The Sphincter of Oddi and Gallbladder Function: *
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The Sphincter of Oddi and Gallbladder Function: *
I. Preservation of Function after Section and Resectionof the Sphincter
ROBERT E. LEMPKE, M.D.
From the Department of Surgery, Veterans Administration Hospital and IndianaUniversity Medical Center, Indianapolis, Indiana
SECTION of the sphincter of Oddi in dogshas been followed almost routinely by thedevelopment of acute and chronic inflam-matory lesions of the biliary tract.3' 6, 13, 14Stasis in the gallbladder resulting from theoperation, with or without reflux of duo-denal contents into the bile ducts, hasbeen incriminated in the development ofthese complications. 4 6, 11, 13 For this reasoncholecystectomy has been recommendedand usually performed whenever thesphincter of Oddi is sectioned, resected orbypassed in man.4'8' 1' It was with con-siderable interest, therefore, that we ob-served not only the absence of clinicallyovert cholecystitis, but also the preserva-tion of function by oral cholecystographyin every patient known to us who had hadthe sphincter defunctionalized withoutprior or concomitant cholecystectomy.These patients, eight in number, are thesubject of this report.
Case ReportsCase 1: 0. L. H., a 45-year-old white man,
had increasingly more frequent attacks of re-current pancreatitis for 16 months before opera-tion on July 17, 1950. A "stenosed" ampulla ofVater through which a "small probe couldbarely be inserted" was incised a distance of5 mm. The gallbladder appeared to be normaland was not removed. The patient continued tohave occasional mild episodes of epigastric painand tenderness when last seen in February 1954.
An oral cholecystogram six days preopera-tively showed normal concentrating ability and
motor function (Fig. 1). On January 31, 1951,six months following sphincter section, a repeatexamination was interpreted as being withinnormal limits (Fig. 2) although the opaquemedium was less concentrated than in the pre-operative film.
Case 2: R. L. T., a 54-year-old white man,had a perforated duodenal ulcer closed elsewherein September 1955. On May 22, 1957 a subtotalgastrectomy for complete pyloric obstruction wasundertaken. During dissection of the foreshortenedduodenum the common bile duct and duct ofWirsung were transected at their point of entryinto the muscularis. A T-tube was placed in thecommon duct with one long limb projectingthrough the severed end. One end of a poly-ethylene tube (O.D. 1.7 mm.) was threaded intothe pancreatic duct and the other end passed upthe common duct and through the abdominalwall beside the T-tube. The duodenum wassutured to the ulcer bed and pancreas around theostia of the ducts as shown in Figure 3. Theoperation was completed with a subtotal gastricresection and antecolic gastrojejunostomy. Thegallbladder was grossly normal and was not dis-turbed. Convalescence was uncomplicated. Therewas no clinical or laboratory evidence of biliaryobstruction.
On June 26, a month following operation, anoral cholecystogram visualized a normal gall-bladder with satisfactory contraction following afat meal. The patient has remained well for twoyears with no complaints referable to the biliarytract. Serum alkaline phosphatase and bilirubinconcentrations have remained within normal limits.A cholecystogram on June 10, 1959 revealed airin the common and cystic ducts, but the gall-bladder was well visualized and considered nor-mal (Fig. 4).
Case 3: W. W. J., a 58-year-old white man,had a four-week history of progressive, painless,
* Submitted for publication December 7, 1959.
LEMPKE Annals of SurgeryNovember 1960
FIG. 1. (left) Case 1. Normal oral cholecystogram six days before sphincterotomy. FIG. 2.(right) Case 1. Cholecystography performed six months after section of the sphincter ofOddi did not result in as dense opacification of the gallbladder as it did preoperatively,although it was considered to be within normal limits. No calculi were visualized. The gall-bladder contracted in response to a meal of fat.
FIG. 3. Case 2. Method of re-establishingbiliary and pancreatic continuity with the duo-denum following accidental resection of theampulla of Vater.
obstructive jaundice when admitted. The jaundicesubsided rapidly. On the fourth day of hospitaliza-tion an oral cholecystogram was attempted. Thegallbladder was not visualized. Periampullarycarcinoma was suspected and exploration per-formed on June 27, 1957. Gross evidence ofbiliary cirrhosis, a limited area of induration inthe head of the pancreas, and a normal gall-bladder without calculi were found. The commonduct was small and "fibrous," and would not ac-cept a 4 mm. Bakes dilator. A fine probe passedthrough the ampulla only with difficulty. Thesphincter of Oddi was sectioned 10 to 11 mm.transduodenally. A wedge removed for micro-scopic examination was "not diagnostic." Thegallbladder was not removed. Convalescence wasuncomplicated and liver function tests had re-turned to normal in three weeks. A final diag-nosis of nonspecific sclerosing choledochitis wasmade.
