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The comprehensive management of gallbladder disease includes not only understanding the principles of safe cholecystectomy, intraoperative cholangiography, and bile duct exploration but also the familiarity of the current endoscopic and surgical therapies for the known associated morbidities and special scenarios. In this chapter, we will review several advanced biliary procedures including both endoscopic and minimally invasive surgical bilioenteric anastomoses as well as transduodenal sphincteroplasty with contemporary approaches, indications, technical description, and existing supportive evidence.

Common bile duct stones have been noted in 10-15% of patients with gall stones, these stones are either primary (formed in the common bile duct) or secondary (formed in the gallbladder and migrate down to the common bile duct). Their management includes ERCP (Endoscopic Retrograde Choledochopancreatography), biliary drainage procedure and choledochal exploration. In this interventional study, we compare between transduodenal sphincteroplasty and choledochoduodenostomy regarding morbidity (anastamotic and duodenal leak, cholangitis, and pancreatitis) and mortality related to each surgical option. A review of 68 patients with lower common bile duct stones presents with different clinical presentations in an interventional study carried in Basrah General Hospital and Al–Moussawi Private Hospital, 22 patients underwent transduodenal sphincteroplasty and, 46 patients underwent choledochoduodenostomy. Both groups received general anesthesia and comparable in age and sex. Statistical analysis done by SPSS (Statistical Package for Social Sciences) version 18. Age and sex are comparable in both groups, the incidence of postoperative cholangitis is 9.09% in the transduodenal sphincteroplasty group and 32.6%in choledochoduodenostomy group which is statistically significant (P value 0.01). The incidence of duodenal and anastamotic leak is 13.6% and 10.9% in transduodenal sphincteroplasty and choledochoduodenostomy group respectively which is statistically not significant (P value 0.707). The incidence of postoperative pancreatitis is 0% and 8.7% in transduodenal sphincteroplasty and choledochoduodenostomy group respectively which is statistically not significant (P value 0.296). The mortality is 0% after transduodenal sphincteroplasty and 6.5% after choledochoduodenostomy. In conclusion, transduodenal sphincteroplasty is better than choledochoduodenostomy in the management of lower common bile duct stones, less postoperative cholangitis, pancreatitis, and lower mortality rate.

症例は63歳,男性.総胆管結石症のため19年前に経十二指腸乳頭括約筋形成術およびTチューブドレナージ術を受けた.逆行性胆管炎を繰り返した後,腹部超音波検査にて肝左葉に径9cmの腫瘍を認めたため入院となった.血中CA19-9は1, 272.5U/mlと上昇していた.腫瘍はCTにて不規則に造影される低吸収域として,血管造影では乏血性の腫瘍としてみられた.内視鏡的逆行性胆管造影では左側肝内胆管の狭窄像を認め,肝内胆管癌を疑い肝拡大左葉+S1切除兼胆管切除,右肝管空腸吻合術を施行した.病理診断は肝内転移を有する末梢型の中分化型胆管細胞癌であった.随伴する慢性胆管炎と肝内結石は腫瘍発生の誘因として考えられた.術後経過は良好であったが, 17カ月目に再発のため死亡した.経十二指腸乳頭括約筋形成術による乳頭機能廃絶のため招来される逆行性胆管炎は胆管癌発生との関与が指摘されており,経過観察には十分な注意を要する.

Background Transduodenal sphincteroplasty (TDS) offers permanent prophylaxis against further stones in the common bile duct (CBD) by allowing continuous free efflux of bile from the papilla. Patients and results In a personal series of 267 consecutive operations, four patients underwent further treatment for recurrent CBD stones during a median follow‐up of 12 years. Three of them received Roux‐en‐Y biliary diversion and had no further symptoms; the fourth patient remains well four years after endoscopic extraction of stones. Discussion Recurrent stone formation is rare after an adequate TDS and probably reflects retained food debris within the CBD. Initial treatment may be endoscopic, but biliary diversion is needed for those with recurrent symptoms.

A case of isolated candidal fungal balls in the common bile duct causing obstructive jaundice and cholangitis is described. There were no predisposing factors. The fungal balls were removed from the common bile duct and a transduodenal sphincteroplasty was performed. Microscopic analysis yielded colonies of candida. Postoperative period was uneventful. At follow-up no evidence of candida infection was evident. He is now 3 years post-surgery and is well.

Transduodenal sphincteroplasty is used when other methods of clearing the common bile duct have failed. A similar approach is sometimes used for local excision of small ampullary adenomas. This chapter details the technique, pitfalls, and strategies for avoiding complications during performance of this procedure.

