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Transduodenal catheter sphincterotomy
MODERN OPERATIVE TECHNIC
Transduodenal Catheter Sphincterotomy TURHAN UYSAL, MD, FACS, Queens, New York
The purpose of this article is to i n t r o d u c e and describe a new technic r a t h e r t h a n to discuss sphincterotomies in detail. T h e technic is as follows.
Technic A f t e r the abdomen is opened, a choledochotomy is made in the usu~i m a n n e r . T h e c o m m o n bile duct is then explored by utilizing Bakes' dilators. A f t e r the diagnosis of a m p u l l a r y fibrosis is established, the d u o d e n u m is kocherized and a duodenotomy is made on its lateral wall at t h e level of the papilla. A p r o p e r sized F r e n c h c a t h e t e r is then passed through the choledochotomy into the duodenum and pulled distally. ( F i g u r e 1.) T h e size of the c a t h e t e r is Chosen a c c o r d b ~ co the stricture. The funnel-shaped tail of tLe c a t h e t e r should not pass through the n a r r o w e d s e g m e n t of the duct because it is l a r g e r t h a n its body; r a t h e r it should become engaged t h e r e i n as the c a t h e t e r is pulled. When enough t r a c t i o n is applied t o the catheter, the narrowed segment of the duct becomes splinted and immobilized on the c a t h e t a r and also becomes prolapsed toward the lumen. (tCigure 2.) T w o Number 4-0 c h r o m i c c a t g u t s u t u r e s a r e now applied to the edge of the papilla a t about the 3 o'clock position j u s t a few millimeters a p a r t f r o m each other. ( F i g u r e 2.) T h e sutures a r e left long. ~rhile the assistant holds the s u t u r e s u n d e r tension, the surgeon holds the c a t h e t e r in his left hand and, keeping his left index finger under lhe prolapsed p o r t i o n o f the duct, he incises the e n t i r e thickness of the strictured s e g m e n t between the sutures. T h e incision is extendcui s u p e r i o r l y until t h e catheter, which is umler tension, slips out o f the common duct, indieating complete division o f the s t r i c t u r e d segment. ~Ihi, ma~, ~m confirm,.~ by p a s s i n g Bake,, dilators. The blade ~f the knife should be directed t o w a r d the a x i s o f the c a t h e t e ~ a t all times, E a c h a u t u r e is now advanced to the proximal end o f t h e sphinc• * t e r ~ t o m y inciston m a lock i ngqe m a n n e r and tied indl~ d~ all~. ( F i g u r e ~l,) Suturing is not.absoluLely n ~ s ~ , r y . T h e p u r l ~ e o f Suturing iS n o t o n l y to
control the bleeding but also to possibly p r e v e n t rej o i n i n g and promote the healing by a p p r o x i m a t i n g the incised duodenal mdcosa and the duct wall• A portion of the duct, f o r biopsy purposes, m a y also be removed with ease using this technic. Now the d u o d e n o t o m y is closed longitudinally (not t r a n s versely) with one layer of flumber 4-0 silk. using seromuscular L e m b e r t technic• The choledochoto m y is also closed with i n t e r r u p t e d N u m b e r 5-0 silk w i t h o u t use of a T - t u b e [1-6]. The Morrison's • t pouch is drained. Because the s t r i c t u r e d segment of the common duct, splinteu on the catheter, becomes prolfipsed and t h e r e f o r e easily available to the surgeon f o r sphincterotomy, whefl the c a t h e t e r is pulled, this technic will r e n d e r ~ h i n c t e r o t o m y m o r e easy and safe t h a n the other technics [7-10].
Case Re port The patient (AM), a thirty-nine year old white woman, was admitted to St. John's Queens Hospital wittT the. chief complaint of intermittent epigastric pain associated with ~yspepsia. Complete work-up revealed cholelithiasis. She had had exploratory taparotomy and cholecystectomy on January 30, 1968, at which time the common duct looked normal and no stone was palpated in the common duct. Bile drained from the cystic duct,' when the clamp was released, was clear. Therefore, no operative cholangiogram was obtained~ Pathology re~,ort was chronic clipleeystitis with lithiasis. She became asymptomatic after the operation. A year later mild, intermittent pain began, which was occasionally associated with nausea but no vomiting. The pain, which also radiated to her back below the interscapular region, was not affected by food ingestion: The pain worsened graduMly and she was again admitted to the SL John's Queens Hospital on April 23, 1969. Laboratory data were as follows: Hemogram and urinalysis gave results within normal limits, and the urine was negative for porphyrins. Fasting blood sugar wa s 1 1 0 m g per~ c e n t and total bitirubin 0.6 rag, with
T r a n s d u o d e n a l C a t h e t e r Spt~inc'terolomy
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Figure 1. The catheter in the c o m m o n bile duct.
