Endoscopic biliary manometry in patients with suspected sphincter of Oddi dysfunction and in patients with cystic dilatation of the bile ducts

Simultaneous laparoscopic removal of a Todani type II choledochal cyst and a microlithiasic cholecystitis

Diverticula of the choledochus, better known as Todani type II cysts, are very rare and represent a predominantly pediatric pathology. Their identification by radiological methods, even if occasional, requires clinical doctors to request a surgical consultation, even for asymptomatic subjects, to proceed with their removal, given the risk of associated neoplasms. The laparoscopic approach for surgical treatment of these cysts has been recently introduced with excellent results. Due to the poor clinical records, currently there are neither shared protocols about their management nor long-term follow-up of operated patients. We report a case of an adult female suffering for years from biliary colic due to the presence of a duodenal diverticulum associated with microlithiasis' cholecystitis, who was laparoscopically treated, with excellent results in terms of symptomatic regression, reduced hospitalization, and no surgery-related complications.

Choledochal cysts: Similarities and differences between Asian and Western countries

Choledochal cysts (CCs) are rare bile duct dilatations, intra-and/or extrahepatic, and have higher prevalence in the Asian population compared to Western populations. Most of the current literature on CC disease originates from Asia where these entities are most prevalent. They are thought to arise from an anomalous pancreaticobiliary junction, which are congenital anomalies between pancreatic and bile ducts. Some similarities in presentation between Eastern and Western patients exist such as female predominance, however, contemporary studies suggest that Asian patients may be more symptomatic on presentation. Even though CC disease presents with an increased malignant risk reported to be more than 10% after the second decade of life in Asian patients, this risk may be overstated in Western populations. Despite this difference in cancer risk, management guidelines for all patients with CC are based predominantly on observations reported from Asia where it is recommended that all CCs should be excised out of concern for the presence or development of biliary tract cancer.

Sphincter of Oddi Dysfunction and the Formation of Adult Choledochal Cyst Following Cholecystectomy: A Retrospective Cohort Study

To determine the causes underlying the formation of adult choledochal cyst.Anomalous pancreaticobiliary junction is the most widely accepted theory regarding the etiology of choledochal cyst. However, choledochal cysts have been found in patients in the absence of this anomaly. Because the number of adult patients with choledochal cyst is increasing, it is important to address this controversy.Bile amylase levels in the cysts of 27 patients (8 males and 19 females) who had undergone cholecystectomy were retrospectively evaluated.The average age of the 27 patients was 45.8 ± 10.1 years and the majority (85.2%) were diagnosed with Todani type I cysts. None of the patients had dilatation of the common bile duct prior to surgery. There were 6 (22.2%) patients with anomalous pancreaticobiliary junction. However, amylase levels did not significantly differ between patients with and without this anomaly (P = 0.251). According to bile amylase levels, pancreatobiliary reflux was present in 21 (77.8%) patients. The mean amylase level significantly differed in patients with pancreatobiliary reflux (23,462 ± 11,510 IU/L) and those without (235 ± 103 IU/L) (P < 0.001). In patients with pancreatobiliary reflux, only 4 patients had anomalous pancreaticobiliary junction. That is, the majority of patients (17/21, 81%) having pancreatobiliary reflux did not have an anomalous junction of the pancreatic and biliary ducts.Since the only explanation for pancreatobiliary reflux in patients with a normal pancreaticobiliary junction is sphincter of Oddi dysfunction, we proposed that the formation of adult choledochal cyst is mainly due to sphincter of Oddi dysfunction.

Choledochal cysts : a review of literature

Choledochal cysts are cystic dilation of extrahepatic duct, intrahepatic duct, or both that may result in significant morbidity and mortality, unless identified early and managed appropriately. The incidence is common in Asian population compared with western counterpart with more than two third of the cases in Asia being reported from Japan. The traditional anatomic classification system is under debate with more focus on etiopathogenesis and other aspects of choledochal cysts. Even though categorized under the same roof, choledochal cysts vary with respect to their natural course, complications, and management. In this review, with the available literature on choledochal cysts, we discuss different views about the etiopathogenesis along with the natural course, complications, diagnosis, and surgical approach for choledochal cysts, which also explains why the traditional classification is questioned by some authors.

