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Follow-up of more than 10 years after endoscopic sphincterotomy for common bile duct stones in young patients
April 1998
Bfliary Disorders A543
G2220 THE INFLUENCE OF CHOLECYSTECTOMY ON THE PORCINE SPHINCTER OF ODDI. EA Stoner, AJK Piotrowicz, DF Evans, CC Hepworth, CC Ainley. GI Science research unit, St. Bartholomew's and the Royal London School of Medicine and Dentistry, London, U.K. Introduction Post cholecystectomy pain syndrome is reported to occur in about 5 % of patients following cholecystectomy. The aetiology of a proportion of such cases have been attributed to sphincter of Oddi (SO) dyskinesia. Neural pathways pass between the duodenum, gallbladder and SO and will be disrupted by cholecystectomy possibly altering the response of the SO to regulatory hormonal control. The porcine and human SO respond similarly to CCK. The porcine model may therefore be a useful to01 in the investigation of post cholecystectomy pain and SO dysfunction. The action of morphine sulphate (MS) on the porcine SO has not been reported to date but stimulates contraction in the human SO. Hypothesis: Cholecystectomy may lead to an alteration in the hormonal response of the SO. Aims: 1) To compare the action of CCK and MS on the SO following either a sham laparotomy or cholecystectomy. 2) To develop an animal model of SO dyskinesia. Methods: Fourteen pigs either underwent a cholecystectomy (Chole) or a laparotomy with manual manipulation of the gallbladder (sham laparotomy (SL)) and were recovered. 7-8 weeks later a laparotomy and duodenotomy was performed SO manometry was carded out using a perfused triple lumen catheter (Wilson-Cook, USA). A 30 minutes base line recording was made. CCK octapeptide (Sigma Chemicals, UK) was then infused intravenously at a rate of 10ng/kg/min for 30 minutes. A 30 minute washout period was then recorded. A bolus of MS (5mg) was then given intravenously and further measurements taken. Results: The data is represented below by the median values (25-75th percentiles).
Pre CCK CCK Pre MS MS
Basal press. (mmHg) SL Chole 9 (5-9) 10 (3-18) 3 (3-18) 9 (3-10) 6 (2-12) 9 (1-13) 12 (10-13) 11 (7-16)
Wave amplitude (mmHg) SL Chole 8 (0-8) 4 (0-10) 1 (0-4) 4 (3-8) 4 (4-7) 4 (0-4) 10 (4-12) 7 (4-12)
Wave frequency (mmHg) SL Chole 1 (0-3) 1 (0-3) 3 (0-4) 3 (3-4) 1 (1-2) 1 (0-3) 3 (3-3) 3 (2-4)
There was no statistical difference by the Mann Whitney U between the sham or cholecystectomy groups for either CCK or MS. When the groups are combined MS significantly (paired t test p<0.01) increases sphincter pressure. Condnsions There does not appear to be a difference in SO hormonal response following cholecystectorny. MS stimulates SO contraction in the pig as in man. The pig is likely to be a good animal model of SO function. • G2221 FOLLOW-UP OF MORE THAN 10 YEARS AFTER ENDOSCOPIC SPHINCTEROTOMY FOR COMMON BILE DUCT STONES IN YOUNG PATIENTS. M. Sugiyam~, M. Tokuhara, N. Hatano, M. Nakashima, T. Mori, Y. Atomi; The First Department of Surgery, Kyorin University School of Medicine, Tokyo, JAPAN Background: With the advent of laparoscopic cholecystectomy, the indications for endoscopic sphincterotomy (ES) have been extended to young patients with choledocholithiasis. However, the long-term results of ES are largely unknown. To evaluate the role of ES for choledocholithiasis in young patients, the current study analyzed the short-term and long-term (> 10 years) results of ES in young patients (_<60 years). Furthermore, the relation of stone classification and long-term outcomes was analyzed. Methods: Between 1977 and 1986, 115 patients younger than 60 years of age underwent ES for choledocholithiasis. Stone classifications, and early and long-term outcomes of ES were retrospectively analyzed. Results: