Common Bile Duct and Oddi Sphincter Pressure Before and After Endoscopic Papillotomy in Patients with Common Bile Duct Stones P. FUNCH-JENSEN, A. CSENDES, M.D., F.A.C.S.,* A. KRUSE, M.D., M. J. OSTER, M.D., E. AMDRUP, M.D., PH.D.
From the Departments of Surgical Gastroenterology and Diagnostic Radiology, Arhus Kommunehospital, University of Arhus, Arhus, Denmark
Pressures in the Oddi sphincter and common bile duct were determined before, immediately after and several weeks after endoscopic papillotomy. Fifteen patients were included in the study. Significant decreases in Oddi sphincter and common bile duct pressures were found and the decrease in Oddi sphincter pressure was to some extent dependent upon the length of the papillotomy.
PREVIOUS STUDIES have shown that the Oddi sphincter is a high pressure zone with phasic activity, creating a gradient between the common bile duct and the duodenum.2-4'7 The purpose of this study was to evaluate the effect of endoscopic papillotomy on these conditions. Materials and Methods Fifteen patients (10 females and 5 males) with a mean age of 66.2 years (range: 39-85) gave their informed consent to be included in this investigation. Six patients were studied before, immediately after and four weeks after endoscopic papillotomy (EPT). Six patients were studied before and immediately after EPT whereas three patients were available only four weeks after EPT. After an overnight fast the patients were premedicated with 0.5 mg Atropine and 50 mg Pethidine (Mepiridine®). One hour later, immediately before the introduction of the endoscope, 5-10 mg Diazepam was administered intravenously. A 195 cm long Teflon® catheter with an inner diameter of 1.0 mm was used for manometric examination. The end was closed and a 1 mm circular side hole was con-
structed 1 cm from the tip. The recording catheter was constantly perfused with sterile 0.88% saline at a rate of 1 ml/minute through a heavy-duty infusion pump (Braun Unita I, West Germany) with greased glass syringe. The catheter was attached to an external transducer (Elema Siemens 746, Sweden) which was connected to a direct writer (Mingograph 82, Elema Siemens, Sweden). The characteristics of this system can be summarized as, low increase in base line pressure (8 mmHg) and a pressure rise rate of 80 mmHg/ second after sudden occlusion of the recording hole. After cannulation of the Ampulla of Vater, the correct position of the recording catheter was checked by gentle aspiration of green bile, directly seen in the endoscope through the transparent Teflon catheter.
Clinical research assistant, University of Arhus during this study. Reprint requests: P. Funch-Jensen, Surgical Gastroenterological Department L, Arhus Kommunehospital, DK-8000 Arhus C, Denmark. Supported by grant number 512-7468 from the Danish Medical. Research Council. Submitted for publication: March 13, 1979. *
Before EPT
mm Hg
125 100
75 50
25 0
m.- CBDP
mm
-
I DP
FIG. 1. A tracing from a patient before endoscopic papillotomy (EPT). The common bile duct pressure (CBDP), the Oddi sphincter pressure (OSP) and the intraduodenal pressure (IDP) are shown.
0003-4932/79/0800/0176 $01.15 © J. B. Lippincott Company
176
OSP
Ann. Surg. * August 1979
ENDOSCOPIC PAPILLOTOMY
177
Immediately after EPT mm
Hg
50
25
O- --~ CUD uOuDP FIG. 2. Tracing from a patient immediately after endoscopic papillotomy (EPT) giving the common bile duct pressure (CBDP), the Oddi sphincter pressure (OSP) and the intraduodenal pressure (IDP).
