Oddi括约肌与胆管色素结石形成关系的探讨

目的探讨Oddi括约肌结构及功能异常与胆管色素结石形成之间的关系。方法胆道术后留有T型管的患者123例,使用放射性核素^99mTc—DTPA判断是否存在肠胆反流,以此将患者分为反流组及非反流组,检测空腹血胃动素、胃泌素水平,随机选取53例使用胆道镜测压。采用钡餐透视观察胆管色素结石、非胃肠胆道疾病、胆囊息肉、胆囊胆固醇结石患者的十二指肠降段憩室发生率;十二指肠镜观察原发性胆管色素结石、胆管结石合并胆囊结石、继发于胆囊结石的胆管结石、胆管末端和乳头部炎症狭窄、胆管末端癌和乳头癌、胆囊切除术后综合征患者的十二指肠憩室内（旁）乳头的发生率。结果123例行胆道取石T型管引流术后的患者中有44例检测到十二指肠胆道反流（35．8％）,反流组Oddi括约肌基础压（SOBP）、收缩波幅（SOCA）、胆总管压（CBDP）显著低于对照组（P〈0．01）。反流组血胃动素、胃泌素水平明显低于无反流组及对照组（P〈0．01）。血胃动素与SOBP、血胃泌素与SOBP及CBDP呈正相关。钡餐摄影显示胆总管色素结石患者十二指肠降段憩室发生率达36．62％,明显高于其他3组（P〈0．05）。胆管胆色素结石患者十二指肠憩室内（旁）乳头的发生率明显高于继发于胆囊结石的胆管结石组、胆管末端和乳头部炎症狭窄组及胆管末端癌和乳头癌组（P〈0．05）。结论胆管色素结石患者存在明显的肠胆反流和胆系感染,Oddi括约肌结构与功能状态与胆管色素结石形成密切相关,其解剖及功能异常是胆管色素结石形成的重要原因。     

Oddi括约肌功能障碍

主持人 :胆胰肠结合部包括胆总管胰后段和壶腹、胰头及其主副胰管 ,十二指肠二、三、四段 ,以及与这些脏器相关的血管、淋巴和神经等结缔组织。这一区域在解剖上复杂多变 ,是连接胆道、胰腺、胃肠道的枢纽 ,且变异多见 ;在功能上较复杂 ,一些功能性的改变亦能引起严重的后果 ;在诊断和治疗上比较棘手 ,直观性、创伤小的诊断方法较少 ,恶性病变的根治范围广、并发症多 ,使该区域恶性肿瘤的根治率低 ,对于性质难以判断的肿块 ,在处理上更是进退维谷。近年来 ,胆胰十二指肠结合部外科取得了较大进展 ,内镜手术在某些疾病的治疗上取代了传统方法 ;各种扩大、改良根治术和区域性切除术在原Whipple手术的基础上得以开展 ,其远期疗效尚有待于进一步探讨。本期特邀国内肝胆胰外科界知名专家撰写笔谈 ,针对该区域较新颖或者有必要重申的手术方法进行详细讲解 ,使之更趋规范化、科学化。同时 ,针对临床工作中经常碰到的难题进行解答与讨论 ,力图能为广大读者在胆胰肠结合部外科疾病的认识上提供一些新颖的或更清晰的思路。     

Oddi括约肌功能的电生理研究与启示

上世纪Rugero Oddi对胆总管下端括约肌结构的发现和命名,奠定了Oddi括约肌功能研究的基础.然而时至今日,我们对胆胰结合部的了解仍然不足,特别是Oddi括约肌((sphincter of Oddi,SO)的基础研究仍明显滞后于临床,如何准确评价SO的功能及诊治Oddi括约肌功能障碍(sphincter ofOddi dysfunction,SOD)仍是一个难题.在临床上大部分SOD都发生在胆囊切除术后的病人,缺乏典型的症状和影像学改变,诊断非常困难[1-4].     

