Sphincter of Oddi Manometry: Reproducibility of Measurements and Effect of Sphincterotomy in the EPISOD Study

( Alejandro L Suarez ),( Qi Pauls ),( Valerie Durkalski-mauldin ),( Peter B Cotton ) 대한소화기기능성질환·운동학회(구 대한소화관운동학회) 2016 Journal of Neurogastroenterology and Motility (JNM Vol.22 No.3

Background/Aims The reproducibility of sphincter of Oddi manometry (SOM) measurements and results of SOM after sphincterotomy has not been studied sufficiently. The aim of our study is to evaluate the reproducibility of SOM and completeness of sphincter ablation. Methods The recently published Evaluating Predictors and Interventions in sphincter of Oddi dysfunction (EPISOD) study included 214 subjects with post-cholecystectomy pain, and fit the criteria of sphincter of Oddi dysfunction type III. They were randomized into 3 arms, irrespective of manometric findings: sham (no sphincterotomy), biliary sphincterotomy, and dual (biliary and pancreatic). Thirtyeight subjects had both biliary and pancreatic manometries performed twice, at baseline and at repeat endoscopic retrograde cholangiopancreatography after 1-11 months. Sham arm was examined to assess the reproducibility of manometry, and the treatment arms to assess whether the sphincterotomies were complete (elevated pressures were normalized). Results Biliary and pancreatic measurements were reproduced in 7/14 (50%) untreated subjects. All 12 patients with initially elevated biliary pressures in biliary and dual sphincterotomy groups normalized after biliary sphincterotomy. However, 2 of 8 subjects with elevated pancreatic pressures in the dual sphincterotomy group remained abnormal after pancreatic sphincterotomy. Paradoxically, normal biliary pressures became abnormal in 1 of 15 subjects after biliary sphincterotomy, and normal pancreatic pressures became abnormal in 5 of 15 patients after biliary sphincterotomy, and in 1 of 9 after pancreatic sphincterotomy. Conclusions Our data suggest that SOM measurements are poorly reproducible, and question whether we could adequately perform pancreatic sphincterotomy. (J Neurogastroenterol Motil 2016;22:477-482)

Endoscopic Pancreatic Sphincterotomy: Indications and Complications

( Yong Won Joo ),( Jai Hoon Yoon ),( Seung Chul Cho ),( Kang Nyeong Lee ),( Na Rae Ha ),( Hang Lak Lee ),( Oh Young Lee ),( Byung Chul Yoon ),( Ho Soon Choi ),( Joon Soo Hahm ),( Dong Hoo Lee ),( Min 대한내과학회 2009 The Korean Journal of Internal Medicine Vol.24 No.3

Background/Aims: Although a few recent studies have reported the effectiveness of endoscopic pancreatic sphincterotomy (EPST), none has compared physicians` skills and complications resulting from the procedure. Thus, we examined the indications, complications, and safety of EPST performed by a single physician at a single center. Methods: Among 2,313 patients who underwent endoscopic retrograde cholangiopancreatography between January 1996 and March 2008, 46 patients who underwent EPST were included in this retrospective study. We examined the indications, complications, safety, and effectiveness of EPST, as well as the need for a pancreatic drainage procedure and the concomitant application of EPST and endoscopic sphincterotomy (EST). Results: Diagnostic indications for EPST were chronic pancreatitis (26 cases), pancreatic divisum (4 cases), and pancreatic cancer (8 cases). Therapeutic indications for EPST were removal of a pancreaticolith (10 cases), stent insertion for pancreatic duct stenosis (9 cases), nasopancreatic drainage (7 cases), and treatment of sphincter of Oddi dysfunction (1 case). The success rate of EPST was 95.7% (44/46). Acute complications of EPST included five cases (10.9%) of pancreatitis and one of cholangitis (2.2%). EPST with EST did not reduce biliary complications. Endoscopic pancreatic drainage procedures following EPST did not reduce pancreatic complications. Conclusions: EPST showed a low incidence of complications and a high rate of treatment success; thus, EPST is a relatively safe procedure that can be used to treat pancreatic diseases. Pancreatic drainage procedures and additional EST following EPST did not reduce the incidence of procedure-related complications. (Korean J Intern Med 2009;24:190-195)

Recurrence of Bile Duct Stones after Endoscopic Papillary Large Balloon Dilation Combined with Limited Sphincterotomy: Long-Term Follow-Up Study

( Kook Hyun Kim ),( Jung Hyun Rhu ),( Tae Nyeun Kim ) 대한소화기기능성질환·운동학회 2012 Gut and Liver Vol.6 No.1

