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Surgical Sphincteroplasty in 446 Patients PAPER Surgical Sphincteroplasty in 446 Patients James A. Madura, MD; James A. Madura II, MD; Stuart Sherman, MD; Glen A. Lehman, MD Hypothesis: Pancreaticobiliary sphincter disease is re- Results: Excellent or good results were seen in 86.8% liably diagnosed by endoscopic and intraoperative ma- of the patients with sphincter of Oddi dysfunction and nometry. in 63.5% of the patients with pancreas divisum. Com- mon duct and sphincter of Oddi pressures were 0 mm Hg Design: Retrospective review of prospectively col- in all patients after sphincteroplasty. Pancreatic duct and lected data. pancreatic sphincter manometry results were improved in 82.4% of the patients. Biopsy results of the main and Setting: A 400-bed urban university hospital. accessory sphincters demonstrated inflammation and/or fibrosis in 33.9% of ampullae and 43.5% of Patients: Between May 1, 1978, and March 27, 2002, transampullar septa, but this did not correlate with out- 446 patients were treated surgically for dysfunction of come. There was 1 death from a duodenal leak. Compli- the pancreaticobiliary sphincters. There were 376 fe- cations occurred in 34.8% of patients, with pancreatitis males and 70 males (mean±SD age, 41.6±12.5 years). (8.8%), asymptomatic hyperamylasemia (6.0%), and There were 372 patients with sphincter of Oddi dysfunc- wound/abdominal infection (7.1%) the most common. Predictive factors for good outcome were reduction in tion, and 74 with pancreas divisum. Symptoms in- pancreatic duct and sphincter pressures following cluded abdominal pain (100.0%), nausea/vomiting sphincteroplasty. (80.5%), back pain (57.2%), and pancreatitis (22.4%). Conclusion: Good to excellent results may be achieved Interventions: Perfusion manometry has evolved as the by surgical sphincteroplasty when careful patient selec- gold standard for diagnosis, and intraoperative manom- tion by manometry is used. etry was done in 214 patients. All patients underwent transduodenal sphincteroplasty and biopsies of the am- pullae and transampullar septa. Arch Surg. 2005;140:504-513 RANSDUODENAL SPHINC- 3-mm probe through the ampulla, and (3) teroplasty for stenosis of the an abnormal-appearing ampulloduodenal biliopancreatic sphincters junction on cholangiography. Subse- never achieved popularity quently, in patients with postcholecystec- because of lack of specific tomy biliary type symptoms, noninvasive di- diagnostic tools and criteria for opera- agnostic methods were proposed by Nardi T 1 tion. Once endoscopists developed the ca- and Acosta, with the morphine sulfate– pability to make a more secure diagnosis, neostigmine methylsulfate (Prostigmin) they quickly developed techniques to treat provocative test, but its lack of specificity the sphincter problems nonoperatively. resulted in skepticism in the surgical com- munity. However, there are recent reports See Invited Critique of its continuing use as a screening test, with good correlation with outcome. Intraop- at end of article erative biliary manometry and debimetry, as originally described by Caroli2 and later The surgical approach to the biliary modified by White et al,3 enjoyed some sphincteric mechanism originated in the late popularity but required an open surgical 19th century when it was used to extract procedure and again lacked specificity. No- otherwise irretrievable gallstones im- tably, abnormalities in the pancreatic duct pacted in the ampulla of Vater. However, and its sphincter were unable to be de- Author Affiliations: application of surgical sphincterotomy in the tected. It was not until the advent of endo- Departments of Surgery therapy of chronic pancreatitis was not as (Drs J. A. Madura and scopic retrograde cholangiopancreato- J. A. Madura II) and Medicine successful. Many surgeons reported (1) us- graphy (ERCP) and transendoscopic (Drs Sherman and Lehman), ing subjective evidence of sphincter dis- manometry that a reproducible effort The Indiana University Medical ease intraoperatively, such as a fibrotic- evolved to demonstrate anatomical and Center, Indianapolis. feeling ampulla, (2) failure to easily pass a pathophysiologic causes for the diagnosis (REPRINTED) ARCH SURG/ VOL 140, MAY 2005 WWW.ARCHSURG.COM 504 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 of these disorders. As technology developed, hyperten- samples were obtained before the injection and at 30-minute sive and fibrotic pancreaticobiliary sphincters were not only intervals thereafter for 4 hours. The samples were analyzed for identified but were treated therapeutically by endosco- amylase, lipase, aspartate aminotransferase, and alanine ami- pists. notransferase levels. The patients were also monitored for symp- This report details the surgical approach