EST治疗伴或不伴有胆石症的Oddi括约肌乳头狭窄

目的：探讨经内镜胆道括约肌切开术（EST）在治疗伴或不伴有胆石的Oddi括约肌乳头狭窄（PS）的有效性和安全性。 方法：分析2001年1月—2012年9月经内镜逆行胆管胰腺造影术（ERCP）检查的1 218例患者中行EST治疗的110例PS患者临床资料。 结果：患者均有不同程度胆道疼痛、胆总管(CBD)扩张和肝功能异常;110例中34例之前已做胆囊切除术,其中有12例有胆总管结石;余下69例未做胆囊切除术,其中有14例无任何胆结石。所有有或无CBD结石的患者在EST术后各症状均明显改善。 结论：EST是一项治疗伴或不伴胆石的PS的最佳手段,并可以减轻疼痛,恢复扩张胆总管并改善肝功能。     

Oddi＇s括约肌切开成形术43例疗效分析

目的 探讨Oddi＇s括约肌切开成形术的疗效.方法 回顾分析43例括约肌切开成形术的临床资料.其中胆囊切除术后括约肌狭窄11例,胆管壶腹部结石嵌顿3例,胆总管切开取石伴胆管末端狭窄19例,复发性胆源性胰腺炎6例,内镜下括约肌切开术后4例;第1次手术24例,第2次手术19例.结果 腹部切口感染5例,短暂性胆漏2例,括约肌手术处渗血3例,37例（占86%）经5～15年随访,效果满意.结论 正确掌握手术适应证和操作方法,可取得良好效果.     

Oddi括约肌狭窄的诊治体会

目的 探讨Oddi括约肌狭窄的诊断及治疗方法.方法 对1990年至2005年间45例Oddi括约肌狭窄的临床资料进行回顾性分析.结果 45例中有27例术前进行过磁共振胆胰管造影（MRCP）检查,8例获得诊断;25例切开十二指肠行括约肌成形术,术后病理证实为Oddi括约肌狭窄;20例经ERCP确诊,并行内镜括约肌切开术.因MRCP的广泛使用,2000年后Oddi括约肌狭窄的术前诊断率明显提高,2000年前为2/27,2000年后为6/18（χ2=4.79,P＜0.05）.内镜括约肌切开术术后胰腺炎发生率为3/20,经十二指肠Oddi括约肌成形术术后胰腺炎发生率为4/25（χ2=0.01,P＞0.9）.结论 MRCP是诊断Oddi括约肌狭窄理想的非损伤性检查;内镜括约肌切开术是治疗Oddi括约肌狭窄的有效方法.     

横断胆管、胆肠Roux-en-Y吻合术治疗Oddi括约肌松弛症39例临床分析

Oddi括约肌(SO,Sphincter of Oddi)松弛症,属Oddi括约肌关闭不全的重型.临床上多表现为反复发作的右上腹疼痛.多见于胆管结石症,通过松弛的括约肌可引起复发性胆管炎胆结石[1].回顾性分析我院2001年1月至2011年1月收治的76例Oddi括约肌松弛症患者,其中39例采用横断胆管、胆肠Roux-en-Y吻合术,疗效满意,报告如下. 1 临床资料 1.1 诊断标准[2]     

肠胆反流与胆色素结石形成的关系

目前认为胆色素结石的成因与胆汁淤积,加上胆道细菌产生的外源性β-葡萄糖苷酶分解胆汁中的结合胆红素等诸多因素有关,而且许多研究都认为胆道细菌的来源与Oddi括约肌松弛导致肠胆反流有着密切的关系。笔者总结目前研究现状并结合自己的相关研究与思考,探讨肠胆反流与胆管色素结石形成的关系。     

