Toouli J, Roberts-Thomson I C, Kellow J, Dowsett J, Saccone G T, Evans P, Jeans P, Cox M, Anderson P, Worthley C, Chan Y, Shanks N, Craig A
GI Surgical Unit, Flinders Medical Centre, Adelaide, Australia.
Gut. 2000 Jan;46(1):98-102. doi: 10.1136/gut.46.1.98.
Endoscopic sphincterotomy for biliary-type pain after cholecystectomy remains controversial despite evidence of efficacy in some patients with a high sphincter of Oddi (SO) basal pressure (SO stenosis).
To evaluate the effects of sphincterotomy in patients randomised on the basis of results from endoscopic biliary manometry.
Endoscopic biliary manometry was performed in 81 patients with biliary-type pain after cholecystectomy who had a dilated bile duct on retrograde cholangiography, transient increases in liver enzymes after episodes of pain, or positive responses to challenge with morphine/neostigmine. The manometric record was categorised as SO stenosis, SO dyskinesia, or normal, after which the patient was randomised in each category to sphincterotomy or to a sham procedure in a prospective double blind study. Symptoms were assessed at intervals of three months for 24 months by an independent observer, and the effects of sphincterotomy on sphincter function were monitored by repeat manometry after three and 24 months.
In the SO stenosis group, symptoms improved in 11 of 13 patients treated by sphincterotomy and in five of 13 subjected to a sham procedure (p = 0.041). When manometric records were categorised as dyskinesia or normal, results from sphincterotomy and sham procedures did not differ. Complications were rare, but included mild pancreatitis in seven patients (14 episodes) and a collection in the right upper quadrant, presumably related to a minor perforation. At three months, the endoscopic incision was extended in 19 patients because of manometric evidence of incomplete division of the sphincter.
In patients with presumed SO dysfunction, endoscopic sphincterotomy is helpful in those with manometric features of SO stenosis.
尽管有证据表明，对于部分Oddi括约肌（SO）基础压力较高（SO狭窄）的患者，内镜下括约肌切开术有效，但胆囊切除术后胆源性疼痛的内镜下括约肌切开术仍存在争议。
根据内镜下胆道测压结果，评估随机分组患者接受括约肌切开术的效果。
对81例胆囊切除术后出现胆源性疼痛的患者进行内镜下胆道测压，这些患者逆行胆管造影显示胆管扩张、疼痛发作后肝酶短暂升高或对吗啡/新斯的明激发试验呈阳性反应。测压记录分为SO狭窄、SO运动障碍或正常，然后在一项前瞻性双盲研究中，将每个类别中的患者随机分为括约肌切开术组或假手术组。由独立观察者每三个月评估一次症状，持续24个月，并在3个月和24个月后通过重复测压监测括约肌切开术对括约肌功能的影响。
在SO狭窄组中，接受括约肌切开术的13例患者中有11例症状改善，接受假手术的13例患者中有5例症状改善（p = 0.041）。当测压记录分类为运动障碍或正常时，括约肌切开术和假手术的结果没有差异。并发症很少见，但包括7例患者出现轻度胰腺炎（14次发作）和右上象限积液，可能与轻微穿孔有关。在3个月时，由于测压显示括约肌未完全切开，19例患者的内镜切口被扩大。
对于推测有SO功能障碍的患者，内镜下括约肌切开术对具有SO狭窄测压特征的患者有帮助。
