HPB Surgery, 1996, Vol.9, pp.199-207 (C) 1996 OPA (Overseas Publishers Association) Reprints available directly from the publisher Amsterdam B.V. Published in The Netherlands Photocopying permitted by license only by Harwood Academic Publishers GmbH Printed in Malaysia Transduodenal Sphincteroplasty an.d Transampullary Septectomy for Papillary Stenos s S.B. KELLY and B.J. ROWLANDS Depa,rtment of Surgery, Institute of Clinical Science, Royal Victoria Hospital, Grosvenor Road, Belfast. BT12 6BJ (Received 10 February 1994) Twenty patients received transduodenal sphincteroplasty and transampullary septectomy between 1987 and 1993. Seven patients had post-cholecystectomy pain which was much improved or abolished in 5 of 7 patients at a mean follow-up of 4 years and 5 months. Four of five patients with chronic pancreatitis were improved at 3 years and 2 months. Three of five patients with recurrent acute pancreatitis were improved at 4 years and 5 months. One of three patients with chronic abdominal pain of hepatobiliary origin was improved at 3 years. Transduodenal sphincteroplasty and transampullary septectomy can relieve pain in patients with post-cholecystectomy pain, recurrent acute pancreatitis, chronic pancreatitis, and chronic abdominal pain of hepatobiliary origin, presumably by improving drainage of the obstructed ducts. KEY WORDS: Transduodenal sphincteroplasty transampullary septectomy papillary stenosis INTRODUCTION without hyperamylassaemia requires a transduodenal operation. Transduodenal sphincteroplasty and trans- The indications for performing transduodenal sphinc- ampullary septectomy should permanently abolish teroplasty and transampullary septectomy are contro- stenosis at both sites5. versial. What is known, however, is that a carefully The aim of this study was to assess the effectiveness performed ablation of the biliary and pancreatic com- of transduodenal sphincteroplasty and trans- ponents of the papilla and its sphincter will lead to ampullary septectomy in patients with post-cholecys- relief of episodic, incapacitating upper abdominal tectomy pain, recurrent acute pancreatitis, chronic pain in selected patients 1. Langenbuch first suggested pancreatitis and chronic abdominal pain of hepato- that stenosis of the sphincter of Oddi might cause biliary origin. This series is unusual in that the diagnosis biliary-like pain. Ever since, this condition has been was made by percutaneous transhepatic cholangio- recognised as a cause of upper abdominal pain occur- gram (PTC) in half of the patients. ring either as an isolated abnormality, or in associa- tion with gallbladder disease, pancreatitis, or both3. Obstruction to the terminal bile duct causing pain PATIENTS AND METHODS with or without jaundice can be treated by endoscopic papillotomy4. On the other hand, obstruction to Twenty patients received transduodenal sphinctero- the terminal pancreatic duct causing pain with or plasty and transampullary septectomy between 1987 and 1993. All patients had severe pain for more than two years which was refractory to medical therapy. Correspondence to: Professor B.J. Rowlands, Department of Surgery, Institute of Clinical Science, Royal Victoria Hospital, Mean age was 44 years (range 20-62 years) and sex Grosvenor Road, Belfast. BT12 6BJ. distribution was 10M: 10F. Operation was indicated 199 200 S.B. KELLY AND B.J. ROWLANDS for one of four different syndromes (Table 1). The chronic pancreatitis. Two patients developed pseu- patients were followed up at the out patient depart- docysts and both had a cyst-gastrostomy performed. ment and by telephone. One patient also had a pancreatic necrosectomy. The aetiology of the pancreatitis was due to gallstones (2), pancreas divisum (2), and alcohol Other investiga- Table 1 Indications for pancreatic sphincteroplasty. (1). tions included liver function tests, serum amylase, Patients M F Mean age gastroscopy, barium meal, barium enema, small bowel (yrs) series, and PABA test. Post-cholecystectomy pain 7 3 4 43 Recurrent acute pancreatitis 5 3 2 45 Chronic pancreatitis 5 3 2 40 3) Chronic pancreatitis Papillary Stenosis diagnosed at cholecystectomy 0 58 Five patients had upper abdominal pain radiating Papillary stenosis diagnosed before cholecystectomy 2 0 2 45 through to the back, accompanied by nausea and vomiting for 8 months to 17 years. These patients were followed up for a mean of 2 years and 7 months (range 1) Post-cholecystectomy pain year and 4 months-5 years and 11 months). Inter- mittent exacerbations of pain were generally not ac- Seven patients had chronic disabling pain in the companied by an elevation of the serum amylase. epigastrium or right hypochondrium which radiated Three patients had evidence of pancreatic exocrine through to the back and was