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.

Postcholecystectomy sphincter of oddi dyskinesia--a diagnostic dilemma--role of noninvasive nuclear and invasive manometric and endoscopic aspects

BACKGROUND

Persistent abdominal pain after cholecystectomy is not uncommon. Sphincter of oddi dysfunction (SOD) is one of the causes for this entity. However, diagnosing SOD is often difficult. Sphincter of oddi manometry (SOM) is the gold standard. Because it is invasive and needs experienced person to perform, simple noninvasive imaging techniques are needed. Other invasive endoscopic methods also play an important role in difficult cases and before therapeutic intervention.

METHODS

Retrospective review of the charts of postcholecystectomy patients who presented with persistent abdominal pain and underwent quantitative hepatobiliary studies (QHBS) as per Sostre et al scoring protocol and simultaneous endoscopic retrograde cholangiopancreatography (ERCP) with SOM between 2003 and 2004. Additional 6 studies with SOM data that had routine nonscoring hepatobiliary study (HBS) were later identified and were included in the study.

RESULTS

A total of 24 HBS studies (22 patients) were identified, 19 performed with scoring (Sostre) and 5 with nonscoring methods. ERCP results were available for 16 patients. SOM results were available for 10 patients. Of the 19 who had Sostre's QHBS, 3 were positive and 16 were negative. All 3 QHBS positive patents also had ERCP with SOM findings of SOD. Of the 16 negative Sostre's QHBS, 8 had ERCP with SOM of which 6 had SOD, 1 had no SOD, and 1 was inconclusive. Eight patients who had negative QHBS/ HBS did not undergo further invasive gastrointestinal procedures and were followed conservatively. The rest of 5 patients with negative HBS had ERCP with SOM findings of biliary and pancreatic SOD.

CONCLUSIONS

From our limited retrospective review, when QHBS by Sostre's is positive there is good correlation to ERCP with SOM. When negative, the agreement with ERCP with SOM is less. However, correlation of Sostre's QHBS is slightly better than nonscoring HBS. Hence, QHBS by Sostre protocol is a simple, noninvasive, and easy to use initial procedure in the management of postcholecystectomy pain syndromes and when positive can guide the gastrointestinal physicians to proceed to invasive ERCP with SOM with confidence.

Diagnosing and treating Sphincter of Oddi dysfunction: a critical literature review and reevaluation

Sphincter of Oddi dysfunction is a pathologic syndrome, without considering etiology, physiopathology, or anatomic aspects of the condition. The clinical manifestations of the syndrome may be a consequence of an "organic stenosis" of the tract or a consequence of "abnormal motility" of the sphincter. Until some years ago, the gold standard technique for studying and treating this pathologic condition was endoscopic retrograde cholangiopancreatography. Two criteria for defining patients in the Milwaukee classification are related to this procedure. The Milwaukee classification was introduced to use clinical and radiologic criteria to define patients with Sphincter of Oddi dysfunction to choose the best treatment. Subsequently, great emphasis has been placed on manometry of the sphincter performed by endoscopic cannulation. The enormous increase of cholecystectomies by means of laparoscopic technique has increased the number of patients who return to their reference-surgeon with a post-cholecystectomy pain and possible Sphincter of Oddi dysfunction. The aim of this paper is to review the literature and to evaluate an up-to-date flow chart for diagnosing and treating the syndrome by using alternative diagnostic procedures that are less invasive than endoscopic retrograde cholangiopancreatography.