Figure 2. The distal c o m m o n duct iS immobilized and prolapsed when the catheter is pulled. Two sutures are up, plied a few millimeters apa~ from each other. The dotted line indicates the sphincterotomy incision.
Intravenous cholangiogram revealed the common d u c t to b e o f n o r m a l c a l i b e r , a n d t h e r e w e r e n o s t o n e s , B i l i a r y r a d i c l e s w e r e a l s o v i s u a l i z e d a n d ~hey s h o w e d no s t o n e s . G a s t r o i n t e s t i n a l s e r i e s , i n t r a v e n o u s p y e l o gram, roentgenogram of t h e chest, a n d b a r i u n ~ enema studies were reported as showing no abnormalities. The patient was discharged from St. John's Queens H o s p i t a l o n ~,lay 9, 1969 a s s h e w a s r e l u c t a n t In u n deruo an exploratory ol)eration. Because of unbearable attacks of abdominal pain she was then admitted to F l u s h i n g H o s p i t a l a n d M e d i c a l C e n t e r on M a y 22. S h e w a s e x p l o r e d o n M a y 23. b u t n o p a t h o l o g y could be f o u n d . T h e p a n c r e a s w a s e x a m i n e d t h o r o u g h l y . T h e common duct seemed normal and no stones were palp a i e d . N e v e r t h e l e s s . i t w a s d e c i d e d to e x p l o r e ti~e c o m m o n d u c t . A c h o l e d o c h o t o m y w a s m a d e j u s t below t h e junction with the cystic duct remnant. A Number 2 Bakes" dilator passed into the duodenum with difficulty but a Number 3 dilator would not pa~. The duodenum was kocherized and duodenotomy performed on its lateral border. It was attempted to pass a Number 3 B a k e s ' d i l a t o r u n d e r d i r e c t v i s i o n , b u t t h i s w a s ~msuccessful. The diagnosis of ampulla~\v fibrosis was obv i o u s . T r a n s d u o d e n a t c a t h e t e r s p h i n e t e r t ) t o m y w a s l~erf o r m e d a s d e s c r i b e d , a n d t h e p a t i e n t ires s i n c e b e e n free of abdominal pain.
Summary A n e w t e c h n i c of c h o l e d o c h a l s p h i n e t e r o t o m y u t i l i z i n g a F r e n c h e~atheter is describecl, a n d i t s
Figure 3. The completion of the opel#. lion. Both edges are st~lu~ed ~.ffh cor~ tinuous N~tr}b~r 4-.0 chrom{c c a l ~ t
use in a thirty-nhm y e a r o h ] w h i t e w o m a n i:s p r e sented. This patient had had eho|ecyst,eetomy |~ro formed for chronic cholecystitis with lithias~ in 1968o A y e a r l a t e r a m t ~ u l l a r y f i b r o s i s d e v e l o | ~ /'or which a transduodenal e~.,theter sphincter~tomy was performed. She has t~en a.~ymptomat~e ever since= References 1. Collins PF: Further ~xperiet~ce w~lh ~ m m o . * ~ ~ ~ suture w i t h o u t intrad~ctat dft~It~e f~ttO~,~n~ ( ~ t ~ ' ~ O chotomy. Brf! I S u ~ 54'. 854. HH~7. 2, Horgan E: RecOnstruc~otJ of co~m~on l~!e d~C¢~. A , ~ Sure 93: 1162. 1931, 3. Madden JL° McCann W J: R e ~ n ~ t ~ t ~ ¢ 1 ~ Q! ~ c~e~.~ b~te dt~ct by end to end a n ~ $ l ~ o s , ~ w ~ { h ~ t ~ ~ e Obstet 112, 305. 19~51. 4., Madden JL. Kand~l~ft S. ~¢:C,t~rln W~. ~ May !96~, O 56. Sure 15: 255. 196~. 107. 1965 5urg C y n i c Ob~,*e,t f ~ : ~ 2 .
S~r£ 138: 2,~. 1~:.~
193:~.
