysplasia was present in nine cases (39%). Long-term survival was correlated independently with tumor grade (P = 0.0031) and a new staging system that assesses local invasiveness (P = 0.0055). No correlation was found between survival and sex, tumor size, or presence of adenoma. Age was significant in univariate analysis (P = 0.0322) but not in multivariate analysis. A simple scoring system based on the grade and stage increased the predictability of survival (P = 0.0004). Application of this scoring system may allow an objective comparison of long-term survival results after resection from different series.

Biochemical prediction of gallstones in acute pancreatitis: a prospective study of three systems

Three clinicobiochemical systems have been proposed for predicting gallstones in acute pancreatitis based on one, three and five factors respectively, but have not been compared in a single prospective study. System 1 is based on the serum transaminase alone; system 2 uses alkaline phosphatase and bilirubin in addition to transaminase; and system 3 involves female gender, age, amylase and alkaline phosphatase in addition to transaminase. Over the 4-year period 1983-86, 368 patients with 391 episodes of acute pancreatitis had clinicobiochemical analysis within 48 h. Of these episodes, 220 were related to gallstones (56 per cent), 62 to alcohol (16 per cent) and 109 to other aetiologies or were idiopathic (28 per cent). Significant differences were found between the biliary and non-biliary groups with respect to sex (139 versus 59 women, P less than 0.002), age (65 +/- 17 versus 52 +/- 19 years, P less than 0.0001) and serum amylase (6041 +/- 6335 versus 4546 +/- 3990 units/l, P less than 0.0001), alkaline phosphatase (257 +/- 225 versus 141 +/- 137 units/l, P less than 0.0001), alanine transaminase (221 +/- 227 versus 72 +/- 119 units/l, P less than 0.0001) and bilirubin (40 +/- 39 versus 24 +/- 30 mumol/l, P = 0.0001). The sensitivity and specificity was 75 per cent and 74 per cent for the one-factor system, 74 per cent and 78 per cent for the three-factor system and 62 per cent and 80 per cent for the five-factor system. The predictive value of a positive result was 78.8 per cent, 81.5 per cent and 80.1 per cent and of a negative result 69.4 per cent, 70.1 per cent and 62.3 per cent for the three systems respectively. The performances of the one- and three-factor systems were marginally better than that of the five-factor system; the one-factor system, however, had the advantage of simplicity.

The histopathology and staging of carcinoma of the ampulla of Vater

Review of 26 resected ampullary carcinomas revealed intestinal type adenocarcinoma in all but one and overtly papillary carcinoma in only one case. Co-existing adenoma of the ampulla was present in 11 cases, over half of which were low-grade carcinomas. Flat duct epithelial dysplasia was present in a further eight cases, the adenocarcinoma in only two of these being well differentiated. The estimated 5 year survival rate, overall, was 52% and, with well differentiated adenocarcinoma, 75%. We recommend a new staging system, based on extent of local and lymph node spread: I = invasion confined to wall of common bile duct; II = infiltration of duodenal or retroperitoneal tissues, excluding pancreas; III = infiltration of pancreas; IV = metastasis to nearby lymph nodes. Long-term survival correlates inversely with stage, both by univariate analysis and independently of grade, so that a simple scoring system, based on a combination of both grade and stage, is an excellent predictor of the long-term outcome, defining two groups, with 5 year survival rates of 79% and 0% (P less than 0.001).

Endoscopic sphincterotomy for common bile duct calculi in patients with gall bladder in situ considered unfit for surgery

Endoscopic sphincterotomy (ES) was attempted in 106 patients with common bile duct (CBD) calculi and gall bladders present, who were considered unfit for surgery on the grounds of age and frailty alone (35%) and/or the presence of major medical problems (65%). Endoscopic sphincterotomy was successful in 105 patients (99%). Early ES related complications occurred in 21 patients (19.8%). Twelve hospital deaths occurred (11.3%), although this was due to biliary causes in only five (4.7%) and one of these was moribund on admission. Complications were more frequent in those in whom initial ES did not clear the common bile duct (30.4%) compared with those in whom this was (11.7%; p = 0.0164). The mortality was also greater in patients in whom there was no ERCP proof of CBD clearance (p = 0.01) unless operated upon. Twelve patients developed gall bladder complications (11.3%) including five with empyema (4.7%). Analysis of clinical, haematological, and biochemical factors together with ERCP findings showed that the only factor which had any value in predicting gall bladder complications was pre-existing cholangitis. The present series was compared with another using ES as a definitive procedure, and with a surgical series. Although there were significant differences in outcome, differences with respect to medical risk factors and the incidence of complications of CBD stones (jaundice, cholangitis, and acute pancreatitis) were striking. Further analysis of these factors may allow a clearer definition of patients most likely to benefit from either ES or surgery.