Common bile duct stones, obstructive jaundice, cholangitis and acute pancreatitis are diseases that can lead to serious complications. In our clinic between May 1993 and October 2011 the results of 101 patients who underwent surgery for common bile duct stone were retrospectively evaluated. Among 101 patients who were included in the study, 45 had symptomatic gallstones accompanied by common bile duct stone, 27 had mechanical icterus, 15 had common bile duct stone and 8 had cholangitis (five patients with suppurative cholangitis), six had acute cholecystitis. Thirthy one patients with common bile duct stones were treated with endoscopic retrograde cholangiopancreatography (ERCP). Surgical procedures were as follows; choledochoduodenostomy in 50 cases, T-tube drainage in 17 patients and transduodenal sphincteroplasty in three patients. Synchronous cholecystectomies were performed in all patients who had not undergone biliary surgery before. Early postoperative mortality was 3.9%. In this study, we detected choledocholithiasis in 11.31% of the all symptomatic cholelithiasis cases. Since our clinic provide tertiary healthcare, this rate becomes 9.85% by excluding those who underwent cholecystectomy for common bile duct stones at other hospitals. Given that the patients who referred to our clinic are in high-risk group, the actual rate of choledocholithiasis in our society is expected to be slightly below that value.

Common bile duct stones, obstructive jaundice, cholangitis and acute pancreatitis are diseases that can lead to serious complications. In our clinic between May 1993 and October 2011 the results of 101 patients who underwent surgery for common bile duct stone were retrospectively evaluated. Among 101 patients who were included in the study, 45 had symptomatic gallstones accompanied by common bile duct stone, 27 had mechanical icterus, 15 had common bile duct stone and 8 had cholangitis (five patients with suppurative cholangitis), six had acute cholecystitis. Thirthy one patients with common bile duct stones were treated with endoscopic retrograde cholangiopancreatography (ERCP). Surgical procedures were as follows; choledochoduodenostomy in 50 cases, T-tube drainage in 17 patients and transduodenal sphincteroplasty in three patients. Synchronous cholecystectomies were performed in all patients who had not undergone biliary surgery before. Early postoperative mortality was 3.9%. In this study, we detected choledocholithiasis in 11.31% of the all symptomatic cholelithiasis cases. Since our clinic provide tertiary healthcare, this rate becomes 9.85% by excluding those who underwent cholecystectomy for common bile duct stones at other hospitals. Given that the patients who referred to our clinic are in high-risk group, the actual rate of choledocholithiasis in our society is expected to be slightly below that value. © 2013 OMU.

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.

The case of a 33-year-old woman with a rare type of choledochal cyst (Choledochocele; Alonso-Lej's type III) is described. The patient had undergone prior cholecystectomy. Hypotonic duodenography showed a smooth defect in the duodenum. Endoscopic retrograde cholangiopancreato-graphy (ERCP) showed a cystic dilatation of the terminal portion of the common bile duct. Endoscopic ultrasonography (EUS) showed a cystic lesion at the same site. This case was preoperatively diagnosed by ERCP and EUS. Transduodenal sphincteroplasty was done and good results were obtained.

Summary Extended transduodenal sphincteroplasty has been suggested as an alternative to choledochoduodenostomy for the surgical management of bile duct stones associated with a periampullary diverticulum but its value has not previously been investigated. Over a 3 year period, nine patients underwent extended transduodenal sphincteroplasty for common bile duct calculi associated with a periampullary diverticulum with no operative or post-operative mortality and minimal morbidity. Follow-up ranging from 20 to 60 months has shown remission of pain in all but one patient, who has had a normal endoscopic cholangiogram and no further episodes of jaundice or cholangitis. Extended transduodenal sphincteroplasty is a safe and effective alternative to choledochoduodenostomy for the surgical management of choledocholithiasis associated with a periampullary diverticulum.

本邦における腸チフスの発生は減少し年間100人程度になっているが, 現在でも長期保菌者がその感染源となることがある.今回われわれは, 胆道系長期保菌者を外科的治療で治癒せしめた症例を経験した.症例は70歳, 男性.糞便検査でチフス菌の排菌を指摘された.腹部超音波検査, computed tomography検査で胆石が認められ, 十二指腸液検査でチフス菌が検出された.腸チフス胆道系保菌者と診断し胆嚢摘除術, 経十二指腸乳頭括約筋形成術を施行した.術後, 胆汁, 糞便からの排菌は消失した.退院1年後の十二指腸液検査, 糞便検査でもチフス菌の排菌はなく治癒と判定した.胆道系長期保菌者では, 病巣の完全除去, 再発・遺残結石の防止が除菌の成否を決める.そのため, 症例により胆道ドレナージ手術も考慮する必要があると考えられた.