For the determination of the Oddi sphincter pressure (OSP) the station pull through technique was employed, the recording hole remaining in the same position for several seconds or minutes. The mean OSP is given as the average of peak pressures and the intraduodenal pressure was taken as zero reference in this calculation as well as in the determination of the common bile duct pressure (CBDP). The Olympus endoscopes JF-B2 and JF-B3 with papillotome were the endoscopes used. In ten patients it was possible to estimate the extension of the papillotomy in millimeters. All values are given as mean + standard error of the mean (SEM). For statistical evaluation the Mann-
Whitney rank sum test was used and significance was considered at the 5% level. Results A tracing before EPT is shown in Figure 1. It can be seen that the Oddi sphincter is a high pressure zone with phasic activity. The effect of EPT upon the OSP is shown in Figures 2 and 3. A significant reduction from 74.4 ± 6.6 mmHg before EPT to 26.3 + 4.5 and 29.3 + 8.5 mmHg immediately and four weeks after EPT was found. Before EPT the mean CBDP was 10.4 + 1.6 mmHg. A significant reduction to 0 mmHg occurred immediately as well as 4 weeks after EPT (Figs. 2 and 3).
mm Hg
80
0 Oddi sphincter pressure
* Common bile duct pressure 60
FIG. 3. The mean Oddi sphincter pressure and common bile duct pressure + standard error of the 40 mean before, immediately after and four weeks after
endoscopic papillotomy (EPT). 20
04
--6
Before EPT
a
Immediately after
&
0p 4 weeks after EPT
FUNCH-JENSEN AND OTHERS
178
Ann. Surg. * August 1979
Length of
PaPd lotomy (mm) 20
r.0,66
151 10
FIG. 4. The
regression line
showing the correlation between the length of the
R euction
25
S0
In no tracings were peristaltic activities observed in the common bile duct. In Figure 4 the reduction in OSP is plotted against the length of the EPT and the regression line drawn. The correlation coefficient was 0.66. Discussion This study confirmed previous findings, that the Oddi sphincter is a high pressure zone with phasic activity.2-4'7 Endoscopic papillotomy reduced the Oddi sphincter pressure significantly. This is in accordance with the findings of Hogan et al.5 The magnitude of the reduction in OSP depended, to some extent on the length of the papillotomy. Under normal conditions, the Oddi sphincter creates a gradient between the common bile duct and the duodenum. This study was in accordance with the findings of Rosch et al. and Hogan et al.,4 that performing papillotomy, thereby reducing the Oddi sphincter pressure, the choledochoduodenal gradient was equalized, this probably allowing duodenocholedochal reflux.I Acknowledgment The authors wish to thank Miss Inge Krogh for excellent technical support.
in OSP ()
papillotomy and the reduction in Oddi sphincter pressure (OSP) in per cent. The correlation coefficient (r) was 0.66.
References 1. Bodner, E., Platzer, S., Foedish, H. J. and Schwamberger, K.: Uber den Duodenobilifiren Reflux nach Totaler Sphincterotomie. Zentralbl. Chir., 99:788, 1974. 2. Csendes, A., Kruse, A., Funch-Jensen, P., et al.: Pressure Measurements in the Biliary and Pancreatic Duct Systems in Controls and in Patients with Gallstones, Previous Cholecystectomy or Common Bile Duct Stones. Gastroenterology, (submitted for publication). 3. Funch-Jensen, P., Csendes, A., Kruse, A. and Oster, M. J.: Common Bile Duct and Oddi Sphincter Pressure in Patients with Common Bile Duct Stones with and without Juxtaampullar Diverticula of the Duodenum. Scand. J. Gastroenterol., 14:253, 1979. 4. Hogan, W. J., Dodds, W. J., Geenen, J. E., et al.: Sphincter of Oddi Motor Activity in Man: A Zone of Unique Phasic High-pressure Contractions. Symposium on Gastrointestinal Motility, Edinbourgh 1977, paper No 66. 5. Hogan, W. J., Geenen, J. E., Schaffer, R. D., et al.: Sphincter of Oddi Pressure Measurement in Biliary Tract Disease Before and After Endoscopic Sphincterotomy. Gastroenterol. Endoscopy, 23:230, 1977. 6. Rosch, W., Koch, H. and Demling, L.: Manometric Studies During ERCP and Endoscopic Papillotomy. Endoscopy, 8:30, 1976. 7. Oster, M. J., Csendes, A., Funch-Jensen, P. and Skjoldborg, H.: Intraoperative Pressure Measurements of the Choledochoduodenal Junction, Common Bile Duct, Cysticocholedochal Junction and Gallbladder in Patients with Gallstones. Surg. Gynecol. & Obstet. (in press).
