Abstract The place of endoscopic sphincterotomy in the treatment of common duct stones leaving the gallbladder in situ remains controversial. Over a 3-year period, 20 elderly high-operative-risk patients with stones in the common duct and intact biliary tree were treated by endoscopic sphincterotomy leaving the gallbladder in situ. Two patients underwent cholecystectomy for persistent symptoms after endoscopic sphincterotomy, and 18 patients were discharged from hospital, with the gallbladder intact. Of the 18 patients, 6 developed recurrent gallbladder problems, with 3 of the 6 dying as a result of these problems. On review of our data, these six patients were in a group of eight who, at the time of original endoscopic retrograde cholangiography (ERC), were shown to have an obstructed cystic duct. The other 10 patients, with a patent cystic duct and discharged with gallbladder in situ, remained symptom free over a median follow-up period of 9 (range 2–42) months. We conclude that if the gallbladder does not fill at ERC (indicating probable cystic duct obstruction), cholecystectomy is warranted. When the gallbladder fills, regular follow-up alone is justified in the absence of symptoms.
Studies in animals have suggested a neural reflex between the gall bladder and the sphincter of Oddi. The aim of this study was to investigate whether sphincter of Oddi motility is altered by distension of the gall bladder in humans. Sphincter of Oddi motility was recorded intraoperatively in 10 patients undergoing elective cholecystectomy for gall stones. The manometry was performed by a triple lumen constantly perfused catheter which was introduced through the cystic duct and positioned across the sphincter of Oddi to record sphincter basal pressure, wave amplitude, and frequency of contractions. In five patients a separate catheter was introduced into the gall bladder after ligation of the cystic duct. This catheter was used to distend the gall bladder. Sphincter of Oddi pressures were measured before, during, and after the distension. In a separate control group of patients (n = 5) basal sphincter of Oddi activity was recorded without distension of the gall bladder. Distension of the gall bladder decreased sphincter of Oddi basal pressure from (mean (SD] 22.8 (8.5) mmHg to 18.6 (6.5) mmHg (p = 0.01, paired t test) and frequency of sphincter of Oddi contractions decreased from 2.6 (1.6) to 1.1 (1.3) contractions/min (p = 0.003, paired t test). The results were significantly different from those of the control group (p less than 0.05, unpaired t test) during the same time period (four minutes). Pulse rate and blood pressure were not affected by the gall bladder distension. The results suggest a local reflex between the gall bladder and the sphincter of Oddi that might be important in the regulation of the pressure within the bile ducts and flow across the sphincter. This reflex is likely to be neurally mediated and injuries to it may be important in the aetiology of postcholecystectomy sphincter of Oddi dysfunction.
Substance P containing nerves are widely distributed throughout the gastrointestinal tract. The aims of this study were to determine the distribution of substance P containing nerves in the extrahepatic biliary tree of the Australian brush‐tailed possum and to characterize the effect of exogenous substance P on the sphincter of Oddi (SO) motility and trans‐sphincteric flow in vivo. Immunohistochemical staining of fixed specimens (n = 8) found moderate numbers of substance P containing nerve cell bodies and fibres throughout the neural plexuses of the SO, in particular in the serosal and intraluminal nerve trunks of the SO and gallbladder. Synthetic porcine substance P (1–2000 ng kg −1 ), administered by close intra‐arterial injection (i.a. n = 7), produced a dose‐dependent elevation in basal pressure [P < 0.01] and an associated dose‐dependent reduction in trans‐sphincteric flow [P < 0.0001]. Substance P had no significant dose‐dependent effect on SO phasic contraction amplitude or frequency. Tetrodotoxin (9 μg kg −1 , i.a.) did not inhibit the effect of substance P on SO motility and trans‐sphincteric flow (n = 5). In conclusion, substance P containing nerves are found throughout the possum extrahepatic biliary tree. Exogenous substance P stimulates SO motility and reduces trans‐sphincteric flow in vivo by acting directly on the sphincter smooth muscle.
PURPOSE: Our aim was to prospectively evaluate pelvic floor retraining (PFR) in improving symptomatic fecal incontinence. METHODS: PFR was used to treat 30 patients with fecal incontinence (28 women; age range, 29-85 (median, 68) years). PFR was performed by a physiotherapist in the outpatient department according to a strict protocol and included biofeedback using an anal plug electromyometer. Manometry (24 patients), pudendal nerve terminal motor latency (PNTML, 16 patients), and anal ultrasound (14 patients) were done before commencing therapy. Independent assessment of symptoms was done at the commencement of therapy, at 6 weeks, and at 6 and 12 months posttherapy. RESULTS: Twenty patients (67 percent) had improved incontinence scores, with eight patients (27 percent) being completely or nearly free of symptoms. Of 28 patients followed up longer than six months, 14 achieved a 25 percent or greater improvement at six weeks, which was sustained in all cases. Fourteen had an initial improvement of less than 25 percent, with only four (29 percent) showing later improvement (P<0.0001). There was no relationship between results of the therapy and patient age, initial severity of symptoms, etiology of incontinence, and results of anal manometry, PNTML, and anal ultrasound. CONCLUSIONS: PFR is a physical therapy that should be considered as the initial treatment in patients with fecal incontinence. An improvement can be expected in up to 67 percent of patients. Initial good results can predict overall outcome.
