clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Sphincterotomy/Sphincteroplasty

for Papillary Dysfunction: Stenosing Papillitis

Frank G. Moody

Introduction

Simple division (5mm) of the anterior surface of the sphincter of Oddi (sphincterotomy) was utilized extensively in the mid 20th century for presumed biliary-pancreatic pain from biliary dyskinesia. Lack of success led to a more generous longer (2–3cm) division of the sphincter with formal sphincteroplasty with only marginal improvement in outcome. Our group and others have utilized a generous sphincteroplasty with division of the transampullary septum to include division of the pancreatic component of the sphincter; with this extended approach, we have achieved good to excellent results in appropriately selected patients. The rationale for the procedure is to allow free egress of bile and pancreatic juice into the duodenum after stimulation from ingestion of a meal. Stenting of even the septotomy can now be accomplished after endoscopic sphincteroplasty in experienced hands.

Indications and Contraindications

Preoperative Investigations and Preparation for Procedure

Preoperative Preparation

■A serious discussion with and commitment by the patient for postoperative narcotic detoxification is strongly suggested

■Perioperative antibiotics (clean-contaminated procedure)

■Perioperative prophylactic heparin and sequential compression devices (SCDs) to minimize venous thrombosis

Procedure:Transduodenal Spincteroplasty with Transampullary Septectomy

STEP 1

The abdomen is entered through the incision for prior cholecystectomy or through a midline incision.

Exposure is optimized by a Thompson retractor or some similar mechanical retractor.

After exploration, the duodenum and head of the pancreas are mobilized by a generous Kocher maneuver; the hepatic flexure of the colon is mobilized inferiorly, with care not to enter Gerotta’s fascia. The head of the pancreas is mobilized from the underlying vena cava and the aorta in the avascular plane behind the duodenum.

This wide mobilization allows access to the cystic duct remnant, common bile duct, and anterior surface of the junction of the middle and lower third of the 2nd part of the duodenum where the papilla of Vater resides; the papilla is usually readily palpable through depressing the lateral duodenal wall against the medical wall.

STEP 2

The biliary tree is intubated to accurately locate the papilla.

Access to the biliary tree is gained through a small opening in the cystic duct remnant or, if necessary, the common bile duct; the latter access can be avoided if you can confidently locate the ampulla by transduodenal palpation.

A 3-Fr. tapered, urethral filiform probe (or a small biliary Fogarty catheter) is passed through the common bile duct and into the duodenum to locate the papilla.

Suspicion of a common bile duct stone may require formal bile duct exploration. Rigid probes (e.g. Bakes dilators) should not be used, because the bile duct is vulnerable to perforation when papillary stenosis is present. Note the operator’s left hand supporting the intrapancreatic portion of the common bile duct as the filiform passes through the papilla.

STEP 3

A 2-cm anterior duodenotomy is made directly over where the filiform leaves the papilla.

Stay sutures are placed at the 2 and 8o’clock position to elevate the papilla up to the level of the duodenotomy.

An incision is made along an 11o’clock plane on the anterior surface of the papilla; use of small iris scissors facilitates transection of the sphincter – cautery should be avoided, because it obscures recognition of the mucosal edges.

Approximating the bile duct epithelium to the duodenal mucosa is carried out in sequential fashion with 5-0 polyglycolic acid sutures; the length of the sphincteroplasty (2–3cm) should be determined by a point where the bile duct separates from the duodenal wall. Care must be taken to precisely approximate the bile duct epithelium and duodenal mucosa in this area.

STEP 4

Papillary stenosis often is associated with marked deformity of the transampullary septum (the tissue that separates the intrapancreatic bile duct from the pancreatic duct within the papilla of Vater).

The ostia of the duct of Wirsung can be difficult to visualize; it may be necessary to gently probe the inferior lip of papilla with the smallest of lacrimal probes.

Once cannulated, the ostia should be dilated with one or two larger probes.

The septum can then be divided safely by a sharp scalpel incision (11 blade) for at least 1cm or to the point where the pancreatic duct measures at least 3mm; deformity or scarring in this region may make this difficult.

A pancreatogram should be obtained at this point if not already done.

STEP 5

The mucosa of the pancreatic duct is approximated to the bile duct epithelium with interrupted 7-0 polyglycolic acid suture utilizing a small ophthalmic needle; this figure reveals what the papilla should look like at completion of the operation. Note that the anterior surface of the papilla has been effaced, and that the bile duct and duct of Wirsung enter the duodenum through separate openings.

STEP 6

The duodenum is closed in two layers with an inner row of a fine absorbable suture, placed in a running Connell, mucosal-inverting fashion, and the outer layer of interrupted seromuscular non-absorbable sutures are placed in interrupted Lembert fashion.

A Jackson-Pratt or similar type of silicon closed-suction drain is positioned in the retroperitoneal bed of the duodenum, and a tag of omentum is sutured over the duodenotomy.

Local Postoperative Complications

■Early:

–Pancreatitis – usually postoperative day 1 – fever, abdominal pain, increased serum amylase

–Atelectasis – usually postoperative day 2 – fever, abnormal chest X-ray

–Cholangitis – usually postoperative day 3 – fever, jaundice

–Bilious drainage – usually postoperative day 3–7 – duodenal leak

–Wound infection – postoperative day 4–7 – fever, increased WBC, tender red wound

–Pulmonary embolus – postoperative day 7–10 – shortness of breath

–Gastrointestinal bleeding may occur from the sphincteroplasty site

■Late:

–Recurrent pain

–Recurrent stenosis of bile or pancreatic duct (± pancreatitis)

–Persistent narcotic dependence

Tricks of the Senior Surgeon

■Select your patients carefully.

■Wear a headlight and use optimal magnification (loops).

■Handle the papilla gently and with great respect.

■Insist on postoperative narcotic detoxification.

■Be kind and empathetic toward the patient with this form of addictive postcholecystectomy pain.

Pancreatic Enucleation

Geoffrey B. Thompson (Open Enucleation),

Michel Gagner (Laparoscopic Enucleation)

Introduction

Enucleation of functioning neuroendocrine neoplasms (insulinomas, selected gastrinomas) and non-functioning, well-circumscribed neuroendocrine neoplasms <2cm has been shown to be appropriate therapy for these benign neoplasms. Overtly malignant neuroendocrine neoplasms require a formal anatomic pancreatic resection.

Indications and Contraindications

– Selective arterial calcium stimulation test (insulinomas, gastrinomas)

– Selective use of octreotide scintigraphy