A Technic for Pancreatobiliary Sphincteroplasty Mark A. Hayes, MD, New Haven, Connecticut C. Elton Cahow, MD, New Haven, Connecticut
Sphincterotomy as a definite operative procedure is rarely, if ever, justifiable. There is conclusive evidence that, like any other sphincter, the sphincter of Oddi when simply divided usually repairs and functions as before. On the contrary, the indications for sphincteroplasty are well established [l-4]; the technics employed, however, are diverse [5]. Difficulties which may arise during sphincteroplasty are, singly or in combination: (1) escape or separation of duodenal mucosa from the common duct wall; (2) bleeding which may obscure the operative field and thus prevent accurate suture approximation of the duodenal and common duct walls; and (3) inadvertent ligation or injury to the opening into the ampulla of the pancreatic duct, particularly if the disease process has narrowed its orifice. A technic for sphincteroplasty as performed at the Yale-New Haven Medical Center is illustrated. It has proven to be safe and simple in ten years’ experience with more than 200 sphincteroplasties resulting in no failures or complications attributable to technical performance. Technic
The sphincteroplasty clamp, especially designed for this operative procedure (Edward Week and Company, Research Triangle Park, NC 27709), is a delicate instrument, 16.5 cm in length, a.nd is emFrom the Department of Surgery, Yale-New Haven Medical Center, New Haven, Connecticut. Reprint requests should be addressed to Mark A. Hayes, MD, Department of Surgery, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06510. Presented at the Fifty-Ninth Annual Meeting of the New England Surgical Society, Dixville Notch, New Hampshire, September 299October 1. 1976.
470
ployed in pairs. As seen in the view shown in Figure 1, one essential element in the design is the angle of the jaws to the handles, permitting application with accuracy and ease, since the handles are directed towards the operator, out of the operative field. The second unique feature of the jaws (Figure 2) is the longitudinal grooving, much like that of the Allen intestinal clamp. In contrast to the “mosquito” clamp which has transverse grooving, the longitudinal grooves minimize the possibility of the grasped tissue slipping from the clamp. The opposing jaws measure 4 by 15 mm. The length is judged to be adequate to grasp the entire sphincteric mechanism [6]. In the conventional Bakes’ dilator, the malleable stem has been replaced by a finely coiled spring. (Figure 3, shown here in multiple exposures.) The significance and purpose of the modified instrument will become apparent. With these two instruments available, the operator conducts a wide and thorough mobilization of the duodenum and head of the pancreas, until the lateral surface of the second duodenum faces directly ventrad. Choledochotomy is not routinely performed as part of the sphincteroplasty procedure. Operative cholangiography is performed via the cystic duct,. (Figure 4.) If the gallbladder had been removed previously, the stump of the cystic duct is reopened. The flexible Bakes’ dilator or a small Robinson catheter is passed through the cystic duct until it can be palpated through the duodenal wall, establishing the location of the ampulla. A small transverse duodenotomy is made; absolute hemostasis is insured with a continuous 4-O absorbable suture circumferentially encompassing the mucosa and the submucosa of the enterotomy.
The American Journal of Surgery
Pancreatobiliary Sphincteroplasty
Manipulation of either the dilator or the catheter gradually enlarges the stenotic sphincter. (Figure 5.) By holding either the catheter or dilator on tension, the orifice of the pancreatic duct is identified. If the opening is not readily evident, a solution of secretin in the dosage of 1 unit/kg body weight is administered intravenously, slowly over a 5 minute period. After the pancreatic duct is identified (for possible subsequent sphincteroplasty and for pancreatography), a grooved director is inserted through the sphincter under the dilator (or catheter), the latter being gradually withdrawn as the director is advanced. (Figure 6.) Under the unusual but not unexperienced situation in which a prior cholecystectomy has been done and the cystic duct is too small to accept a catheter and the common duct is small and thin walled, the entire procedure can be performed via the duode-
notomy. In several patients such findings were associated with an ampullary orifice so small that only a fine flexible probe could be introduced for initial dilation before application of the clamps. The first of the two sphincteroplasty clamps is inserted with the bottom jaw passing along the groove in the director whose convex side is protecting the
Ffgure 3. kEuliip~%? exposures of modMk?dBakes’dffatw, with a finely coiled spring instead of the malleable stem.
Figure 1. The sphincteroplasty clamp, 16.5 cm tong. Note the angle of the jaws to the handle.
-__-.