The aim of this study was to assess the value of colonoscopy as a pen‐operative investigation in patients treated for colorectal cancer by surgical excision. Patients (134 male, 83 female) undergoing curative resection for colorectal carcinoma between August 1984 and January 1989 had colonoscopy within 3 months of surgery. Eleven patients (5%) had a synchronous cancer, which was diagnosed by colonoscopy in eight. In six of these eight, the diagnosis was made after surgery and 3 patients needed a second colectomy. However, in 3 patients the synchronous cancer was removed endoscopically without the need for further surgical resection. Most synchronous cancers had an earlier pathological stage than the index tumour. The rate of synchronous cancers was higher in patients with synchronous benign polyps (16%) than in those without polyps (3%). Colonoscopy is clearly justified as a peri‐operative investigation in all patients undergoing potentially curative resection of colorectal cancer. If possible, the examination should be carried out prior to surgery, to guide the extent of resection.
Upper abdominal symptoms after side-to-side choledochoduodenostomy (CDDY) may be attributed to stagnant bile, food and calculi pooling in the distal bile duct 'sump' with resultant biliary or pancreatic duct obstruction and sepsis. Endoscopic sphincterotomy (ES) provides a means of draining this sump. The aim of this study was to assess outcome following endoscopic retrograde choledochopancreatography (ERCP) and ES in patients with post-CDDY symptoms. Eight such patients (M: F = 1:7) underwent ERCP between September 1981 and March 1987. Their median age was 60 years (range: 37-72 years) and the median period since CDDY was 11 years (range: 1-28 years). The median follow-up after ERCP was 18 months (range: 14-94 months). Presenting symptoms comprised postprandial (one) or intermittent (seven) abdominal pain, cholangitis (three), pancreatitis (one) and jaundice (one). ERCP revealed bile duct abnormalities in four, consisting of filling defects alone (two), anastomotic narrowing with filling defects (one) and sclerosing cholangitis. ES was performed in seven, of whom three (all with filling defects at ERCP) remain asymptomatic and three are significantly improved. One had recurrent pancreatitis for which a sphincteroplasty and pancreatic duct septectomy was performed. ES was not performed in one because of technical difficulties (there being no subsequent improvement). It is concluded that, in patients with post-CDDY biliary symptoms, endoscopic sphincterotomy relieves the symptoms by either producing drainage of the sump at the distal bile duct, or dividing a dysfunctioning sphincter of Oddi.
The upper limit of the normal extrahepatic duct diameter when measured by sonography in our institution is less than half that when measured by endoscopic retrograde cholangiopancreatography (ERCP). The objective of this study was to locate possible sources of this discrepancy by comparing measurements obtained on the same patient by sonography, before and after ERCP. Thirty consecutive patients referred for ERCP were entered into a prospective trial; bile duct measurements were obtained independently by both techniques in 19 patients. Correcting for radiographic magnification, the ERCP measurement was more than twice that obtained by ultrasonography. Among the possible reasons for diverse results that we considered, radiographic magnification, ultrasonic underestimation, and distending effects of retrograde cholangiography (ERCP) were not found to be prominent causes for the marked discrepancy that we observed. The most likely explanation is that the duct in individual patients was being measured at a different level by the two techniques. A retrospective comparison of the studies obtained by each method suggests that the sonographic measurement is most often of the right hepatic duct. If this is the case, the two measurements show no statistically significant difference (P greater than 0.05). A prospective trial is needed to test this hypothesis.
Inducible nitric oxide synthase (iNOS) plays a major role in acute pancreatitis. Selective inhibitors of iNOS are being developed as therapeutic agents. Sphincter of Oddi (SO) dysfunction may cause pancreatitis and nitric oxide is necessary for SO relaxation. A new highly selective iNOS inhibitor, AR-C102222AA (AR-C), is evaluated together with the established iNOS inhibitor, L-N(6)-(1-iminoethyl)lysine (L-NIL), and the selective neuronal nitric oxide synthase (nNOS) blocker S-methyl-l-thiocitrulline (SMTC).In anaesthetized Australian Brush-tailed possums, the effect of topical, i.v. or i.a. administration of these drugs was evaluated on spontaneous SO motility, blood pressure (BP) and pancreatic vascular perfusion. SO motility was recorded by manometry and pancreatic vascular perfusion by laser Doppler fluxmetry. Also, the effect of SMTC and AR-C on electrical field stimulation (EFS)-induced non-cholinergic non-adrenergic (NANC) SO relaxation in vitro was evaluated.Infusion of AR-C (0.1-30 micromol kg(-1)) increased SO contraction frequency (P = 0.026) only at the two highest doses. L-NIL infusion (0.15 to 14.7 micromol kg(-1)) also increased SO contraction frequency at 8.8 micromol kg(-1) (P < 0.05) and reduced SO contraction amplitude at the two highest doses (P < 0.05). SMTC injections (0.5 nmol-2.4 micromol) produced a dose-dependent increase in SO contraction frequency (P = 0.009), but no effect was seen on the other parameters. In vitro SMTC (40-400 microm) inhibited EFS-induced NANC relaxation in a dose-dependent manner (P < 0.0005). In contrast AR-C (10-500 microm) had no effect on EFS-induced NANC relaxation (P > 0.05).At low doses, AR-C does not effect SO motility or EFS-induced NO mediated relaxation. However, high doses of AR-C and L-NIL in vivo influenced SO motility by inhibiting nNOS activity and these effects need be considered in relation to therapeutic doses of this agent.
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