The purpose of treatment for hepatolithiasis is reducing recurrent cholangitis. This study was designed to determine the long-term outcome of Oddi sphincterotomy for hepatolithiasis. Thirty-two consecutive hepatolithiasis patients, including 15 cases that had undergone conventional open surgical transduodenal sphincteroplasty (COSTS) and 17 cases with endoscopic sphincterotomy (EST), were followed up for a long term. We compared the post-treatment rates of recurrent cholangitis and acute cholangitis severe type (ACST) with the ones of pretreatment in each group, respectively. Paired χ2 test was used. In the COSTS group, neither the post-operative rate of recurrent cholangitis (86.7%, 13/15 vs. 100%, 15/15) nor ACST (26.7%, 4/15 vs. 46.7%, 7/15) decreased (p > 0.05) compared with before the operation. In the EST group, the situation was the same: neither the rate of post-EST recurrent cholangitis (76.5%, 13/17 vs. 82.4%, 14/17) nor ACST (29.4%, 5/17 vs. 23.5%, 4/17) were reduced significantly (p > 0.05). Both eradication of hepatobiliary lesions and keeping Oddi sphincter intact should be emphasized in the management of hepatolithiasis. Neither COSTS nor EST is an effective method or can achieve the goal of reducing cholangitis for hepatolithiasis.

Common bile duct stones are a difficult problem, often leading to conversion to an open operation or repeated endoscopic procedures. Both strategies are associated with added morbidity.A new technique was developed to perform a traditional sphincteroplasty using minimally invasive methods. The procedure was performed on two patients with distal common bile duct stones; each patient had previously undergone at least two unsuccessful preoperative endoscopic retrograde cholangiopancreatography procedures by at least two different experienced endoscopists.In both patients, a laparoscopic transduodenal sphincteroplasty was successfully completed. A transduodenal common bile duct exploration was performed at the time of sphincterotomy, successfully clearing the common bile duct in both cases. There were no untoward postoperative sequelae. Follow-up at one year was satisfactory in both patients.Laparoscopic transduodenal sphincteroplasty can be safely performed in patients with common bile duct stones refractory to endoscopic retrograde cholangiopancreatography. This technique offers a new approach to the management of common bile duct stones, and can spare patients the need for an open operation or subsequent endoscopic procedures.

With the advent of laparoscopic cholecystectomy and the impending replacement of open common bile duct exploration, we have reviewed our ten year experience of conventional common bile duct exploration. Open cholecystectomy was performed in 1681 patients and the common bile duct was explored in 325 (19%). Following initial duct exploration, rigid choledo identified residual choledocholithiasis in 58 and periampullary neoplasia in 2 patients. Unexpected retained stones were identified in 3 patients (0.9%). In a further 4 patients, stones which could not be dislodged from the hepatic ducts were confirmed on 10 day T-tube cholangiogram - transduodenal sphincteroplasty had been performed at the time of original surgery in all four. The mortality was 1.9% overall and 1% during the last 5 years. Endoscopic exploration must compare favourably with these data for safe transition to less invasive techniques.

An anomalous elongated pancreaticobiliary common channel encourages reflux up both the biliary tree and the pancreatic ductal system, resulting in progressive choledochal dilatation, cholangitis with ductal calculi, relapsing pancreatitis and malignant change. Transduodenal sphincteroplasty has been used to improve drainage from the abnormal channel. The use of endoscopic sphincterotomy (ES) to establish drainage and minimize the surgical risks is reported in six symptomatic patients with mild choledochal dilatation (common bile duct diameter

Eight patients of choledochal cyst have been diagnosed and six have been managed surgically. There were two children and six adults. Both the children had Type I cyst. They were managed by excision of the cysts. One lady with associated stone and carcinoma of the gall bladder underwent radical cholecystectomy with excision of segments IV and V of liver. Second lady with intrahepatic porcelain gall bladder had a choledochocele and was treated by transduodenal sphincteroplasty. Fifth patient, an 82 years old man with symptomatic gall stone with Type I choledochal cyst was subjected to just a cholecysto-jejunostomy. A 54 years old man with a Type IV cysts has undergone excision of the cyst. In patients undergoing excision of choledochal cysts, the biliary tract was reconstructed by a Roux-en-Y hepaticojejunostomy. Two of our patients never turned up for surgery. All the operated patients were asymptomatic during the follow-up period of 6 months to 24 months.