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Transduodenal Catheter Sphincterotomy TURHAN UYSAL, MD, FACS, Queens, New York
The purpose of this article is to i n t r o d u c e and describe a new technic r a t h e r t h a n to discuss sphincterotomies in detail. T h e technic is as follows.
Technic A f t e r the abdomen is opened, a choledochotomy is made in the usu~i m a n n e r . T h e c o m m o n bile duct is then explored by utilizing Bakes' dilators. A f t e r the diagnosis of a m p u l l a r y fibrosis is established, the d u o d e n u m is kocherized and a duodenotomy is made on its lateral wall at t h e level of the papilla. A p r o p e r sized F r e n c h c a t h e t e r is then passed through the choledochotomy into the duodenum and pulled distally. ( F i g u r e 1.) T h e size of the c a t h e t e r is Chosen a c c o r d b ~ co the stricture. The funnel-shaped tail of tLe c a t h e t e r should not pass through the n a r r o w e d s e g m e n t of the duct because it is l a r g e r t h a n its body; r a t h e r it should become engaged t h e r e i n as the c a t h e t e r is pulled. When enough t r a c t i o n is applied t o the catheter, the narrowed segment of the duct becomes splinted and immobilized on the c a t h e t a r and also becomes prolapsed toward the lumen. (tCigure 2.) T w o Number 4-0 c h r o m i c c a t g u t s u t u r e s a r e now applied to the edge of the papilla a t about the 3 o'clock position j u s t a few millimeters a p a r t f r o m each other. ( F i g u r e 2.) T h e sutures a r e left long. ~rhile the assistant holds the s u t u r e s u n d e r tension, the surgeon holds the c a t h e t e r in his left hand and, keeping his left index finger under lhe prolapsed p o r t i o n o f the duct, he incises the e n t i r e thickness of the strictured s e g m e n t between the sutures. T h e incision is extendcui s u p e r i o r l y until t h e catheter, which is umler tension, slips out o f the common duct, indieating complete division o f the s t r i c t u r e d segment. ~Ihi, ma~, ~m confirm,.~ by p a s s i n g Bake,, dilators. The blade ~f the knife should be directed t o w a r d the a x i s o f the c a t h e t e ~ a t all times, E a c h a u t u r e is now advanced to the proximal end o f t h e sphinc• * t e r ~ t o m y inciston m a lock i ngqe m a n n e r and tied indl~ d~ all~. ( F i g u r e ~l,) Suturing is not.absoluLely n ~ s ~ , r y . T h e p u r l ~ e o f Suturing iS n o t o n l y to
control the bleeding but also to possibly p r e v e n t rej o i n i n g and promote the healing by a p p r o x i m a t i n g the incised duodenal mdcosa and the duct wall• A portion of the duct, f o r biopsy purposes, m a y also be removed with ease using this technic. Now the d u o d e n o t o m y is closed longitudinally (not t r a n s versely) with one layer of flumber 4-0 silk. using seromuscular L e m b e r t technic• The choledochoto m y is also closed with i n t e r r u p t e d N u m b e r 5-0 silk w i t h o u t use of a T - t u b e [1-6]. The Morrison's • t pouch is drained. Because the s t r i c t u r e d segment of the common duct, splinteu on the catheter, becomes prolfipsed and t h e r e f o r e easily available to the surgeon f o r sphincterotomy, whefl the c a t h e t e r is pulled, this technic will r e n d e r ~ h i n c t e r o t o m y m o r e easy and safe t h a n the other technics [7-10].
Case Re port The patient (AM), a thirty-nine year old white woman, was admitted to St. John's Queens Hospital wittT the. chief complaint of intermittent epigastric pain associated with ~yspepsia. Complete work-up revealed cholelithiasis. She had had exploratory taparotomy and cholecystectomy on January 30, 1968, at which time the common duct looked normal and no stone was palpated in the common duct. Bile drained from the cystic duct,' when the clamp was released, was clear. Therefore, no operative cholangiogram was obtained~ Pathology re~,ort was chronic clipleeystitis with lithiasis. She became asymptomatic after the operation. A year later mild, intermittent pain began, which was occasionally associated with nausea but no vomiting. The pain, which also radiated to her back below the interscapular region, was not affected by food ingestion: The pain worsened graduMly and she was again admitted to the SL John's Queens Hospital on April 23, 1969. Laboratory data were as follows: Hemogram and urinalysis gave results within normal limits, and the urine was negative for porphyrins. Fasting blood sugar wa s 1 1 0 m g per~ c e n t and total bitirubin 0.6 rag, with
T r a n s d u o d e n a l C a t h e t e r Spt~inc'terolomy
r .(
.