The current management of choledochal cysts

Choledochal cyst disease is uncommon. The presentation of the disease is being seen more commonly in the adult population than in the pediatric population, particularly in the West, making this a diagnosis a general surgeon should consider when evaluating a patient with biliary disease. The diagnosis of this disease has been greatly facilitated by improving technologies, particularly MRCP and interventional techniques of PTC. The consequences of not treating choledochal cysts can result in malignant transformation. When possible, complete surgical excision of the cyst is recommended and should be performed as early as possible to prevent complications and the progression of liver fibrosis. Long-term follow-up is required for surveillance for late complications and for cancer, particularly in type IV and V choledochal cysts where complete excision is not possible.

Pancreatitis complicated with dilated choledochal remnant after congenital choledochal cyst excision

We describe here three cases of pancreatitis after congenital choledochal cyst excision. In these three cases, the choledochal remnant in the pancreas head was markedly dilated, probably because of an incomplete resection of the cyst at the primary operation, and an increase in intraluminal pressure of the pancreatic duct caused by a dynamic obstruction by a protein plug or a pancreatic calculus. Complete cyst excision, including the choledochal wall in the pancreas, is therefore strongly recommended.

Under pressure: choledochal malformation manometry

PURPOSE

The cause of choledochal (cystic or fusiform) malformation is not known. A favoured hypothesis suggests that abnormal reflux of activated pancreatic secretions via a common pancreatobiliary channel may initiate mucosal injury and mural weakness leading to bile duct dilatation, at normal intraduct pressures. However, bile duct pressures in both normal or disease states are not known in such children.

METHODS

Intraoperative choledochal pressure (CP) measurements were made before any other manipulation. Bile was cultured and its amylase content measured. Biochemical liver function (bilirubin, aspartate aminotransferase, gamma-glutamyl transpeptidase, and alkaline phosphatase) was measured. Data were quoted as median (interquartile range). Statistical tests were parametric, where appropriate, and P = .05 was regarded as significant.

RESULTS

Twenty-five children (age 2.5 [1.25-5.91] years) with choledochal (cystic [n = 13] and fusiform [n = 12]) malformation coming to surgery were studied. Median CP was 13 (8.5-17) mm Hg. Median bile amylase was 6722 (241-18,000) IU/L. Choledochal pressure inversely correlated with bile amylase (r = -0.60, P = .001), serum aspartate aminotransferase (r = 0.46, P = .01), and log gamma-glutamyl transpeptidase (r = 0.4, P = .04) but not with bilirubin (P = .11), alkaline phosphatase (P = .20), or age (P = .11). No difference in CP, bile amylase, or liver biochemistry could be identified between the 2 biliary phenotypes. All bile cultures were sterile.

CONCLUSIONS

Increased CP is inversely related to the level of bile amylase (and hence degree of the functional common channel). This suggests that obstructive stenosis at the level of the pancreatobiliary junction (but not the ampulla) may be a causal factor in a proportion of choledochal malformations.