Early complications occurred in nine patients (7.8%), but there were no mortalities. ES and stone clearance were successful in 110 patients, Longterm information was available in 103 of the 110 patients, with a mean overall follow-up duration of 14.2 years (range, 10.4-19.3 years). Ten patients (9.7%) developed late complications, including common bile duct stone recurrence and/or acute cholangitis (nine patients; seven with and two without papillary stenosis) and acute cholecystitis (one of 23 patients with the gallbladder in situ). Stone recurrence and cholangitis occurred 1.7-11.0 years (mean, 5.3 years) after ES. The choledochal complication rate was higher in patients with calcium bilirubinate stones at ES (seven of 69 patients) than in those with cholesterol stones (two of 41 patients). Choledochal complications were endoscopically manageable. Conclusion: Approximately 10% of patients develop late complications after ES. Careful follow-up after ES is necessary, particularly for patients with calcium bilirnbinate stones at ES. However, endoscopic re-treatment is safe and effective. ES is a reasonable alternative for treating choledocholithiasis, even in young patients.
• G2222 MAGNETIC RESONANCE CHOLANGIO-PANCREATOGRAPHY FOR DIAGNOSING ANOMALOUS PANCREATICOBILIARY JUNCTION. M. Sugivama, Y. Izumisato, M. Tokuhara, M. Nakashima, T. Mori, Y. Atomi, J. Hachiya; The First Department of Surgery and Department of Radiology, Kyofin University School of Medicine, Tokyo, JAPAN Aim: Anomalous pancreaticobiliary junction (APBJ) (a long common channel), with or without congenital choledochal cyst (CCC), is frequently associated with biliary tract carcinoma. Screening for APBJ is valuable in patients with suspected APBJ who show a dilated bile duct, polypoid gallbladder lesions (carcinomas or adenomas) or a diffusely thickened gallbladder mucosa (hyperplasia) on ultrasonography, or acute pancreatitis of unknown etiology. ERCP depicts APBJ most reliably but is invasive and there is a potential of morbidity. Accordingly, noninvasive and accurate techniques are needed for diagnosing APBJ. We assessed the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) for patients with APBJ. Method: In 192 adult patients with pancreatobiliary disease, breath-hold (1-18 sec) MRCP was performed using a 1.5-T superconductive unit (Magnetom Vision; Siemens, Germany) and a half-Fourier acquisition Singleshot turbo spin-echo (HASTE) sequence. In all patients, the length of the common channel demonstrated by MRCP was compared with that demonstrated by ERCP. In 13 patients with APBJ (the common channel > 15 mm on ERCP), the diagnostic accuracy of MRCP for associated biliary diseases was evaluated. Result: No complications were encountered in performing MRCP. On ERCP, the common channel measured 15-25 mm (mean, 19 ram) in patients with APBJ and 0-7 mm (mean, 4 ram) in those with normal junction. On MRCP, the length of the common channel was calculated to be 12-21 mm (mean, 16 ram) in 11 (85%) of 13 patients with APBJ. In the remaining two patients, the junction was not seen. In 158 (88%) of 179 patients with normal junction, MRCP identified the junction with the channel measuring 0 mm in length. MRCP failed to demonstrate the junction in the remaining 21 patients. When a 12-mm common channel length was a criterion for diagnosing APBJ by MRCP, the sensitivity and specificity were 85% and 100%, respectively. In patients with APBJ, MRCP allowed detailed visualization of CCC (all eight patients) but failed to depict carcinoma (one patient) and mucosal hyperplasia (seven patients) of the gallbladder. Conclusion: MRCP is a noninvasive and accurate imaging method for diagnosing APBJ and CCC. Patients with suspected APBJ should undergo further investigation utilizing