Figure 2. Alternate view of clamp showing longitudinal grooving.
Volume 137, April 1979
Figure 4. Operative chota~aphy performed through the cystic duct and catheter or dilator focalization of the stenotfc sphincter.
471
Hayes and Cahow
Figure 5. Enlargemenf of the stenofic sphincter to idenfify the orifice of the pancreatic duct.
pancreatic duct. (Figure 7.) The clamp, with its heel directed ventrad to about the five o’clock position, is closed firmly. The grooved director is moved to the seven o’clock position, and the procedure repeated with the second clamp, making certain that the points of the clamps approximate one another as closely as possible. The final positioning of the clamps permits the sharp excision of a triangular portion of sphincteric complex about 15 mm long to be examined histologically and provides a patulous nonsphincteric end-to-side choledochoduodenostomy. (Figure 8.) If uncertainty arises as to the integrity of the pancreatic duct, a repeat intravenous administration of secretin is given for visualization. (Figure 9.) Interrupted 4-O arterial silk is employed for direct vision, over the clamp, overlapping suture of the duodenal wall to the wall of the common bile duct. (Figure 10.) It is important to emphasize, as shown in the insert, the method of suturing, overlapping to prevent bleeding after removal of the clamp. Each suture is placed and held. The suture at the apex of the triangle is important unless a second application of the clamps is judged to be necessary. With the
472
Figure 6. A grooved director is inserted through the sphincter under the dilator (or catheter), fhe latter being gradually withdra mmas the director is advanced.
sutures held taut, the clamp is withdrawn and the sutures tied individually. Throughout this portion of the procedure a fine polyethylene catheter remains in the pancreatic duct for protection of the duct and later pancreatography. The final result is a patulous 15 mm sphincteroplasty (Figure ll), accomplished with accurate approximation in virtually a bloodless field. If pancreatography indicates stricture at the orifice of the pancreatic duct, sphincteroplasty in an identical fashion is performed on that opening. Closure of the duodenotomy is made transversely with a single layer of seromuscular nonabsorbable sutures. Adventitial provisions, such as a T tube and Penrose drain, are employed as necessary. Summary
A technic for pancreatobiliary sphincteroplasty providing accurate approximation of tissues in a bloodless field has been presented. It is suitable and adaptable to the common duct with duodenum, as well as pancreatic duct with common duct.
The American Journal ol Surgery
Pancreatobiliary Sphincteroplasty
Figure 7. The first sphincterotomy clamp is inserted with the bottom jaw passing akmg the groove in the dkector and closed. With the director in the seven o’clock position, the procedure is repeated with the second clamp.
Figure 8. Final positioning of the clamps for excision of a triangular portion of sphincteric complex.
References 1. Carey LC: The Pancreas. St. Louis, C. V. Mosby, 1973.
2. Gambill EE: Pancreatitis. St. Louis, C. V. Mosby, 1973. 3. Howard JM, Jordan GL: Surgical Diseases of the Pancreas. Philadelphia, J. B. Lippincott, 1960. 4. White TT: Indications for sphincteroplasty as opposed to choledochoduodenostomy. Ann Surg 126: 165, 1973. 5. Malt RA (ed): Surgical Techniques Illustrated, ~012, no. 4, Boston, Little, Brown, 1977. 6. Boyden EA: The anatomy of the choledochoduodenal junction in man. Surg Gynecol O&et 104: 641, 1957.
Discussion James Foster (Farmington, CT): Surgical craftsmanship, although of great importance to our patients, usually has a small place on most surgical programs. Therefore, it is a distinct pleasure to learn of a new and useful technic and to see it so well illustrated by drawings rather than photographs. However, I must confess that I do not always see the pancreatic duct orifice as clearly as you have shown it to us. I have three brief questions. Is the clamp commercially available? Why do you use silk when there are many less noxious choices of suture for mucosal repair in 1978? And finally, the results of endoscopic papillotomy suggest that our incision and repair may not need to be as long as many have thought. Have you studied your patients mano-
volume 137, April 1979
Figure 9. Repeat intravenous secretin administration for visualization.