Acute cholangitis in association with acute pancreatitis: incidence, clinical features and outcome in relation to ERCP and endoscopic sphincterotomy

Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) have been shown to be valuable in managing patients with acute cholangitis, their role in patients who have simultaneous acute cholangitis and acute pancreatitis is not known. We have reviewed 32 consecutive patients presenting with both conditions over ten years which represents 23.0 per cent of all cases of gallstone-related acute cholangitis and 14.4 per cent of all cases of biliary acute pancreatitis admitted during the same period. The majority of patients were elderly (median 76 years) and female (75 per cent). Five patients had previously undergone cholecystectomy. Eleven patients were clinically shocked (34 per cent) and blood cultures were positive in 9/14 cases (64 per cent). Twenty patients (63 per cent) had a predicted severe attack of acute pancreatitis (modified Glasgow criteria). Common bile duct (CBD) stones were identified in 15 of 23 patients with successful ERCP. Of these 23 patients, 9 were treated by endoscopic sphincterotomy (ES) alone, 5 by ES and surgery, 4 by surgery alone and 5 were treated conservatively. There was one death (4.3 per cent). Nine patients were managed without cholangiography; four had surgery and five were treated conservatively. There were three deaths (33 per cent; P = 0.10). Evidence of recent CBD stone passage was apparent in eight patients (25 per cent) compared with five out of eighty-seven patients (5.7 per cent) with acute cholangitis alone (P less than 0.005). The results indicate that ERCP and ES may have an important role in the management of these patients.

Long term follow-up of patients with side to side choledochoduodenostomy and transduodenal sphincteroplasty

From a consecutive series of 190 patients with choledochoduodenostomy (CDD) and 56 patients with transduodenal sphincteroplasty (TDS), there were 10 and 3 hospital deaths respectively. A long term follow-up study was performed on the remainder. Late deaths occurred in 35 CDD and 5 TDS patients. Serious long term complications occurred in 3.3% of CDD cases, comprising 5 cases of 'sump syndrome' and a further case of cholangitis in the presence of a clear biliary tree. Cholangitis occurred in 2 of the TDS patients (3.8%). Recurrent common duct stones were found in 3 of the 'sump syndrome' cases (1.6%) and one of the TDS patients with cholangitis (1.9%). Eighty-eight per cent of the CDD patients and 90.2% of the TDS patients, who were reviewed, were subjectively well. Serum alkaline phosphatase was raised in 21.6% of the CDD patients and only 3.4% of the TDS group (P less than 0.05). Radiological studies showed that the CDD stoma admitted air and barium more often than the TDS stoma (P less than 0.001). Neither the biochemical nor the radiological findings correlated with the long term symptomatic results of the two procedures. Dynamic HIDA scans showed a shorter time to peak activity in the common hepatic duct for both CDD (P less than 0.01) and TDS (P less than 0.05) as compared with endoscopic sphincterotomy (ES). These long-term clinical, biochemical and radiological results are similar to those reported following ES.

Treatment and outcome in 52 consecutive cases of ampullary carcinoma

The results of treatment and outcome in 52 consecutive patients presenting to Leicester from 1972 to 1984 are presented. The number of patients diagnosed increased from two per year before the introduction of duodenoscopy to nearly five per year afterwards. Endoscopic drainage (ED) was attempted in 21 patients with a success rate of 81 per cent. In eight cases ED was used pre-operatively and in the remainder as definitive treatment. Twenty-four patients had a Whipple's resection (12.5 per cent mortality), four patients had a local resection (no deaths), ten patients had surgical bypass (60 per cent mortality) and thirteen patients had ED alone (23 per cent mortality). The major risk factor score was significantly greater in patients undergoing surgical bypass compared with Whipple's resection. Age and risk factor scores were significantly greater in patients who had ED drainage alone than in surgical patients. The 5 year survival rate for resection was 56 per cent versus 13 per cent for drainage procedures (P less than 0.001). Survival in resection cases was directly related to the degree of tumour differentiation and a new staging system. It is proposed that all patients with ampullary tumours should have endoscopic biopsy followed by ED; Whipple's resection remains the surgical treatment of choice.

Study of common bile duct exploration and endoscopic sphincterotomy in a consecutive series of 438 patients

The outcome of 438 consecutive patients who had exploration of the common bile duct and/or endoscopic sphincterotomy (ES) in a 5-year period was reviewed. Patients were analysed according to four groups: 59 patients had planned ES followed by surgery resulting in 14 major complications (23.7 per cent) including 3 deaths (5.1 per cent) (group 1); 248 patients had surgery alone with 21 major complications (8.5 per cent) including 10 deaths (4.0 per cent) (group 2); 114 patients with gallbladder in situ underwent ES alone with 22 major complications (19.3 per cent) including 9 deaths (7.9 per cent) (group 3); 17 patients with remote cholecystectomy also had ES alone with 3 major complications (17.6 per cent) including 3 deaths (17.6 per cent) (group 4). There was no difference in mortality between the groups. Compared with group 2, major complications were significantly higher in group 1 (chi 2 = 11.0, d.f. = 1, P less than 0.001) and in group 3 (chi 2 = 8.6, d.f. = 1, P less than 0.003). Patients in group 3, however, were significantly older than those in groups 1 and 2, and the former also had higher medical and total risk factor scores than the latter (all P less than 0.001). The results indicate that routine pre-operative ES is of questionable value. ES alone is justified in elderly high risk patients; mortality in this group might be reduced by improved management of post-ES complications.