豚鼠不全性胆道梗阻早期Oddi括约肌功能的变化

目的:观察豚鼠胆道不全性梗阻后早期Oddi括约肌(SO)肌电活动及压力的变化。方法:16只英国短毛豚鼠随机均分假手术组与模型组,分别行假手术与制作胆总管不全性梗阻模型,期间测定胆总管直径;术后1周,再次检测两组胆总管直径、肝功能指标、SO肌电活动与动力学指标。结果:术后假手术组胆总管直径无明显改变(P0.05),而模型组较术前明显增大(P0.05)。与假手术组比较,模型组血清胆红素、肝酶水平明显升高(均P0.05);SO快波幅度和慢波振幅显著降低(均P0.05),但快波和慢波频率无统计学差异(均P0.05);SO基础压明显升高,但SO峰压明显降低(均P0.05),而SO收缩频率无统计学差异(P0.05)。结论:不全性胆总管梗阻可使豚鼠SO快、慢波振幅降低,SO基础压升高、收缩峰压降低,这可能是胆道不全性梗阻时易诱发急性胆源性胰腺炎的重要机制之一。     

Sphincter of Oddi dysfunction after Roux-en-Y gastric bypass

BackgroundPatients who have undergone Roux-en-Y gastric bypass for morbid obesity may develop postoperative abdominal pain disorders that require surgical evaluation. Chronic pancreatitis and pain associated with sphincter of Oddi dysfunction (SOD) is an uncommon disorder whose clinical diagnosis is problematic without sphincter of Oddi manometry. To evaluate the diagnosis and treatment of SOD in the gastric bypass population, a retrospective review and analysis of gastric bypass patients who had undergone transduodenal sphincteroplasty (TS) for SOD was undertaken.MethodsThe medical records of patients who had undergone TS after gastric bypass at the Medical University of South Carolina Digestive Disease Center from January 2002 to December 2006 were evaluated for outcomes-based data with the approval of the institutional review board for the evaluation of human subjects. Long-term patient outcomes were assessed using the Medical Outcomes Study Short Form 36-item, version 2, quality-of-life survey.ResultsA total of 16 women (median age 49 years) were identified who had undergone TS with biliary sphincteroplasty and pancreatic ductal septoplasty for SOD. The indications for surgery included pain (100%), nausea (31%), weight loss (13%), and recurrent pancreatitis (31%). The diagnosis of SOD was supported by magnetic resonance cholangiopancreatography with secretin stimulation. Three postoperative complications (18.8%) developed, but no mortality. The average length of hospital stay was 5 days (range 2–9). Of the 16 patients, 13 (81%) responded to the survey follow-up. The mean length of follow-up was 28 months (range 16–57). Of the 13 patients, 11 (85%) reported pain improvement after surgery. The survey's norm-based scores were similar to those of a representative population.ConclusionSOD should be considered in the differential diagnosis of gastric bypass patients with pancreatobiliary pain after cholecystectomy. When the clinical history is supported by laboratory and magnetic resonance cholangiopancreatography data, TS can be undertaken with low morbidity and good patient outcomes. SOD is a notable disorder in the gastric bypass population. With appropriate patient selection, TS can be beneficial.     

Oddi括约肌异常的分类及防治对策

Oddi括约肌是位于十二指肠降段（第二段）内侧偏下部位肠壁内向肠腔突出的含有纵行、斜行及环形的平滑肌。由三个部分组成：单纯包绕胆管的部分称之为胆管括约肌，胰管部分为胰管括约肌，胆胰管合并后共同部为乳头括约肌。胆管和胰管末端在十二指肠括约肌内的终末膨大部分称为Vater壶腹。     