MRCP. G2223 A BILIARY PAIN SCALE AS A PREDICTOR OF LONG-TERM OUTCOME AFTER SURGICAL SPHINCTEROPLASTY FOR PRIMARY SPHINCTER OF ODDI DYSFUNCTION. P.Sukumar, D.S.Kaplan, A.K.Roy, J.D.Halverson. Departments of Medicine and Surgery, SUNY Health Science Center, Syracuse NY. Predictors of favorable outcome after surgical sphincteroplasty for primary Sphincter of Oddi dysfunction (SOD) is variable. This study evaluated whether preoperative evaluation of symptoms using a new biliary pain scale correlated with clinical outcome after sphincteroplasty. Methods: 10 patients (10 females and 2 males, with mean age of 45.4yrs) with documented primary SOD (all had elevated basal sphincter pressure > 40ram of Hg on biliary manometry), underwent surgical sphincteroplasty after having failed endoscopic sphincterotomy. All patients had previous or concomitant cholecystectomy and had normal liver enzymes. Mean duration of follow up was 2.5 years. 8 patients were available for evaluation on follow-up. A biliary pain scale (0-I00) comprised of intensity, location, nature, duration, provocation, and relationship of pain to eating was used to evaluate the preoperative symptomatology. A pain analog scale (0-5) was used to assess the clinical response after sphincteroplasty. Results: Pre0p. biliary pain scale P0stop. pain analog scale Nonresponders 3/8 33.8 - 8.1 5 Complete responders 3/8 80.0 ± 10.0" 0 Partial responders 2/8 66.0 _+6.0 2.5 * p < 0.025 by unpaired _ttest between nonresponders and complete responders Conclusions: Several variables have been described in the literature as predictors of outcome after surgical sphincteroplasty for primary SOD. Based on our study we conclude that a total biliary pain score of < 50 prior to surgery correlates with poor clinical outcome. This pain scale may be useful as a noninvasive test to predict successful outcome from surgical sphincteroplasty for primary SOD.
Bfliary Disorders A543
G2220 THE INFLUENCE OF CHOLECYSTECTOMY ON THE PORCINE SPHINCTER OF ODDI. EA Stoner, AJK Piotrowicz, DF Evans, CC Hepworth, CC Ainley. GI Science research unit, St. Bartholomew's and the Royal London School of Medicine and Dentistry, London, U.K. Introduction Post cholecystectomy pain syndrome is reported to occur in about 5 % of patients following cholecystectomy. The aetiology of a proportion of such cases have been attributed to sphincter of Oddi (SO) dyskinesia. Neural pathways pass between the duodenum, gallbladder and SO and will be disrupted by cholecystectomy possibly altering the response of the SO to regulatory hormonal control. The porcine and human SO respond similarly to CCK. The porcine model may therefore be a useful to01 in the investigation of post cholecystectomy pain and SO dysfunction. The action of morphine sulphate (MS) on the porcine SO has not been reported to date but stimulates contraction in the human SO. Hypothesis: Cholecystectomy may lead to an alteration in the hormonal response of the SO. Aims: 1) To compare the action of CCK and MS on the SO following either a sham laparotomy or cholecystectomy. 2) To develop an animal model of SO dyskinesia. Methods: Fourteen pigs either underwent a cholecystectomy (Chole) or a laparotomy with manual manipulation of the gallbladder (sham laparotomy (SL)) and were recovered. 7-8 weeks later a laparotomy and duodenotomy was performed SO manometry was carded out using a perfused triple lumen catheter (Wilson-Cook, USA). A 30 minutes base line recording was made. CCK octapeptide (Sigma Chemicals, UK) was then infused intravenously at a rate of 10ng/kg/min for 30 minutes. A 30 minute washout period was then recorded. A bolus of MS (5mg) was then given intravenously and further measurements taken. Results: The data is represented below by the median values (25-75th percentiles).
