Lim Chin Hong, Jahansouz Cyrus, Freeman Martin L, Leslie Daniel B, Ikramuddin Sayeed, Amateau Stuart K
Division of Upper Gastrointestinal & Bariatric Surgery, Department of Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore.
Division of Minimally Invasive Gastrointestinal Surgery and Medicine, Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, USA.
Obes Surg. 2017 Oct;27(10):2656-2662. doi: 10.1007/s11695-017-2696-4.
Sphincter of Oddi dysfunction (SOD) is thought to be a cause of chronic abdominal pain post Roux-en-Y gastric bypass, and current practice of performing endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy is not supported by evidence. In addition to the complexity and risks of the procedure in patients with Roux-en-Y anatomy, the outcomes are uncertain and debatable. We performed a retrospective review and analysis of post-gastric bypass patients who had undergone ERCP with sphincterotomy to determine the effectiveness in patients with suspected SOD.
Over a period of 5 years at the University of Minnesota, we retrospectively reviewed a prospectively collected database of a cohort of patients whom had a previous Roux-en-Y gastric bypass and whom had a subsequent ERCP for suspected SOD. Patients were categorized by modified Milwaukee classification, and outcomes were evaluated by patients' self-reporting of symptoms at follow-up.
We identified 50 patients who underwent laparoscopic-assisted gastrostomy for endoscopic retrograde cholangiopancreatography post Roux-en-Y gastric bypass over the study period. Within this group, 35 patients (70%) were suspected to have SOD. Nine patients (25.7%) were classified as type I, 19 patients (54.3%) type II, and seven patients (20%) type III. Thirty-four patients (97.1%) had biliary sphincterotomy, and 17 patients (48.6%) had both biliary and pancreatic sphincterotomy. Fourteen (40%) had repeated ERCP. At median follow-up of 11.5 months, type I SOD had two responders (25%), type II had nine responders (52.9%), and type III had one responder (14.3%). A subgroup analysis did not show significant differences in improvement of symptoms between patients whom had single versus repeated ERCP or biliary sphincterotomy alone versus both biliary and pancreatic sphincterotomy. Three patients (9%) had post-ERCP pancreatitis.
SOD in patients post Roux-en-Y gastric bypass is complex due to multiple confounding factors. Rome III and Milwaukee classification systems assist us in the diagnosis and treatment of sphincter dysfunction until we have a better way to predict treatment response post sphincterotomy. Current treatment is based on the type of disorder and anatomy of biliary ducts. Types I and II sphincter dysfunction particularly associated with dilated biliary duct on imaging have the best response to endoscopic sphincterotomy and therefore should be considered taking into account the risks and benefit. Repeated sphincterotomy and concurrent pancreatic sphincterotomy is generally not useful.
Oddi括约肌功能障碍（SOD）被认为是Roux-en-Y胃旁路术后慢性腹痛的一个原因，目前进行或不进行括约肌切开术的内镜逆行胰胆管造影（ERCP）操作实践并无证据支持。除了Roux-en-Y解剖结构患者手术的复杂性和风险外，其结果也不确定且存在争议。我们对接受了括约肌切开术的胃旁路术后患者进行了回顾性研究与分析，以确定对疑似SOD患者的有效性。
在明尼苏达大学的5年时间里，我们回顾性分析了一个前瞻性收集的数据库，该数据库包含一组曾接受Roux-en-Y胃旁路手术且随后因疑似SOD接受ERCP的患者。患者按改良的密尔沃基分类法进行分类，并通过患者随访时的症状自我报告来评估结果。
在研究期间，我们确定了50例接受腹腔镜辅助胃造口术以在Roux-en-Y胃旁路术后进行内镜逆行胰胆管造影的患者。在该组中，35例患者（70%）疑似患有SOD。9例患者（25.7%）被分类为I型，19例患者（54.3%）为II型，7例患者（20%）为III型。34例患者（97.1%）进行了胆管括约肌切开术，17例患者（48.6%）进行了胆管和胰管括约肌切开术。14例（40%）患者接受了重复ERCP。在中位随访11.5个月时，I型SOD有2例症状缓解者（25%），II型有9例症状缓解者（52.9%），III型有1例症状缓解者（14.3%）。亚组分析未显示单次与重复ERCP患者之间或仅进行胆管括约肌切开术与胆管和胰管括约肌切开术患者之间症状改善的显著差异。3例患者（9%）发生了ERCP术后胰腺炎。
由于多种混杂因素，Roux-en-Y胃旁路术后患者的SOD情况较为复杂。在我们有更好的方法预测括约肌切开术后的治疗反应之前，罗马III和密尔沃基分类系统有助于我们对括约肌功能障碍进行诊断和治疗。目前的治疗基于疾病类型和胆管解剖结构。I型和II型括约肌功能障碍，尤其是影像学上与胆管扩张相关的，对内镜括约肌切开术反应最佳，因此应在考虑风险和益处的基础上予以考虑。重复括约肌切开术和同时进行胰管括约肌切开术通常并无益处。