Haemorrhage into a urachal cyst presenting as an 'acute abdomen'

A previously well 3 year old Asian girl presented as an emergency with the acute onset of generalized abdominal pain. On examination her abdomen was distended with generalized tenderness and guarding most marked centrally. Under anaesthesia a central abdominal mass arising from the pelvis was palpated which on proceeding to laparotomy was found to be a blood-filled urachal cyst. This was excised and her recovery was uneventful. Subsequent investigations have revealed no associated renal tract abnormalities.

Surgical complications of amyloid disease

The case of a man with primary systemic amyloidosis without myelomatosis and long-term survival is described. The patient has had major surgical complications from large amyloid deposits in the colon, dorsal spine and peritoneal cavity. The patient remains well 14 years after diagnosis.

Choledochoduodenostomy, transduodenal sphincteroplasty and sphincterotomy for calculi of the common bile duct

The clinical features, indications and operative results in a consecutive series of 246 patients who underwent choledochoduodenostomy (CDD) and transduodenal sphincterotomy or sphincteroplasty (TDS) over a period of ten years (1972 to 1981) were reviewed. The over-all mortality for CDD was ten of 190 patients (5.3 per cent) and three of 56 patients for TDS (5.4 per cent). The over-all major morbidity rate for these procedures was 11.6 per cent for CDD and 21.4 per cent for TDS. This was not a statistically significant difference, but there were more elderly patients (more than 65 years old) in the CDD group (60.5 per cent) than in the TDS group (21.4 per cent) (p less than 0.001). The major morbidity rate associated with elective operations was 10.7 per cent for CDD and 20.0 per cent for TDS which is significant (p less than 0.05). Long term follow-up study (one to 12 years and mean of four and one-half years) revealed six patients in the CDD group with sump syndrome or cholangitis, or both, (3.3 per cent) and three patients in the TDS group had cholangitis develop (5.7 per cent). Over-all, the results compared favorably with the published results of endoscopic sphincterotomy. We conclude that CDD is the operation of choice when a permanent biliary drainage procedure is indicated and TDS should be reserved for instances of ampullary gallstone impaction.

Prospective randomised study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones

One hundred and twenty patients with known common bile duct stones were entered into a prospective randomised study of preoperative endoscopic sphincterotomy and stone clearance (group 1) versus surgery alone (group 2). Five patients were incorrectly entered; the 55 patients randomised to group 1 and the 60 randomised to group 2 were well matched with respect to clinical features and biochemical and medical risk factors. In group 1 endoscopic stone clearance was successful in 50 patients (91%); five of these patients refused elective surgery, though this was subsequently necessary in one. In group 2 common bile duct stones were cleared surgically in 54 of 59 patients (91.5%); one patient was treated by endoscopic sphincterotomy alone because of a myocardial infarct. The overall major complication rate in group 1 was 16.4% and included two deaths; in group 2 this was 8.5% and included one death. The minor complication rate in group 1 was 16.4% and that in group 2 13.6%. These differences in outcome were not significant. Despite a significant reduction in total hospital stay of patients in group 1, these results do not support the routine use of preoperative endoscopic sphincterotomy in patients having biliary surgery for stones in the common bile duct.

Management of acute cholangitis and the impact of endoscopic sphincterotomy

Ninety-four patients admitted to Leicester Hospitals with acute cholangitis since 1977 were reviewed to coincide with the availability of endoscopic sphincterotomy (ES). Thirty-four were men and sixty were women, their mean age was 69.7 years and the median hospital stay was 20 days. There were 15 deaths (16 per cent) by 30 days in patients with significantly lower initial serum albumin levels (P less than 0.005) and significantly higher serum urea levels (P less than 0.05) than survivors. Eighty-two patients had common bile duct (CBD) calculi of whom 71 underwent early decompression of the biliary tree either surgically (28) or by ES(43). Early surgical decompression was associated with a significantly higher 30 day mortality (6/28) than early ES (2/43) (P less than 0.02) despite the fact that patients undergoing early ES were significantly older (P less than 0.02) and had significantly more medical risk factors (P less than 0.05). Of the 43 patients undergoing early ES 7 had had a previous cholecystectomy, 13 underwent subsequent elective cholecystectomy with no mortality and the remaining 23 had the gallbladder left in situ because of advanced age (mean age 79 years) and frailty. Only 2 of the 23 have since required cholecystectomy. We suggest that patients with acute cholangitis who do not rapidly respond to conservative treatment should undergo early ES with early surgery reserved for those who do not improve following ES. Elective cholecystectomy following successful ES can often be avoided in the elderly and frail.