to pancre- toms of typical upper abdominal pain, nausea, and/or vomit- ing. A result was considered positive if the enzyme levels atic and biliary sphincters during the past 2 decades of increased by greater than 4 times the baseline values. the 20th century, and presents an experience with many The modified Caroli apparatus described by White et al3 was patients studied and treated by a team of gastroenterolo- attached via sterile intravenous tubing to a Silastic ventricular gists and a single surgeon (James A. Mudura). catheter carefully positioned in the supra-ampullary common duct. Two 1-minute measurements of the rate of flow of iso- METHODS tonic sodium chloride solution through the common bile duct were obtained, followed by measurement of the height of the column of isotonic sodium chloride solution remaining in PATIENTS the tubing. Normal flow was accepted as a mean±SD of 23±7 mL/min of isotonic sodium chloride solution, and normal pres- Between May 1, 1978, and March 27, 2002, 446 patients under- sure as a mean±SD of 11±4 mL of isotonic sodium chloride went transduodenal sphincteroplasty for stenosis or other abnor- solution. malities of the pancreaticobiliary sphincters. There were 376 fe- Low-flow perfusion capillary manometry was done intra- males and 70 males (mean±SD age, 41.6±12.5 years; range, 7-74 operatively with equipment similar to that used in endoscopic years). Of the 372 patients diagnosed as having sphincter of Oddi biliopancreatic manometry. A triple-lumen side perfusion cath- dysfunction (SOD), 100 were patients who had previously un- eter was inserted into the biliary and pancreatic ducts and slowly dergone sphincter ablation either endoscopically (n=73) or sur- withdrawn. It was attached to a low-pressure capillary perfu- gically (n=27). In the 74 patients with pancreas divisum (PD), sion device (Arndorfer Medical, Greenvale, Wis) that was con- 33 underwent previous sphincterotomy or sphincteroplasty. nected to an 8-channel data recorder (model MMS 200; Narco The patients’ symptoms had been present for an average of Biosystems, Austin, Tex). Serial pressures were recorded in the 35 months, and included abdominal pain in 100.0%, nausea biliary and pancreatic ducts and in their respective sphincters. and/or vomiting in 80.5%, referred back pain in 57.2%, diar- Results were compared with published standard basal pres- rhea in 25.8%, and documented pancreatitis in 22.4%. Other sures. The accepted norm for the diagnosis of SOD is a mean reported symptoms included weight loss in 17.7% and fatty food basal pressure higher than 40 mm Hg in the sphincter of Oddi intolerance in 23.8%. Prior operations included cholecystec- and the pancreatic sphincter. A pancreatic duct mean basal pres- tomy in 71.1%, gynecologic operations in 47.5%, and appen- sure of 24 mm Hg was accepted as the upper limit of normal in dectomy in 41.3%. Of all patients, 81.6% underwent preopera- these patients. tive ERCP, but not all underwent transendoscopic manometry. Cholecystectomy was performed in all patients who had not In addition, most patients underwent numerous investigative undergone it previously. Transduodenal sphincteroplasty was studies preoperatively to rule out other intra-abdominal dis- performed in a standard fashion through a longitudinal duo- ease as a source for their symptoms. denal incision centered over the major ampulla. The pancre- Initially in this group of patients, the morphine-neostigmine 1 atic orifice was identified and intubated with a metallic probe provocative test, as described by Nardi and Acosta, was done in to prevent pancreatic ductal occlusion during the biliary sphinc- 290 patients. Seventy-one patients consented to a postoperative teroplasty. The choledochal and duodenal mucosae were ap- test. Intraoperative evaluation of the sphincter of Oddi was done 3 proximated with fine absorbable sutures. Pancreatic duct and using a modified Caroli apparatus, as described by White et al, sphincter manometry was then performed, and data were re- in those patients suspected of having stenotic biliary pancreatic corded. If the initial pancreatic duct pressure was lower than sphincter mechanisms and in other patients undergoing routine 24 mm Hg, pancreatic duct sphincteroplasty was not done, which biliary surgery. Those patients with elevated common duct pres- occurred in 11 patients. Next, the pancreatic ductal orifice was sures and diminished transsphincteric flow were considered ap- opened and its edges were sewn to the choledochal mucosa with propriate candidates for transduodenal sphincteroplasty. All pa- synthetic nonabsorbable sutures. Finally, pancreatic duct and tients underwent intraoperative cholangiography to rule out pancreatic sphincter zone pressure measurements were ob-
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