473
Hayes and Cahow
FigureIO. Placement of the sutures
estimates of good or gratifying results have gone from 80 to 70 to 60 to 50. About ten or fifteen years ago we wrote a little article for Surgery, Gynecology, and Obstetrics which described longitudinally grooved snaps to be placed in the ampulla for this operation. We did not angle them, because it is fairly easy to angle them during the operation. I think Dexon@ is the best suture material to use. I often have trouble finding the pancreatic duct. I perform longitudinal duodenotomy because I like to have the ability to go up or down and extend my incision. I never found it necessary to put any stitches in the cut duodenum. There are only three or four bleeding points. An Allis clamp is put on these and 10 to 15 minutes later it is removed, and there is no bleeding.
Figure 17. Final 15 mm sphincteroplasty.
metrically to determine early and late the proper length for a sphincter incision, and will the endoscopist replace the need for your clamp and technic in the future? George Nardi (Boston, MA): With Dr. Bartlett’s help, I got involved with this operation many years ago, and we now have about 300 patients that we have been following up for fifteen to twenty years. I do not know what gratifying results are, since as the years go by I find that recurrent symptoms develop in my patients with gratifying results, even after five years or more. We are doing more pancreatectomies, even total pancreatectomies, and recently have been transplanting islet cells back to try to ameliorate the diabetes. We are still not clear as to what kind of disease we are treating. Nevertheless, the described procedure provides good palliation in a number of cases, and over the years my
474
C. Elton Cahow (closing): Dr. Foster, about four years ago when I discussed this technic with you, I said I was using catgut. You said that catgut sutures are going to dissolve, and the closure wound will fall apart. So now we use silk. There is a smaller clamp for the pancreatic duct, but very often a clamp is not necessary in the pancreatic duct at all. You make an incision, put in a suture, and it holds very well. The question arises as to how large the sphincteroplasty should be. In all the series in which sphincteroplasties and the old sphincterotomies were reviewed, it was believed that if there is a “two way street,” cholangitis does not develop. The rate of cholangitis in large series is 1 to 2 per cent. If the entire sphincter is not transected or if it becomes stenotic and there is little narrowing, then food can get in that cannot get out, and cholangitis develops. We think it is important to transect both the inferior and superior sphincters, which are about 1.8 cm apart. As far as pancreatitis is concerned, I agree with Dr. Nardi. One must be very cautious in choosing patients who have had pancreatitis secondary to stenosis of the sphincter. These patients do have recurrences of pancreatitis following sphincteroplasty. Dexon is an excellent suture material for use in sphincteroplasties, although I think almost any type that will survive the first six weeks is fine.
The American Journal 01 Surgery
Sphincterotomy as a definite operative procedure is rarely, if ever, justifiable. There is conclusive evidence that, like any other sphincter, the sphincter of Oddi when simply divided usually repairs and functions as before. On the contrary, the indications for sphincteroplasty are well established [l-4]; the technics employed, however, are diverse [5]. Difficulties which may arise during sphincteroplasty are, singly or in combination: (1) escape or separation of duodenal mucosa from the common duct wall; (2) bleeding which may obscure the operative field and thus prevent accurate suture approximation of the duodenal and common duct walls; and (3) inadvertent ligation or injury to the opening into the ampulla of the pancreatic duct, particularly if the disease process has narrowed its orifice. A technic for sphincteroplasty as performed at the Yale-New Haven Medical Center is illustrated. It has proven to be safe and simple in ten years’ experience with more than 200 sphincteroplasties resulting in no failures or complications attributable to technical performance. Technic
The sphincteroplasty clamp, especially designed for this operative procedure (Edward Week and Company, Research Triangle Park, NC 27709), is a delicate instrument, 16.5 cm in length, a.nd is emFrom the Department of Surgery, Yale-New Haven Medical Center, New Haven, Connecticut. Reprint requests should be addressed to Mark A. Hayes, MD, Department of Surgery, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06510. Presented at the Fifty-Ninth Annual Meeting of the New England Surgical Society, Dixville Notch, New Hampshire, September 299October 1. 1976.