From the Departments of Surgical Gastroenterology and Diagnostic Radiology, Arhus Kommunehospital, University of Arhus, Arhus, Denmark
Pressures in the Oddi sphincter and common bile duct were determined before, immediately after and several weeks after endoscopic papillotomy. Fifteen patients were included in the study. Significant decreases in Oddi sphincter and common bile duct pressures were found and the decrease in Oddi sphincter pressure was to some extent dependent upon the length of the papillotomy.
PREVIOUS STUDIES have shown that the Oddi sphincter is a high pressure zone with phasic activity, creating a gradient between the common bile duct and the duodenum.2-4'7 The purpose of this study was to evaluate the effect of endoscopic papillotomy on these conditions. Materials and Methods Fifteen patients (10 females and 5 males) with a mean age of 66.2 years (range: 39-85) gave their informed consent to be included in this investigation. Six patients were studied before, immediately after and four weeks after endoscopic papillotomy (EPT). Six patients were studied before and immediately after EPT whereas three patients were available only four weeks after EPT. After an overnight fast the patients were premedicated with 0.5 mg Atropine and 50 mg Pethidine (Mepiridine®). One hour later, immediately before the introduction of the endoscope, 5-10 mg Diazepam was administered intravenously. A 195 cm long Teflon® catheter with an inner diameter of 1.0 mm was used for manometric examination. The end was closed and a 1 mm circular side hole was con-
structed 1 cm from the tip. The recording catheter was constantly perfused with sterile 0.88% saline at a rate of 1 ml/minute through a heavy-duty infusion pump (Braun Unita I, West Germany) with greased glass syringe. The catheter was attached to an external transducer (Elema Siemens 746, Sweden) which was connected to a direct writer (Mingograph 82, Elema Siemens, Sweden). The characteristics of this system can be summarized as, low increase in base line pressure (8 mmHg) and a pressure rise rate of 80 mmHg/ second after sudden occlusion of the recording hole. After cannulation of the Ampulla of Vater, the correct position of the recording catheter was checked by gentle aspiration of green bile, directly seen in the endoscope through the transparent Teflon catheter.
Clinical research assistant, University of Arhus during this study. Reprint requests: P. Funch-Jensen, Surgical Gastroenterological Department L, Arhus Kommunehospital, DK-8000 Arhus C, Denmark. Supported by grant number 512-7468 from the Danish Medical. Research Council. Submitted for publication: March 13, 1979. *
Before EPT
mm Hg
125 100
75 50
25 0
m.- CBDP
mm
-
I DP
FIG. 1. A tracing from a patient before endoscopic papillotomy (EPT). The common bile duct pressure (CBDP), the Oddi sphincter pressure (OSP) and the intraduodenal pressure (IDP) are shown.
0003-4932/79/0800/0176 $01.15 © J. B. Lippincott Company
176
OSP
Ann. Surg. * August 1979
ENDOSCOPIC PAPILLOTOMY
177
Immediately after EPT mm
Hg
50
25
O- --~ CUD uOuDP FIG. 2. Tracing from a patient immediately after endoscopic papillotomy (EPT) giving the common bile duct pressure (CBDP), the Oddi sphincter pressure (OSP) and the intraduodenal pressure (IDP).