Pre CCK CCK Pre MS MS
Basal press. (mmHg) SL Chole 9 (5-9) 10 (3-18) 3 (3-18) 9 (3-10) 6 (2-12) 9 (1-13) 12 (10-13) 11 (7-16)
Wave amplitude (mmHg) SL Chole 8 (0-8) 4 (0-10) 1 (0-4) 4 (3-8) 4 (4-7) 4 (0-4) 10 (4-12) 7 (4-12)
Wave frequency (mmHg) SL Chole 1 (0-3) 1 (0-3) 3 (0-4) 3 (3-4) 1 (1-2) 1 (0-3) 3 (3-3) 3 (2-4)
There was no statistical difference by the Mann Whitney U between the sham or cholecystectomy groups for either CCK or MS. When the groups are combined MS significantly (paired t test p<0.01) increases sphincter pressure. Condnsions There does not appear to be a difference in SO hormonal response following cholecystectorny. MS stimulates SO contraction in the pig as in man. The pig is likely to be a good animal model of SO function. • G2221 FOLLOW-UP OF MORE THAN 10 YEARS AFTER ENDOSCOPIC SPHINCTEROTOMY FOR COMMON BILE DUCT STONES IN YOUNG PATIENTS. M. Sugiyam~, M. Tokuhara, N. Hatano, M. Nakashima, T. Mori, Y. Atomi; The First Department of Surgery, Kyorin University School of Medicine, Tokyo, JAPAN Background: With the advent of laparoscopic cholecystectomy, the indications for endoscopic sphincterotomy (ES) have been extended to young patients with choledocholithiasis. However, the long-term results of ES are largely unknown. To evaluate the role of ES for choledocholithiasis in young patients, the current study analyzed the short-term and long-term (> 10 years) results of ES in young patients (_<60 years). Furthermore, the relation of stone classification and long-term outcomes was analyzed. Methods: Between 1977 and 1986, 115 patients younger than 60 years of age underwent ES for choledocholithiasis. Stone classifications, and early and long-term outcomes of ES were retrospectively analyzed. Results: Early complications occurred in nine patients (7.8%), but there were no mortalities. ES and stone clearance were successful in 110 patients, Longterm information was available in 103 of the 110 patients, with a mean overall follow-up duration of 14.2 years (range, 10.4-19.3 years). Ten patients (9.7%) developed late complications, including common bile duct stone recurrence and/or acute cholangitis (nine patients; seven with and two without papillary stenosis) and acute cholecystitis (one of 23 patients with the gallbladder in situ). Stone recurrence and cholangitis occurred 1.7-11.0 years (mean, 5.3 years) after ES. The choledochal complication rate was higher in patients with calcium bilirubinate stones at ES (seven of 69 patients) than in those with cholesterol stones (two of 41 patients). Choledochal complications were endoscopically manageable. Conclusion: Approximately 10% of patients develop late complications after ES. Careful follow-up after ES is necessary, particularly for patients with calcium bilirnbinate stones at ES. However, endoscopic re-treatment is safe and effective. ES is a reasonable alternative for treating choledocholithiasis, even in young patients.