Sphincteroplasty is a transduodenal method of producing a terminal choledochoduodenostomy as wide as the supraduodenal common duct. The sphincters affecting common and pancreatic ducts are destroyed, making the opening noncontractile and permanent. To achieve this, the common and duodenal walls are divided between clamps and oversewn. The resulting stoma differs anatomically and physiologically from that of sphincterotomy, which leaves functioning sphincter behind. This is demonstrable by postoperative T-tube pressure and flow studies before and after morphine, and free reflux and stomal permanence after sphincteroplasty. Such an opening prevents trapping of overlooked stones or bile stasis with stone formation.

A 91-case experience with immediate transduodenal sphincteroplasty in the management of acute biliary pancreatitis was reviewed. Diagnosis was made by clinical evidence of acute pancreatitis, absence

Summary On the basis of the results obtained in 712 patients, an evaluation of the effectiveness of transduodenal sphincteroplasty is presented. This procedure has proved to be appropriate in treating benign obstruction of the common bile duct as well as choledocholithiasis. Mortality was 1.1 per cent and long-term results were satisfactory in 97 per cent of the cases. Only sixteen patients required reoperation for residual or recurrent stones or for stricture of the sphincter of Oddi. Compared with choledochoduodenostomy, sphincteroplasty avoids the hazards of the so-called sump syndrome and of ascending cholangitis by reflux of intestinal contents into the common duct. A high incidence of postoperative pancreatitis in patients who undergo sphincteroplasty has not been observed.

Article, 信州医学雑誌 33(6): 514-521(1985)

Summary Treatment with oral prednisolone appears to have precipitated an episode of ascending cholangitis in an asymptomatic 55-year-old patient. He had undergone a Polya partial gastrectomy, a cholecystectomy and a sphincteroplasty 19, 6 and 2 years earlier, respectively. The cholangitis was complicated by septicaemia with six different enteric organisms including aerobes and anaerobes. He developed liver and lung abscesses, and an indolent Pseudomonas aeruginosa septic arthritis of both hip joints. The patient eventually made a complete recovery, but required surgical replacement of both hips.

1. 1. The anatomy and physiology of the constricting mechanisms at the lower end of the common duct are reviewed. 2. 2. The need for complete elimination of these operations are demonstrable by postcertain cases of recurrent pancreatitis and in problems of extrahepatic biliary obstruction has been stressed. 3. 3. Elimination of these sphincteric mechanisms requires sphincteroplasty and cannot be accomplished by sphincterotomy. 4. 4. Key points in the technic of sphincteroplasty are outlined. 5. 5. The importance of a pancreatic ductogram in selecting the surgical approach in patients with recurrent pancreatitis is re-emphasized. 6. 6. The anatomic differences between sphincteroplasty and sphincterotomy are described. 7. 7. The physiologic differences between these operations are demonstrable by postoperative T tube pressure studies, postoperative T tube cholangiograms, postoperative cineradiography, postoperative upper gastrointestinal studies, and clinical results. 8. 8. Indications and contraindications for sphincteroplasty are outlined. 9. 9. Two hundred forty-one sphincteroplasties are reported with an over-all mortality of 1.24 per cent and a morbidity of 4.9 per cent. 10. 10. Of the ninety-five patients with recurrent pancreatitis and no intrapancreatic ductal obstruction , 90.5 per cent were improved or asymptomatic after sphincteroplasty. This optimistic figure is misleading since forty-four of the ninety-five patients had calculous biliary tract disease, and a substantial number might have been relieved by eradication of this alone. However, in fifty patients with recurrent pancreatitis, no calculous disease, and no intrapancreatic ductal obstruction, the benefits derived appear to be due to the sphincteroplasty. 11. 11. All of the 146 patients with extrahepatic biliary tract obstruction were relieved of symptoms by sphincteroplasty. One hundred thirty-nine of these were operated upon for multiple common duct stones. No recurrent or residual stones developed after sphincteroplasty. 12. 12. Although sphincteroplasty should be performed only by a surgeon familiar with biliary tract surgery, we believe that if the technic outlined is carefully followed, the operation may be accomplished with minimal morbidity and mortality.

