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PubMed2000

Manometry based randomised trial of endoscopic sphincterotomy for sphincter of Oddi dysfunction.

BACKGROUND: Endoscopic sphincterotomy for biliary-type pain after cholecystectomy remains controversial despite evidence of efficacy in some patients with a high sphincter of Oddi (SO) basal pressure (SO stenosis). AIM: To evaluate the effects of sphincterotomy in patients randomised on the basis of results from endoscopic biliary manometry. METHODS: Endoscopic biliary manometry was performed in 81 patients with biliary-type pain after cholecystectomy who had a dilated bile duct on retrograde cholangiography, transient increases in liver enzymes after episodes of pain, or positive responses to challenge with morphine/neostigmine. The manometric record was categorised as SO stenosis, SO dyskinesia, or normal, after which the patient was randomised in each category to sphincterotomy or to a sham procedure in a prospective double blind study. Symptoms were assessed at intervals of three months for 24 months by an independent observer, and the effects of sphincterotomy on sphincter function were monitored by repeat manometry after three and 24 months. RESULTS: In the SO stenosis group, symptoms improved in 11 of 13 patients treated by sphincterotomy and in five of 13 subjected to a sham procedure (p = 0.041). When manometric records were categorised as dyskinesia or normal, results from sphincterotomy and sham procedures did not differ. Complications were rare, but included mild pancreatitis in seven patients (14 episodes) and a collection in the right upper quadrant, presumably related to a minor perforation. At three months, the endoscopic incision was extended in 19 patients because of manometric evidence of incomplete division of the sphincter. CONCLUSION: In patients with presumed SO dysfunction, endoscopic sphincterotomy is helpful in those with manometric features of SO stenosis.

Adult↗
PubMed2000

Quantitative hepatobiliary scintigraphy and endoscopic sphincter of Oddi manometry in patients with suspected sphincter of Oddi dysfunction: assessment of flow-pressure relationship in the biliary tract.

OBJECTIVE: In the present study, the diagnostic efficacy of quantitative hepatobiliary scintigraphy (QHBS) was compared with that of endoscopic sphincter of Oddi (SO) manometry (ESOM) in patients with a suspected SO dysfunction (SOD) of biliary type II or III. METHODS: Twenty cholecystectomized patients with SOD biliary types II and III were investigated by QHBS and by ESOM. Twenty asymptomatic cholecystectomized patients served as controls for scintigraphy. ESOM was performed by applying the station pull-through method. Then SO basal pressure and phasic contraction characteristics were determined. During QHBS, time-activity curves were generated, and the time-to-peak (Tmax), the half-time of excretion (T(1/2)), the duodenal appearance time (DAT) and the hilum-to-duodenum transit time (HDTT) were then calculated. At the 60th minute of QHBS, 5 ng/kg body weight/min caerulein was administered. RESULTS: In patients with SOD and elevated SO basal pressure (> 40 mmHg), QHBS parameters, such as Tmax and T(1/2) calculated from regions of interest over the hepatic hilum and common bile duct, HDTT and DAT proved to be significantly increased compared to controls: 28.7 +/- 4.3 versus 21.1 +/- 4.6 min, 39.7 +/- 15.4 versus 18.8 +/- 2.6 min, 9.0 +/- 3.6 versus 2.3 +/- 1.3 min and 27.1 +/- 4.9 versus 16.6 +/- 3.0 min, respectively. In contrast, in patients with SOD and normal SO basal pressure, QHBS parameters did not differ significantly from the controls. For the pooled data on the symptomatic patients with SOD, a statistically significant linear correlation was found between the SO basal pressure and the QHBS parameters. Although HDTT was the most sensitive scintigraphic parameter (89%), the combined sensitivity and specificity of Tmax and T(1/2) of the common bile duct reached 100%. No scintigraphic sign of a paradoxical response to cholecystokinin was detected. CONCLUSIONS: QHBS is a useful non-invasive diagnostic method for the selection of SOD patients with an elevated SO basal pressure. A significant correlation has been established between the trans-papillary bile flow measured by QHBS and the SO basal pressure determined by ESOM.

Adult↗