The treatment of ampullary stenosis by endoscopic sphincterotomy (EST)

Post-cholecystectomy syndrome and sphincter of Oddi dysfunction: past, present and future

Post-cholecystectomy syndrome and the concept of a causal relationship to sphincter of Oddi dysfunction, despite the controversy, has presented a clinically relevant conflict for decades. Historically surgeons, and now gastroenterologists have expended tremendous efforts towards trying to better understand the dilemma that is confounded by unique patient phenotypes. Areas covered: This review encompasses the literature from a century of experience on the topic of post-cholecystectomy syndrome. Relevant historical and anecdotal experiences are examined in the setting of insights from evaluation of recently available controlled data. Expert commentary: Historical observations and recent data suggest that patients with post-cholecystectomy syndrome can be categorized as follows. Patients with sphincter of Oddi stenosis will most often benefit from treatment with sphincterotomy. Patients with classic biliary pain and some objective evidence of biliary obstruction may have a sphincter of Oddi disorder and should be considered for endoscopic evaluation and therapy. Patients with atypical post-cholecystectomy pain, without any evidence consistent with biliary obstruction, and/or with evidence for another diagnosis or dysfunction should not undergo ERCP.

The role of endoscopic biliary sphincterotomy for the treatment of type 1 biliary dysfunction (papillary stenosis) with or without biliary stones

BACKGROUND

This study assesses the safety and effectiveness of endoscopic biliary sphincterotomy (ES) in the treatment of papillary stenosis (PS) with and without biliary stones.

METHODS

The records of all patients who had endoscopic retrograde cholangiopancreatography (2,689 patients) from January 1, 1991, to August 1, 2010, were reviewed. There were 117 patients with PS who had ES.

RESULTS

All patients had biliary pain, a dilated common bile duct (CBD) with a maximum diameter of 10 to 25 mm, and elevated liver function tests. There were 46 patients who had prior cholecystectomy of whom 20 patients had CBD stones. The remaining 71 patients had no prior biliary surgery; there were no biliary stones in 14 patients. All patients were symptom free after ES with or without CBD stone retrieval.

CONCLUSIONS

ES is the optimal treatment for PS in patients with or without biliary stones. ES eliminates pain, corrects CBD dilation, and restores LFTs to normal.

Endoscopic sphincterotomy for stenosis of the sphincter of Oddi

BACKGROUND

Sphincter of Oddi dysfunction (SOD) is one of the causes of postcholecytectomy syndrome and biliary pain. Endoscopic sphincterotomy (EST) is recommended in some cases for patients refractory to conservative treatment. By the Milwaukee classification, patients with biliary pain can be divided into three groups. Group I patients show all the objective signs suggestive of a disturbed bile outflow-i.e., elevated liver function tests, dilated common bile duct (CBD), and delayed contrast drainage during endoscopic retrograde cholangio pancreatography (ERCP). Group II patients have biliary-type pain along with one or two of the criteria from group I. Group III patients have only biliary pain, with no other abnormalities. This study confirms the effectiveness of EST for the relief of symptoms in group I patients (papillary stenosis).

METHODS

Between 1989 and 1999, we treated eight patients clinically diagnosed as having group I papillary stenosis by EST. Their ages ranged from 52 to 73 years. In addition to biliary pain, all patients were found to have dilated CBD, elevated enzyme levels, and delayed contrast drainage at ERCP. None of the patients had CBD stones or other causes of obstruction. Sphincter of Oddi manometry was not performed.

RESULTS

EST was successfully performed in eight patients. Each patient had a very large papilla. A false orifice was found in one patient. In five patients, endoscopic cannulation of the bile duct was very difficult. The use of a long, tapered catheter and guidewire papillotomy was necessary in four patients. A precut papillotomy was performed in one patient. All patients achieved resolution of their symptoms after EST. There were no complications. The average length of the follow-up period was 26 months.

CONCLUSIONS

SOD is a real entity that continues to pose a diagnostic dilemma. EST is an effective and safe modality for the treatment of papillary stenosis (group I patients). SOD manometry is not necessary before EST in group I patients.