Structural and mechanical remodelling of the common bile duct after obstruction

Biliary obstruction in man, most often caused by cholelithiasis, induces remodelling of the bile ducts. Obstruction-induced structural remodelling of the common bile duct (CBD) has been previously described. The mechanical changes that accompany the structural remodelling, however, have not been studied in detail. The aim of this study is to quantify the structural and mechanical changes in the CBD at different time intervals after acute obstruction. The CBD was ligated in the pig, near the duodenum, and studied after 3 h, 12 h, 2 days, 8 days and 32 days (n=5 in each group). One additional animal in each group was sham-operated. At each scheduled time, the CBD was mechanically tested in vitro with a computer-controlled volume infusion system to study the pressure-volume relationship of the CBD segment. A video camera provided simultaneous measurements of the outer dimensions of the CBD at the various pressures. The diameter and wall thickness of the CBD increased about three-fold in the 32-day group compared to the sham group (P < 0.001). The circumferential stress-strain relationship differed between groups (P < 0.001); it was shifted to the right, indicating softening, in the 3-h, 12-h, and 2-day groups and to the left, indicating stiffening, in the 8-day and 32-day group, compared to the sham group. The longitudinal stress-strain curves were all shifted to the left of the circumferential stress-strain curves (P < 0.05). The collagen area increased during obstruction (P < 0.001) but no correlation between the size of the collagen area and the biomechanical parameters was found. A practical implication of the present study serves as a warning to surgeons. A reduction in the wall stiffness in the first several days of obstruction along with an increased duct diameter and a decreased wall thickness suggest that operative procedures such as suturing, anastomosis and procedures related to ERCP must be performed with special care to avoid damage to the CBD.

Normal and anomalous pancreaticobiliary union in children and adolescents

BACKGROUND

The normal length of the pancreaticobiliary union (common channel) in the pediatric population is not known, nor is the frequency of anomalous pancreaticobiliary union and the extent to which it is associated with pancreaticobiliary disease.

METHODS

ERCP was performed on 136 patients younger than 1 year (group 1) and 128 older than 1 year (group 2).

RESULTS

In group 1 the average length of the common channel was 1.8 +/- 0.61 mm with a maximal length of 3 mm (mean plus 2 standard deviations). In group 2 the average length and maximal length of the common channel increased with age. In the 1 to 3 year age range the average length was 2.2 +/- 0.47 mm with a maximal length of 2.7 mm, in the 4 to 6 year range it was 2.8 +/- 0.40 mm (3.6 mm maximal), in the 7 to 9 year range it was 3.2 +/- 0.43 mm (4.1 mm maximal), in the 10 to 12 year range it was 3.9 +/- 0.5 mm (4.4 mm maximal), and in the 13 to 15 year range it was 4.0 +/- 0.51 mm (5 mm maximal). The prevalence of the anomalous pancreaticobiliary union was 25% (66/264). In group 1 the anomaly was present in 4.4% (6 of 136) of patients, 1.3% (1/76) with neonatal hepatitis, 4.6% (3/44) with biliary atresia, and 100% (2/2) with choledochal cyst. In group 2 the anomaly was present in 46.9% (60/128) of patients, 100% (57/57) with choledochal cyst and 15.7% (3/19) with idiopathic recurrent pancreatitis without bile duct dilatation.

CONCLUSIONS

The mean length of the common channel increases with age. The maximum normal length of the common channel in neonates and infants younger than 1 year is 3 mm. It increases with age to a maximum of 5 mm in children and adolescents between 13 and 15 years of age. Anomalous pancreaticobiliary union is relatively common among children and adolescents undergoing ERCP in our center, including those with idiopathic recurrent pancreatitis (15.7%). ERCP is valuable in the diagnosis of this anomaly.

Sphincter of Oddi dysfunction in children with recurrent pancreatitis and anomalous pancreaticobiliary union: an etiologic concept

BACKGROUND

The exact cause of recurrent pancreatitis among patients with anomalous pancreaticobiliary union is not known. Sphincter of Oddi dysfunction has been implicated as a mechanism. This study evaluated sphincter of Oddi function in children with anomalous pancreaticobiliary union and recurrent pancreatitis and assessed the results of endoscopic sphincterotomy in the management of this condition.

METHODS

We retrospectively reviewed 128 endoscopic retrograde cholangiopancreatographic (ERCP) studies performed on children older than 1 year and adolescents with pancreaticobiliary disease. In 64 instances, ERCP was performed because of recurrent pancreatitis. Nine patients underwent sphincter of Oddi manometry followed by endoscopic sphincterotomy, and these patients were included in this study. A basal pressure greater than 35 mm Hg was considered diagnostic for sphincter of Oddi dysfunction. Follow-up data were obtained retrospectively from the patients' relatives and referring physicians.