accompanied by nausea insufficiency and two patients also had endocrine in- and vomiting. These patients were followed up for a sufficiency. Two patients had previously undergone mean of 4 years and 7 months (range year and 2 distal pancreatectomy and splenectomy and one pa- months-6 years and 8 months) after sphincteroplasty. tient had drainage of several pancreatic abscesses. The Nifedipine was successful at relieving the pain in aetiology of the pancreatitis was due to alcohol (3), only one of three patients. Intermittent jaundice was idiopathic (1), and pancreas divisum (1). The patient present in three patients. All patients had a chole- with pancreas divisum developed a pancreatico-pleu- cystectomy performed for gallstones 8 months to 13 ral fistula. ERCP revealed a dilated, ectatic pancreatic years earlier. Only one patient had an exploration of duct with a pseudocyst at the tail of the pancreas the common bile duct. Cannulation of the bile duct at draining into the fistula (Fig. 1). One patient had a ERCP in two patients produced pain identical to that small pseudocyst in the tail of the pancreas and a large of which they had been complaining. One of tliese splenic cyst (Fig. 2). Other investigations included patients had an endoscopic sphincterotomy, but al- liver function tests, serum amylase, gastroscopy, though this helped initially, it was only effective for 6 PABA test, and in one patient a percutaneous ultra- weeks and therefore a sphincteroplasty was performed sound-guided pancreatogram was attempted but this with an excellent result. Liver biopsy was performed in was unsuccessful. two patients and was normal. Other investigations included liver function tests, serum amylase, gastro- scopy, barium meal, barium enema, and oesophageal 4) Chronic abdominal pain of hepatobiliary origin manometry. Three patients with chronic abdominal pain of hepatobiliary origin were followed up for a mean of 3 years and 3 months (range year and 6 months-6 2) Recurrent acute pancreatit& years and 4 months). One patient had a cholecys- Five patients had recurrent acute pancreatitis during tectomy for gallbladder stones. Operative cholan- the previous 3-14 years. These patients were followed giogram showed normal anatomy with no stones but up for a mean of 3 years and 4 months (range 9 no passage of contrast into the duodenum. Upon months-6 years) after sphincteroplasty. Attacks of inspection at laparotomy, excessive fibrosis of the pancreatitis were usually accompanied by hyperamy- papilla was found and so a sphincteroplasty was per- lassaemia and between episodes patients were largely formed. Stones were present in the gallbladder. Two free of pain. None were noted to have pancreatic patients presented with upper abdominal pain, vomit- exocrine or endocrine insufficiency. One patient had ing and cholestatic liver function tests. Pre-operative several episodes of jaundice. Two patients had pan- PTC confirmed papillary stenosis (Fig. 3). Both pa- creas divisum on ERCP but there was no evidence of tients had gallbaldder stones. PAPILLARY STENOSIS 201 Figure 1 ERCP demonstrating pancreas divisum, chronic pancreatitis and a pseudocyst at the tail of the pancreas connecting with a pancreatico-pleural fistula. Diagnosis Operative technique The various tests which were used for diagnosis, either An oblique incision is made in the second part of the singly or in combination, are listed in Table 2. The duodenum and the papilla is identified on the medial Nardi test (morphine-prostigmine provocation test), wall. A biliary sphincteroplasty 15-20 mm in length is which is somewhat controversial, relies on the repro- performed and the mucosae of the duodenum and duction of pain and a sharp rise in serum pancreatic common bile duct are coapted with 5/0 Vicryl sutures. enzymes (amylase, lipase or amidase). A positive test The orifice of the duct of Wirsung is then identified on requires a relatively normal pancreas secreting against the lower lip of the ampulla at 5 o'clock. The common a closed and competent sphincter. Serum amylase was septum between the terminal portions of the bile duct measured and symptoms recorded for hour after an and pancreatic duct is then incised for 10-15 mm, intramuscular injection of saline and for 4 hours after using fine-pointed scissors and sutures of 5/0 Vicryl to an intramuscular injection of morphine 10 mg plus coapt the mucosae. At the end of the procedure both prostigmine mg. The test was considered positive if ducts should be widely patent, presenting a double- the morphine-prostigmine injection reproduced pain barrelled appearance (Figure 4). The duodenotomy is and caused a fourfold elevation in serum amylase. closed in two layers with 2/0 Vicryl. 202 S.B. KELLY AND B.J. ROWLANDS Figure 2 CAT scan