• G2222 MAGNETIC RESONANCE CHOLANGIO-PANCREATOGRAPHY FOR DIAGNOSING ANOMALOUS PANCREATICOBILIARY JUNCTION. M. Sugivama, Y. Izumisato, M. Tokuhara, M. Nakashima, T. Mori, Y. Atomi, J. Hachiya; The First Department of Surgery and Department of Radiology, Kyofin University School of Medicine, Tokyo, JAPAN Aim: Anomalous pancreaticobiliary junction (APBJ) (a long common channel), with or without congenital choledochal cyst (CCC), is frequently associated with biliary tract carcinoma. Screening for APBJ is valuable in patients with suspected APBJ who show a dilated bile duct, polypoid gallbladder lesions (carcinomas or adenomas) or a diffusely thickened gallbladder mucosa (hyperplasia) on ultrasonography, or acute pancreatitis of unknown etiology. ERCP depicts APBJ most reliably but is invasive and there is a potential of morbidity. Accordingly, noninvasive and accurate techniques are needed for diagnosing APBJ. We assessed the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) for patients with APBJ. Method: In 192 adult patients with pancreatobiliary disease, breath-hold (1-18 sec) MRCP was performed using a 1.5-T superconductive unit (Magnetom Vision; Siemens, Germany) and a half-Fourier acquisition Singleshot turbo spin-echo (HASTE) sequence. In all patients, the length of the common channel demonstrated by MRCP was compared with that demonstrated by ERCP. In 13 patients with APBJ (the common channel > 15 mm on ERCP), the diagnostic accuracy of MRCP for associated biliary diseases was evaluated. Result: No complications were encountered in performing MRCP. On ERCP, the common channel measured 15-25 mm (mean, 19 ram) in patients with APBJ and 0-7 mm (mean, 4 ram) in those with normal junction. On MRCP, the length of the common channel was calculated to be 12-21 mm (mean, 16 ram) in 11 (85%) of 13 patients with APBJ. In the remaining two patients, the junction was not seen. In 158 (88%) of 179 patients with normal junction, MRCP identified the junction with the channel measuring 0 mm in length. MRCP failed to demonstrate the junction in the remaining 21 patients. When a 12-mm common channel length was a criterion for diagnosing APBJ by MRCP, the sensitivity and specificity were 85% and 100%, respectively. In patients with APBJ, MRCP allowed detailed visualization of CCC (all eight patients) but failed to depict carcinoma (one patient) and mucosal hyperplasia (seven patients) of the gallbladder. Conclusion: MRCP is a noninvasive and accurate imaging method for diagnosing APBJ and CCC. Patients with suspected APBJ should undergo further investigation utilizing MRCP. G2223 A BILIARY PAIN SCALE AS A PREDICTOR OF LONG-TERM OUTCOME AFTER SURGICAL SPHINCTEROPLASTY FOR PRIMARY SPHINCTER OF ODDI DYSFUNCTION. P.Sukumar, D.S.Kaplan, A.K.Roy, J.D.Halverson. Departments of Medicine and Surgery, SUNY Health Science Center, Syracuse NY. Predictors of favorable outcome after surgical sphincteroplasty for primary Sphincter of Oddi dysfunction (SOD) is variable. This study evaluated whether preoperative evaluation of symptoms using a new biliary pain scale correlated with clinical outcome after sphincteroplasty. Methods: 10 patients (10 females and 2 males, with mean age of 45.4yrs) with documented primary SOD (all had elevated basal sphincter pressure > 40ram of Hg on biliary manometry), underwent surgical sphincteroplasty after having failed endoscopic sphincterotomy. All patients had previous or concomitant cholecystectomy and had normal liver enzymes. Mean duration of follow up was 2.5 years. 8 patients were available for evaluation on follow-up. A biliary pain scale (0-I00) comprised of intensity, location, nature, duration, provocation, and relationship of pain to eating was used to evaluate the preoperative symptomatology. A pain analog scale (0-5) was used to assess the clinical response after sphincteroplasty. Results: Pre0p. biliary pain scale P0stop. pain analog scale Nonresponders 3/8 33.8 - 8.1 5 Complete responders 3/8 80.0 ± 10.0" 0 Partial responders 2/8 66.0 _+6.0 2.5 * p < 0.025 by unpaired _ttest between nonresponders and complete responders Conclusions: Several variables have been described in the literature as predictors of outcome after surgical sphincteroplasty for primary SOD. Based on our study we conclude that a total biliary pain score of < 50 prior to surgery correlates with poor clinical outcome. This pain scale may be useful as a noninvasive test to predict successful outcome from surgical sphincteroplasty for primary SOD.