Oral cholecystography two, eight and 21months postoperatively (Fig. 5) was interpretedon each occasion as showing normal concentrat-ing ability and contraction following a fat mealwithout evidence of calculi. The patient has re-mained asymptomatic and liver function tests havecontinued to be within normal limits.
Volume 152Number 5 THE SPHINCTER OF ODDI AND GALLBLADDER FUNCTION
Case 4: J. L. C., a 38-year-old white man, hadhepatitis in 1942, following yellow fever vac-cination. Subsequently, he had recurrent episodesof anorexia and right upper quadrant pain radiat-ing to the right subscapular region. In June 1955,he was admitted for similar complaints associatedfor the first time with obstructive jaundice. Oralcholecystography did not visualize the gallbladder.Laparotomy on June 27 revealed a grossly normal,small gallbladder without calculi. The pancreasand liver were thought to be normal althoughthe latter showed evidence of biliary obstructionmicroscopically (Fig. 6a). The common duct wasthickened. A Randall stone forcep could not bepassed through the ampulla. Transduodenalsphincterotomy was performed and the commonduct drained with a 10 F catheter. The operativediagnosis was nonspecific sclerosing choledochitis.The patient's recovery was complicated by theaccidental removal of the biliary catheter on thenight of operation and bleeding from the sub-hepatic drain site and upper gastro-intestinal tracton the thirteenth postoperative day. An x-raystudy three days later did not disclose the bleed-ing site but did demonstrate reflux of barium intothe common and cystic ducts. Operation on July
FIG. 4. Case 2. Oral cholecystogram two yearsafter operation. Air was demonstrated in theextrahepatic biliary tract. The concentrating andmotor functions of the gallbladder were preserved.No calculi.
FIG. 5. Case 3. Normal cholecystogram 21 monthsafter sphincterotomy.
FIC. 6a. Case 4. Liver biopsy at the time ofsphincterotomy. The architecture of the liver waswell preserved with no significant abnormality ofthe portal triads. Some retention of bile in thecentral area of the lobules with early lake forma-tion (solid black area immediately above centralvein) is compatible with the diagnosis of biliaryobstruction ( x 200).
FIG. 6b. Case 4. Chronic cholecystitis seentwo years after a sphincterotomy that permittedreflux into the common duct (x 100).
FIG. 6c. Case 4. Liver biopsy at the timeof cholecystectomy. The portal triads containsmall numbers of inflammatory cells includinglymphocytes and a few eosinophilic granulocytes.There is no evidence of biliary obstruction(x 200).
Annals of SurgeryNovember 1960
15 also failed to reveal the cause of the continuedbleeding. The sectioned sphincter of Oddi wasseen to be well healed and patent.The patient recovered but continued to have
subelinical icterus until July 1957 when he de-veloped mild jaundice and constant pain in theright upper quadrant of the abdomen. Hepa-tomegaly was present. X-ray study of the duo-denum again revealed reflux of barium into thecommon duct (Fig. 7). The gallbladder was veryfaintly opacified on July 31 and somewhat moredensely six days later when a double dose ofcontrast media was given (Fig. 8). Motor func-tion in response to a fat meal was satisfactory.At operation the common duct was dilated andcontained amorphous sediment. A probe passedinto the duodenum readily and the sphincter wasdilated to 8 mm. with only moderate difficulty.The gallbladder, somewhat thickened and sur-rounded by adhesions, was removed. Pathologicdiagnosis was chronic cholecystitis (Fig. 6b).The ampulla was edematous and showed no evi-dence of the previous section. A 12 to 13-mm.incision was necessary to reopen it completely.Liver biopsy revealed only a mild pericholangiticinfiltration of inflammatory cells including lym-phocytes and a few eosinophilic leucocytes.There was no evidence of biliary obstruction(Fig. 6c). The patient convalesced uneventfullyand all liver function tests returned to normal.He was asymptomatic when last seen two monthsafter operation.
Case 5: V. L. D. B., a 44-year-old Negro man,had recurrent episodes of epigastric distress at-tributed to duodenal ulcer for ten years andproven recurrent pancreatitis with calcificationfor two years. A 10-mm. transduodenal sphincter-otomy was performed on April 17, 1958. Explora-tion of the duct of Wirsung and an operativepancreatogram demonstrated the presence ofcalcification and dilatation of the duct, and apseudocyst. The gallbladder appeared to be nor-mal and was not removed. The patient made anuneventful recovery and has had no recurrenceof symptoms in one year. Evidence of pancreaticislet cell injury, manifested by abnormal glucosetolerance preoperatively, progressed to clin