The results of 118 consecutive common bile duct explorations via transduodenal sphincteroplasty are presented and analysed. The operations were performed for suspected choledocholithiasis by one surgeon over a 10-year period. Choledocholithiasis was proved in 22 per cent of the cholecystectomies carried out during this period and tended to present significantly earlier in females, 14·5 per cent presenting before 35 years of age. One hundred and four survivors were traced and 93·5 per cent had achieved a good result at a mean 5-year follow-up.

A new pine needle-shaped sound was devised to facilitate transduodenal sphincteroplasty. Use of this sound avoids a false passage, obtains correct direction of an incision of the papilla, and controls bleeding during the suture procedure.

Three cases of choledocholithiasis presenting with obstructive jaundice in infancy are reported. Ultrasonography demonstrated a grossly dilated common bile duct in all three cases. It failed, however, to demonstrate the calculi that were situated at the distal end of the common duct. Percutaneous transhepatic cholangiography was valuable in one patient in outlining the biliary tract and in identifying the cause of the obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) was employed in a child, aged three years, in whom it was possible to proceed to endoscopic sphincterometry with clearance of the common duct. In small infants, transduodenal sphincteroplasty would appear to be the procedure of choice.

Review of a 26-year experience with transduodenal sphincteroplasty and sphincterotomy was undertaken (1) to analyze critically the indications for and results of these procedures and (2) to determine which preoperative factors correlate with a good or poor outcome. Of 109 patients, 78 underwent sphincteroplasty, whereas 31 had a transduodenal sphincterotomy. Surgical indications included: group 1, 53 patients with common duct stones; group 2, 28 patients with dyskinesia or stenosis of the sphincter of Oddi (without choledocholithiasis or recurrent pancreatitis); and group 3, 28 patients with recurrent pancreatitis. Three elderly group 1 patients who presented with cholangitis died after surgery (a hospital mortality of 2.7%). Seventy-nine of the 103 patients (77%) in whom follow-up was obtained achieved an excellent or good result. Results were almost identical with sphincteroplasty and sphincterotomy. Abnormal preoperative liver function tests were the only predictors of a good postoperative outcome (p less than 0.05). Group 3 patients (good results in 63%) had significantly poorer (p less than 0.05) outcome than group 1 and 2 patients. Results were worst in group 3 patients who had undergone previous abdominal or pelvic surgery (p less than 0.025) and in group 2 patients who were narcotic users (p less than 0.025). The authors conclude that transduodenal sphincteroplasty or sphincterotomy can be performed relatively safely, but caution that careful selection of patients is important when the indication for surgery is either ampullary stenosis or recurrent pancreatitis.

Acute pancreatitis is manifested by severe, steady epigastric pain often accompanied by nausea and vomiting. Physical findings are variable and inconsistent. The causative mechanism probably is an obstructive process and an actively secreting gland.The most reliable laboratory test is determining the serum amylase level, which is almost uniformly elevated in the early course of the disease.Treatment is conservative, with symptomatic, supportive and prophylactic measures. Transduodenal sphincteroplasty and exploration of the pancreatic duct may benefit carefully selected patients who do not respond to conservative measures.

Ninety-two patients underwent a transduodenal sphincteroplasty and transampullary septectomy (extended papilloplasty) for chronic, incapacitating upper abdominal pain over an 11-year period. Seventy-nine had a prior cholecystectomy; 42 of 56 patients with reported pathology had documented gallstone disease. Serious morbidity included two moderately severe cases of postoperative pancreatitis and a pulmonary embolus. There were no deaths. Operative findings revealed stenosing papillitis (n = 45), transampullary septitis (n = 40), and papillary dysfunction (n = 7). Histologic examination of septal biopsy specimens revealed inflammation in 34 cases and fibrosis in 19 cases. There were no microscopic abnormalities in 39 biopsy specimens. The results at 1 to 10 years in 83 patients is as follows: good in 36 patients (no pain--43%), fair in 27 patients (occasional pain--33%), and poor in 20 patients (unrelieved by the procedure--24%). Patients with prior sphincteroplasty (12 of 15 with a fair to good result) benefitted the most from the procedure. Those who underwent concomitant cholecystectomy responded poorly. Risk factors for failure include alcoholism, drug addiction, mental illness, and duodenal ulcer disease. The finding of papillary cholesterolosis at operation also was accompanied by a less than optimal result. Transduodenal sphincteroplasty with transampullary septectomy provides long-term benefit to carefully selected patients with chronic abdominal pain after cholecystectomy.