Background/Aims: Endoscopic papillary large-balloon dilation combined with limited endoscopic sphincterotomy (EPLBD+ES) is promising for the treatment of common bile duct (CBD) stones. The aim of this study was to clarify the recurrence rate and the risk factors for CBD stones after EPLBD+ES. Methods: In total, 100 patients who underwent EPLBD+ES from 2006 to 2007 were evaluated retrospectively. One hundred and nine patients who were treated with endoscopic sphincterotomy (ES) from 2004 to 2005 were set as the historical control group. Various risk factors for the recurrence of bile duct stones were analyzed. Results: Of the 209 patients, the duration of follow-up was 32.5±4.5 months in the EPLBD+ES group and 31.8±6.0 months in the ES group. The recurrence rate of CBD stones was 11.0% (11/100) in the EPLBD+ES group and 13.8% (15/109) in the ES group (p=0.546). The cumulative recurrence rate of stones was not signifi cantly different between the EPLBD+ES and ES groups (log rank, p=0.537). Univariate analysis showed that the diameter of the CBD (≥22 mm) was the only predictive variable that could differentiate recurrence from nonrecurrence in the EPLBD+ES group. Multivariate analysis revealed that the diameter of the bile duct was the only risk factor for stone recurrence (p=0.022; odds ratio, 1.175; 95% confi dence interval, 1.023 to 1.348). Conclusions: The recurrence rate of CBD stones after EPLBD+ES is comparable to that of the ES group, and a dilated CBD appears to increase the risk of bile duct stone recurrence. (Gut Liver 2012;6:107-112)

Burdick’s Technique for Biliary Access Revisited

Mahesh Kumar Goenka,Vijay Kumar Rai 대한소화기내시경학회 2015 Clinical Endoscopy Vol.48 No.1

The precut sphincterotomy is used to facilitate selective biliary access in cases of difficult biliary cannulation. Needle-knife precut papillotomy is the standard of care but is associated with a high rate of complications such as pancreatitis, duodenal perforation, bleeding, etc. Sometimes during bowing of the sphincterotome/cannula and the use of guide wire to facilitate biliary cannulation, inadvertent formation of a false passage occurs in the 10 to 11 o’clock direction. Use of this step to access the bile duct by the intramucosal incision technique was first described by Burdick et al., and since then two more studies have also substantiated the safety and efficacy of this non-needle type of precut sphincterotomy. In this review, we discuss this non-needle technique of precut sphincterotomy and also share our experience using this ‘‘Burdick’s technique.’’

Obstructive Jaundice Caused by Clonorchiasis-associated Duodenal Papillitis: A Case Report

임준욱,주광로,신현필,차재명,이정일,임성직 대한의학회 2011 Journal of Korean medical science Vol.26 No.1

We describe an unusual presentation of Clonorchis sinensis infection with obstructive jaundice due to duodenal papillitis which was relieved dramatically by endoscopic sphincterotomy. A 26-yr-old male presented with complaints of fatigue, weight loss and painless jaundice. The history was significant for frequent ingestion of raw freshwater fish. The patient underwent endoscopic retrograde cholangiopancreatography for evaluation of obstructive jaundice. The duodenal papilla was markedly edematous with a bulging configuration and hyperemic changes at the orifice. Cholangiography revealed mild bile duct dilatation and irregular wall changes with multiple indentations. However, there were no biliary stricture or stones noted as the cause of obstructive jaundice. We performed an endoscopic sphincterotomy for effective bile drainage through the duodenal papilla. After the sphincterotomy, the patient’s jaundice was dramatically improved. Pathology of the duodenal papilla showed eosinophilic infiltration of the mucosa. Parasitic eggs, consistent with the diagnosis of C. sinensis, were found in the bile sample.

거대 담낭결석의 내시경적 치료 1예 : 내시경적 유두절개술 후 총수담관으로 하행한 거대 담낭결석 Migrated from the Gallbladder through Cystic Duct after Endoscopic Sphincterotomy

이은우,여향순,임동윤 조선대학교 부설 의학연구소 2000 The Medical Journal of Chosun University Vol.25 No.1

The reason why to migrate a large gallbladder stone into the common bile duct (CBD) remains to be established, but among various reasons the diameter of cystic duct appears to be the most important. None of the gallbladder stones with diameters greater than the cystic duct could be passed through it. However, pre-existing CBD stone increases biliary pressure that consequently dilates the cystic duct system retrogradely, allowing larger stones to migrate into the gut. Furthermore, sphincterotomy may actually prevent formation of gallbladder stone and enhance the removal of pre-existing stones from the gallbladder. We recently have experienced a case of a large CBD stone migrated from the gallbladder through the cystic duct after endoscopic sphincterotomy. The cholangitic symptoms were caused by the stone migrated from gallbladder, but several days later got well. So far any side effects related to this removed stone are not found out since we have successfully extracted a large CBD stone (3.5 x 2cm) with mechanical lithotripsy.