::?- >
;.: ~ i~ ' ~
3~
'
!
XX.\
..... " ..... gM~-
Figure 1. The catheter in the c o m m o n bile duct.
Figure 2. The distal c o m m o n duct iS immobilized and prolapsed when the catheter is pulled. Two sutures are up, plied a few millimeters apa~ from each other. The dotted line indicates the sphincterotomy incision.
Intravenous cholangiogram revealed the common d u c t to b e o f n o r m a l c a l i b e r , a n d t h e r e w e r e n o s t o n e s , B i l i a r y r a d i c l e s w e r e a l s o v i s u a l i z e d a n d ~hey s h o w e d no s t o n e s . G a s t r o i n t e s t i n a l s e r i e s , i n t r a v e n o u s p y e l o gram, roentgenogram of t h e chest, a n d b a r i u n ~ enema studies were reported as showing no abnormalities. The patient was discharged from St. John's Queens H o s p i t a l o n ~,lay 9, 1969 a s s h e w a s r e l u c t a n t In u n deruo an exploratory ol)eration. Because of unbearable attacks of abdominal pain she was then admitted to F l u s h i n g H o s p i t a l a n d M e d i c a l C e n t e r on M a y 22. S h e w a s e x p l o r e d o n M a y 23. b u t n o p a t h o l o g y could be f o u n d . T h e p a n c r e a s w a s e x a m i n e d t h o r o u g h l y . T h e common duct seemed normal and no stones were palp a i e d . N e v e r t h e l e s s . i t w a s d e c i d e d to e x p l o r e ti~e c o m m o n d u c t . A c h o l e d o c h o t o m y w a s m a d e j u s t below t h e junction with the cystic duct remnant. A Number 2 Bakes" dilator passed into the duodenum with difficulty but a Number 3 dilator would not pa~. The duodenum was kocherized and duodenotomy performed on its lateral border. It was attempted to pass a Number 3 B a k e s ' d i l a t o r u n d e r d i r e c t v i s i o n , b u t t h i s w a s ~msuccessful. The diagnosis of ampulla~\v fibrosis was obv i o u s . T r a n s d u o d e n a t c a t h e t e r s p h i n e t e r t ) t o m y w a s l~erf o r m e d a s d e s c r i b e d , a n d t h e p a t i e n t ires s i n c e b e e n free of abdominal pain.
Summary A n e w t e c h n i c of c h o l e d o c h a l s p h i n e t e r o t o m y u t i l i z i n g a F r e n c h e~atheter is describecl, a n d i t s
Figure 3. The completion of the opel#. lion. Both edges are st~lu~ed ~.ffh cor~ tinuous N~tr}b~r 4-.0 chrom{c c a l ~ t
use in a thirty-nhm y e a r o h ] w h i t e w o m a n i:s p r e sented. This patient had had eho|ecyst,eetomy |~ro formed for chronic cholecystitis with lithias~ in 1968o A y e a r l a t e r a m t ~ u l l a r y f i b r o s i s d e v e l o | ~ /'or which a transduodenal e~.,theter sphincter~tomy was performed. She has t~en a.~ymptomat~e ever since= References 1. Collins PF: Further ~xperiet~ce w~lh ~ m m o . * ~ ~ ~ suture w i t h o u t intrad~ctat dft~It~e f~ttO~,~n~ ( ~ t ~ ' ~ O chotomy. Brf! I S u ~ 54'. 854. HH~7. 2, Horgan E: RecOnstruc~otJ of co~m~on l~!e d~C¢~. A , ~ Sure 93: 1162. 1931, 3. Madden JL° McCann W J: R e ~ n ~ t ~ t ~ ¢ 1 ~ Q! ~ c~e~.~ b~te dt~ct by end to end a n ~ $ l ~ o s , ~ w ~ { h ~ t ~ ~ e Obstet 112, 305. 19~51. 4., Madden JL. Kand~l~ft S. ~¢:C,t~rln W~. ~ May !96~, O 56. Sure 15: 255. 196~. 107. 1965 5urg C y n i c Ob~,*e,t f ~ : ~ 2 .
S~r£ 138: 2,~. 1~:.~
193:~.
~)t*.: C ~ ¢ ~