470
ployed in pairs. As seen in the view shown in Figure 1, one essential element in the design is the angle of the jaws to the handles, permitting application with accuracy and ease, since the handles are directed towards the operator, out of the operative field. The second unique feature of the jaws (Figure 2) is the longitudinal grooving, much like that of the Allen intestinal clamp. In contrast to the “mosquito” clamp which has transverse grooving, the longitudinal grooves minimize the possibility of the grasped tissue slipping from the clamp. The opposing jaws measure 4 by 15 mm. The length is judged to be adequate to grasp the entire sphincteric mechanism [6]. In the conventional Bakes’ dilator, the malleable stem has been replaced by a finely coiled spring. (Figure 3, shown here in multiple exposures.) The significance and purpose of the modified instrument will become apparent. With these two instruments available, the operator conducts a wide and thorough mobilization of the duodenum and head of the pancreas, until the lateral surface of the second duodenum faces directly ventrad. Choledochotomy is not routinely performed as part of the sphincteroplasty procedure. Operative cholangiography is performed via the cystic duct,. (Figure 4.) If the gallbladder had been removed previously, the stump of the cystic duct is reopened. The flexible Bakes’ dilator or a small Robinson catheter is passed through the cystic duct until it can be palpated through the duodenal wall, establishing the location of the ampulla. A small transverse duodenotomy is made; absolute hemostasis is insured with a continuous 4-O absorbable suture circumferentially encompassing the mucosa and the submucosa of the enterotomy.
The American Journal of Surgery
Pancreatobiliary Sphincteroplasty
Manipulation of either the dilator or the catheter gradually enlarges the stenotic sphincter. (Figure 5.) By holding either the catheter or dilator on tension, the orifice of the pancreatic duct is identified. If the opening is not readily evident, a solution of secretin in the dosage of 1 unit/kg body weight is administered intravenously, slowly over a 5 minute period. After the pancreatic duct is identified (for possible subsequent sphincteroplasty and for pancreatography), a grooved director is inserted through the sphincter under the dilator (or catheter), the latter being gradually withdrawn as the director is advanced. (Figure 6.) Under the unusual but not unexperienced situation in which a prior cholecystectomy has been done and the cystic duct is too small to accept a catheter and the common duct is small and thin walled, the entire procedure can be performed via the duode-
notomy. In several patients such findings were associated with an ampullary orifice so small that only a fine flexible probe could be introduced for initial dilation before application of the clamps. The first of the two sphincteroplasty clamps is inserted with the bottom jaw passing along the groove in the director whose convex side is protecting the
Ffgure 3. kEuliip~%? exposures of modMk?dBakes’dffatw, with a finely coiled spring instead of the malleable stem.
Figure 1. The sphincteroplasty clamp, 16.5 cm tong. Note the angle of the jaws to the handle.
-__-.
Figure 2. Alternate view of clamp showing longitudinal grooving.
Volume 137, April 1979
Figure 4. Operative chota~aphy performed through the cystic duct and catheter or dilator focalization of the stenotfc sphincter.
471
Hayes and Cahow
Figure 5. Enlargemenf of the stenofic sphincter to idenfify the orifice of the pancreatic duct.
pancreatic duct. (Figure 7.) The clamp, with its heel directed ventrad to about the five o’clock position, is closed firmly. The grooved director is moved to the seven o’clock position, and the procedure repeated with the second clamp, making certain that the points of the clamps approximate one another as closely as possible. The final positioning of the clamps permits the sharp excision of a triangular portion of sphincteric complex about 15 mm long to be examined histologically and provides a patulous nonsphincteric end-to-side choledochoduodenostomy. (Figure 8.) If uncertainty arises as to the integrity of the pancreatic duct, a repeat intravenous administration of secretin is given for visualization. (Figure 9.) Interrupted 4-O arterial silk is employed for direct vision, over the clamp, overlapping suture of the duodenal wall to the wall of the common bile duct. (Figure 10.) It is important to emphasize, as shown in the insert, the method of suturing, overlapping to prevent bleeding after removal of the clamp. Each suture is placed and held. The suture at the apex of the triangle is important unless a second application of the clamps is judged to be necessary. With the
472
Figure 6. A grooved director is inserted through the sphincter under the dilator (or catheter), fhe latter being gradually withdra mmas the director is advanced.
sutures held taut, the clamp is withdrawn and the sutures tied individually. Throughout this portion of the procedure a fine polyethylene catheter remains in the pancreatic duct for protection of the duct and later pancreatography. The final result is a patulous 15 mm sphincteroplasty (Figure ll), accomplished with accurate approximation in virtually a bloodless field. If pancreatography indicates stricture at the orifice of the pancreatic duct, sphincteroplasty in an identical fashion is performed on that opening. Closure of the duodenotomy is made transversely with a single layer of seromuscular nonabsorbable sutures. Adventitial provisions, such as a T tube and Penrose drain, are employed as necessary. Summary
A technic for pancreatobiliary sphincteroplasty providing accurate approximation of tissues in a bloodless field has been presented. It is suitable and adaptable to the common duct with duodenum, as well as pancreatic duct with common duct.