Tension Pneumothorax after Endoscopic Retrograde Pancreatocholangiogram

송상윤,이교선,나국주,안병희 대한의학회 2009 Journal of Korean medical science Vol.24 No.1

We report a case of tension pneumothorax after an endoscopic sphincterotomy. A 78-yr-old woman presented with progressing dyspnea. She had undergone an endoscopic retrograde cholangiopancreatogram three days before due to acute cholecystitis. She underwent endoscopic sphincterotomy for stone extraction, but the procedure failed. On arrival to our hospital, she complained about severe dyspnea and she had subcutaneous emphysema. A computed tomogram scan revealed severe subcutaneous emphysema, right-side tension pneumothorax, and pneumoretroperitoneum. Contrast media injected through a transnasal biliary drainage catheter spilled from the second portion of the duodenum. A second abdominal computed tomogram showed multiple air densities in the retroperitoneum and peritoneal cavity, which were consistent with panperitonitis. We recommended an emergent laparotomic exploration, but the patient’s guardians refused. She died eventually due to septic shock. Endoscopic retrograde cholangiopancreatogram is a popular procedure for biliary and pancreatic diseases, but it can cause severe complications such as intestinal perforation. Besides perforations, air can spread through the abdominal cavity, retroperitoneum, mediastinum, and the neck soft tissue, eventually causing pneumothorax. Early recognition and appropriate management is crucial to an optimal output of gastrointestinal perforation and pneumothorax.

The outcome of endoscopic management of bile leakage after hepatobiliary surgery

( Seon Ung Yun ),( Young Koog Cheon ),( Chan Sup Shim ),( Tae Yoon Lee ),( Hyung Min Yu ),( Hyun Ah Chung ),( Se Woong Kwon ),( Taek Gun Jeong ),( Sang Hee An ),( Gyung Won Jeong ),( Ji Wan Kim ) 대한내과학회 2017 The Korean Journal of Internal Medicine Vol.32 No.1

Background/Aims: Despite improvements in surgical techniques and postoperative patient care, bile leakage can occur after hepatobiliary surgery and may lead to serious complications. The aim of this retrospective study was to evaluate the efficacy of endoscopic treatment of bile leakage after hepatobiliary surgery. Methods: The medical records of 20 patients who underwent endoscopic retrograde cholangiopancreatography because of bile leakage after hepatobiliary surgery from August 2009 to September 2014 were reviewed retrospectively. Endoscopic treatment included insertion of an endoscopic retrograde biliary drainage stent after endoscopic sphincterotomy. Results: Most cases of bile leakage presented as percutaneous bile drainage through a Jackson-Pratt bag (75%), followed by abdominal pain (20%). The sites of bile leaks were the cystic duct stump in 10 patients, intrahepatic ducts in five, liver beds in three, common hepatic duct in one, and common bile duct in one. Of the three cases of bile leakage combined with bile duct stricture, one patient had severe bile duct obstruction, and the others had mild strictures. Five cases of bile leakage also exhibited common bile duct stones. Concerning endoscopic modalities, endoscopic therapy for bile leakage was successful in 19 patients (95%). One patient experienced endoscopic failure because of an operation-induced bile duct deformity. One patient developed guidewire-induced microperforation during cannulation, which recovered with conservative treatment. One patient developed recurrent bile leakage, which required additional biliary stenting with sphincter-otomy. Conclusions: The endoscopic approach should be considered a first-line modality for the diagnosis and treatment of bile leakage after hepatobiliary surgery.

Case Review of Impacted Bile Duct Stone at Duodenal Papilla: Detection and Endoscopic Treatment

주광로,차재명,정성원,신현필,이정일,서유진,주선형,방성조 연세대학교의과대학 2010 Yonsei medical journal Vol.51 No.4

Purpose: A bile duct stone impacted at the duodenal papilla is an urgent condition that can rapidly lead to either suppurative cholangitis or acute pancreatitis due to almost complete obstruction of the bilio-pancreatic outflow. This study evaluated the clinical characteristics and results of endoscopic treatment for a bile duct stone impacted at the duodenal papilla. Materials and Methods: Forty-six patients who had been diagnosed with an impacted papillary stone were retrospectively reviewed. Results: The typical features of acute cholangitis (Charcot’s triad) and pancreatitis were only observed only in 10 patients (21.7%) and 17 patients (37.0%), respectively. After the endoscopic retrograde cholangiopancreatography,30 patients (65.2%) were found to have a solitary stone impacting the duodenal papilla and 16 patients had one or more stones in the bile duct. On the radiological studies, the former patients were associated more commonly with no visible stone or no bile duct dilatation (p < 0.05). All impacted papillary stones were successfully removed by endoscopic sphincterotomy: 23 by a needle knife and 23 by a pull type papillotome. The procedure-related complications (n = 7, 4 bleeding, 3pancreatitis) were not serious and did not differ, based on endoscopic findings and the procedure used. Conclusion: A bile duct stone impacted at the duodenal papilla requires both clinical and radiographic evidence to support the diagnosis. Endoscopic sphincterotomy, either with a needle knife or a pull type papillotome,was safe and effective for removing the impacted papillary stone.

담도에 국한되어 증상을 유발한 석회쓸개즙 2 예

윤성우,이지영,하경호,이수경,한나,배효근,박선자 고신대학교 의과대학 2010 고신대학교 의과대학 학술지 Vol.25 No.2

Limy bile is a rare condition characterized by excessive precipitation of calcium carbonate in the gallbladder or bile duct. Recently we experienced two cases with obstructive jaundice in which limy bile in the common bile duct but not in the gallbladder for one case, and in the common bile duct and intra hepatic duct but not in the gallbladder for another case. The patients were treated by endoscopic sphincterotomy. Here, we report the cases and review the literature.