RESULTS

An anomalous pancreaticobiliary union was found in 18 of 64 (28%) patients with recurrent pancreatitis. The 9 patients who underwent sphincter manometry and endoscopic sphincterotomy were 5 girls and 4 boys 2.9 to 17 years of age (mean 7.8 years). A choledochal cyst was found in 7 of these 9 patients. Two patients had anomalous pancreaticobiliary union without common bile duct dilatation. All 9 patients had sphincter of Oddi dysfunction (mean basal pressure 96 +/- 37.8 mm Hg, range 48 to 156 mm Hg). The length of the common channel was 22.8 +/- 5.5 mm, and the length of the sphincter of Oddi segment was 12.1 +/- 1.9 mm (p < 0.001). In all patients the sphincter of Oddi segment was located within the duodenal wall. The mean follow-up period after endoscopic sphincterotomy was 26.4 months (range 18 to 38 months). Eight patients had excellent results defined as absence of symptoms and no subsequent episodes of acute pancreatitis. Treatment of 1 patient was considered moderately successful because the patient still had occasional pain without pancreatic enzyme elevation but no subsequent episodes of acute pancreatitis. One patient had mild postprocedural pancreatitis.

CONCLUSIONS

Recurrent pancreatitis and anomalous pancreaticobiliary union are associated with sphincter of Oddi dysfunction in children and adolescents. Endoscopic sphincterotomy is beneficial to these patients.

Obstructing choledochocele: diagnosis by endoscopic ultrasound

This report demonstrates the use of endoscopic ultrasound in the diagnosis of choledochocele. The patient was an elderly female who presented with abdominal pain, weight loss, and biliary obstruction. At endoscopic ultrasound a 5 cm cystic lesion was found near the ampulla, which clearly communicated with the common bile duct.

Innervation of the sphincter of Oddi: physiology and considerations of pharmacological intervention in biliary dyskinesia

The sphincter of Oddi is a small sphincter which is strategically placed at the junction of the bile duct and pancreatic duct with the duodenum. It regulates the flow of bile and pancreatic juice into the duodenum and prevents reflux of duodenal contents into the ducts. The structure of the sphincter of Oddi differs from species to species and consequently its physiological action varies in different species. Anatomical and immunohistochemical investigations have demonstrated that the sphincter of Oddi is richly innervated by cholinergic, adrenergic and peptidergic neurons. In addition, neural connections exist between the sphincter, gallbladder and proximal gastrointestinal tract. These nerves in addition to hormones are important in the control of sphincter of Oddi motility and function. The normal human sphincter of Oddi is characterized by prominent phasic contractions which are superimposed on a modest basal pressure. These contractions are present throughout the interdigestive period. The contractions and basal pressure are inhibited by ingestion of a meal or infusion of cholecystokinin octapeptide, thus enhancing the flow of bile and pancreatic juice into the duodenum. Sphincter of Oddi dysfunction has been described in patients who present with recurrent biliary type pain and no evidence of a structural cause for the pain. Motility disorders characterized as an elevated basal pressure, rapid contraction frequency, paradoxical response to cholecystokinin octapeptide or excess of retrograde contractions have been identified. A number of pharmacologically active substances have been used in an attempt to treat these patients. Such pharmaceuticals include nitrites, Ca2+ channel blockers and smooth muscle relaxants. Their effect is transient and side effects relating to cardiovascular actions preclude their longterm use. Division of the sphincter either endoscopically or by open operation has been demonstrated by prospective clinical trials to be the most efficacious treatment for patients with a stenosed sphincter manometrically demonstrated by a high basal pressure. Improved understanding of the controlling mechanisms of sphincter of Oddi motility and the pathophysiology of sphincter of Oddi dysfunction should assist in the development of effective pharmacotherapy for these disorders.