The American Journal ol Surgery
Pancreatobiliary Sphincteroplasty
Figure 7. The first sphincterotomy clamp is inserted with the bottom jaw passing akmg the groove in the dkector and closed. With the director in the seven o’clock position, the procedure is repeated with the second clamp.
Figure 8. Final positioning of the clamps for excision of a triangular portion of sphincteric complex.
References 1. Carey LC: The Pancreas. St. Louis, C. V. Mosby, 1973.
2. Gambill EE: Pancreatitis. St. Louis, C. V. Mosby, 1973. 3. Howard JM, Jordan GL: Surgical Diseases of the Pancreas. Philadelphia, J. B. Lippincott, 1960. 4. White TT: Indications for sphincteroplasty as opposed to choledochoduodenostomy. Ann Surg 126: 165, 1973. 5. Malt RA (ed): Surgical Techniques Illustrated, ~012, no. 4, Boston, Little, Brown, 1977. 6. Boyden EA: The anatomy of the choledochoduodenal junction in man. Surg Gynecol O&et 104: 641, 1957.
Discussion James Foster (Farmington, CT): Surgical craftsmanship, although of great importance to our patients, usually has a small place on most surgical programs. Therefore, it is a distinct pleasure to learn of a new and useful technic and to see it so well illustrated by drawings rather than photographs. However, I must confess that I do not always see the pancreatic duct orifice as clearly as you have shown it to us. I have three brief questions. Is the clamp commercially available? Why do you use silk when there are many less noxious choices of suture for mucosal repair in 1978? And finally, the results of endoscopic papillotomy suggest that our incision and repair may not need to be as long as many have thought. Have you studied your patients mano-
volume 137, April 1979
Figure 9. Repeat intravenous secretin administration for visualization.
473
Hayes and Cahow
FigureIO. Placement of the sutures
estimates of good or gratifying results have gone from 80 to 70 to 60 to 50. About ten or fifteen years ago we wrote a little article for Surgery, Gynecology, and Obstetrics which described longitudinally grooved snaps to be placed in the ampulla for this operation. We did not angle them, because it is fairly easy to angle them during the operation. I think Dexon@ is the best suture material to use. I often have trouble finding the pancreatic duct. I perform longitudinal duodenotomy because I like to have the ability to go up or down and extend my incision. I never found it necessary to put any stitches in the cut duodenum. There are only three or four bleeding points. An Allis clamp is put on these and 10 to 15 minutes later it is removed, and there is no bleeding.
Figure 17. Final 15 mm sphincteroplasty.
metrically to determine early and late the proper length for a sphincter incision, and will the endoscopist replace the need for your clamp and technic in the future? George Nardi (Boston, MA): With Dr. Bartlett’s help, I got involved with this operation many years ago, and we now have about 300 patients that we have been following up for fifteen to twenty years. I do not know what gratifying results are, since as the years go by I find that recurrent symptoms develop in my patients with gratifying results, even after five years or more. We are doing more pancreatectomies, even total pancreatectomies, and recently have been transplanting islet cells back to try to ameliorate the diabetes. We are still not clear as to what kind of disease we are treating. Nevertheless, the described procedure provides good palliation in a number of cases, and over the years my
474
C. Elton Cahow (closing): Dr. Foster, about four years ago when I discussed this technic with you, I said I was using catgut. You said that catgut sutures are going to dissolve, and the closure wound will fall apart. So now we use silk. There is a smaller clamp for the pancreatic duct, but very often a clamp is not necessary in the pancreatic duct at all. You make an incision, put in a suture, and it holds very well. The question arises as to how large the sphincteroplasty should be. In all the series in which sphincteroplasties and the old sphincterotomies were reviewed, it was believed that if there is a “two way street,” cholangitis does not develop. The rate of cholangitis in large series is 1 to 2 per cent. If the entire sphincter is not transected or if it becomes stenotic and there is little narrowing, then food can get in that cannot get out, and cholangitis develops. We think it is important to transect both the inferior and superior sphincters, which are about 1.8 cm apart. As far as pancreatitis is concerned, I agree with Dr. Nardi. One must be very cautious in choosing patients who have had pancreatitis secondary to stenosis of the sphincter. These patients do have recurrences of pancreatitis following sphincteroplasty. Dexon is an excellent suture material for use in sphincteroplasties, although I think almost any type that will survive the first six weeks is fine.
The American Journal 01 Surgery