Sphincter of Oddi dysfunction: results of treatment by endoscopic sphincterotomy

From a consecutive series of 451 patients with post-cholecystectomy symptoms referred for endoscopic retrograde cholangiopancreatography (ERCP), 40 (9 per cent) were diagnosed as having sphincter of Oddi dysfunction. Eight patients were excluded from the study because of incomplete data (n = 6) or additional diagnoses (n = 2). Thirty of the patients had successful ERCP and endoscopic sphincterotomy (ES); this failed in the remaining two because of severe papillary stenosis (6.3 per cent). Endoscopic biliary manometry was performed in 23 patients (77 per cent). Immediate post-ES complications occurred in eight patients (25 per cent). At a median follow-up of 46 months (range 10-88 months) 19 patients had a good outcome (63.3 per cent) and 11 patients had a poor outcome (36.7 per cent). Patients with a good outcome tended to have a delay of months or years following cholecystectomy before the development of symptoms (median 6 years versus 0 years, P = 0.0003). At ERCP, patients with a good outcome had greater common bile duct diameters (mean +/- s.d. mm, 12.6 +/- 3.6 versus 8.8 +/- 1.8, P = 0.0003) and delayed drainage from the biliary tree of injected contrast (13 versus 2 patients, P = 0.02). Endoscopic biliary manometry was abnormal in all 15 patients with a good outcome in whom it was performed but in only 3 out of 8 patients with a poor outcome (P = 0.003). Sphincter of Oddi dysfunction is an important, albeit uncommon, cause of post-cholecystectomy symptoms. ES provides symptomatic relief in the majority of patients but improved criteria for predicting outcome are required.     

Sphincter of Oddi motility

Recent developments of manometric and endoscopic instrumentation have rekindled interest in sphincter of Oddi function. As a result of human and animal studies, our understanding of normal sphincter of Oddi physiology has increased and possible motility abnormalities are being identified. Manometric studies have shown that the sphincter of Oddi is characterized by prominent phasic contractions which are super-imposed on a low tonic pressure. The phasic contractions are orientated mainly in an antegrade direction; however, both simultaneous and retrograde contractions are registered. Cineradiography has demonstrated that the phasic contractions have a propulsive function, expelling small volumes of fluid from the common bile duct into the duodenum. Intravenously administered cholecystokinin-octapeptide normally inhibits the phasic contractions and reduces the sphincter tone. Motility abnormalities may occur if the sphincter of Oddi exhibits abnormally high tone, alteration in the direction of the phasic contractions, abnormal changes in the contraction frequency, or abnormal responses to hormonal stimulation. Preliminary human studies demonstrate disorders in sphincter of Oddi motility patterns, suggesting that motility abnormalities may be associated with choledocholithiasis, dyskinesia and idiopathic relapsing pancreatitis.     

The diagnosis and management of Sphincter of Oddi dysfunction: a systematic review

Objectives

Sphincter of Oddi dysfunction (SOD) is a benign pathological syndrome. The clinical manifestations may be a consequence of an anatomical stenosis or sphincter dysmotility. Manometry is invasive and has an associated morbidity. Non-invasive investigations have been evaluated to ameliorate risk but have unknown efficacy. The review aims to critically appraise current evidence for the diagnosis and management of SOD.

Methods

A systematic review of articles containing relevant search terms was performed.

Results

Manometry is the current gold standard in selecting which patients are likely to benefit from endoscopic sphincterotomy (ES). It can, however, be misleading. Several non-invasive investigations were identified. These have poor sensitivities and specificities compared to manometry. There is a paucity of data examining the investigation’s specific ability to select patients for ES. Outcomes of ES for Type I SOD are favourable irrespective of manometry. Types II and III SOD may respond to an initial trial of medical therapy. Manometry may predict response to ES in Type II SOD, but not in Type III.

Conclusions

Non-invasive investigations currently lack sufficient sensitivities and specificities for routine use in diagnosing SOD. Type I SOD should be treated with ES without manometry. Manometry may be useful for Type II SOD. However, whilst data is lacking a therapeutic trial of Botox^TM or trial stenting may bean alternative. Careful and thorough patient counselling is essential. Type III SOD is associated with high complications from manometry and poor outcomes from ES. Alternative diagnoses should be thoroughly sought and its management should be medical.