For the determination of the Oddi sphincter pressure (OSP) the station pull through technique was employed, the recording hole remaining in the same position for several seconds or minutes. The mean OSP is given as the average of peak pressures and the intraduodenal pressure was taken as zero reference in this calculation as well as in the determination of the common bile duct pressure (CBDP). The Olympus endoscopes JF-B2 and JF-B3 with papillotome were the endoscopes used. In ten patients it was possible to estimate the extension of the papillotomy in millimeters. All values are given as mean + standard error of the mean (SEM). For statistical evaluation the Mann-
Whitney rank sum test was used and significance was considered at the 5% level. Results A tracing before EPT is shown in Figure 1. It can be seen that the Oddi sphincter is a high pressure zone with phasic activity. The effect of EPT upon the OSP is shown in Figures 2 and 3. A significant reduction from 74.4 ± 6.6 mmHg before EPT to 26.3 + 4.5 and 29.3 + 8.5 mmHg immediately and four weeks after EPT was found. Before EPT the mean CBDP was 10.4 + 1.6 mmHg. A significant reduction to 0 mmHg occurred immediately as well as 4 weeks after EPT (Figs. 2 and 3).
mm Hg
80
0 Oddi sphincter pressure
* Common bile duct pressure 60
FIG. 3. The mean Oddi sphincter pressure and common bile duct pressure + standard error of the 40 mean before, immediately after and four weeks after
endoscopic papillotomy (EPT). 20
04
--6
Before EPT
a
Immediately after
&
0p 4 weeks after EPT
FUNCH-JENSEN AND OTHERS
178
Ann. Surg. * August 1979
Length of
PaPd lotomy (mm) 20
r.0,66
151 10
FIG. 4. The
regression line
showing the correlation between the length of the
R euction
25
S0
In no tracings were peristaltic activities observed in the common bile duct. In Figure 4 the reduction in OSP is plotted against the length of the EPT and the regression line drawn. The correlation coefficient was 0.66. Discussion This study confirmed previous findings, that the Oddi sphincter is a high pressure zone with phasic activity.2-4'7 Endoscopic papillotomy reduced the Oddi sphincter pressure significantly. This is in accordance with the findings of Hogan et al.5 The magnitude of the reduction in OSP depended, to some extent on the length of the papillotomy. Under normal conditions, the Oddi sphincter creates a gradient between the common bile duct and the duodenum. This study was in accordance with the findings of Rosch et al. and Hogan et al.,4 that performing papillotomy, thereby reducing the Oddi sphincter pressure, the choledochoduodenal gradient was equalized, this probably allowing duodenocholedochal reflux.I Acknowledgment The authors wish to thank Miss Inge Krogh for excellent technical support.
in OSP ()
papillotomy and the reduction in Oddi sphincter pressure (OSP) in per cent. The correlation coefficient (r) was 0.66.
References 1. Bodner, E., Platzer, S., Foedish, H. J. and Schwamberger, K.: Uber den Duodenobilifiren Reflux nach Totaler Sphincterotomie. Zentralbl. Chir., 99:788, 1974. 2. Csendes, A., Kruse, A., Funch-Jensen, P., et al.: Pressure Measurements in the Biliary and Pancreatic Duct Systems in Controls and in Patients with Gallstones, Previous Cholecystectomy or Common Bile Duct Stones. Gastroenterology, (submitted for publication). 3. Funch-Jensen, P., Csendes, A., Kruse, A. and Oster, M. J.: Common Bile Duct and Oddi Sphincter Pressure in Patients with Common Bile Duct Stones with and without Juxtaampullar Diverticula of the Duodenum. Scand. J. Gastroenterol., 14:253, 1979. 4. Hogan, W. J., Dodds, W. J., Geenen, J. E., et al.: Sphincter of Oddi Motor Activity in Man: A Zone of Unique Phasic High-pressure Contractions. Symposium on Gastrointestinal Motility, Edinbourgh 1977, paper No 66. 5. Hogan, W. J., Geenen, J. E., Schaffer, R. D., et al.: Sphincter of Oddi Pressure Measurement in Biliary Tract Disease Before and After Endoscopic Sphincterotomy. Gastroenterol. Endoscopy, 23:230, 1977. 6. Rosch, W., Koch, H. and Demling, L.: Manometric Studies During ERCP and Endoscopic Papillotomy. Endoscopy, 8:30, 1976. 7. Oster, M. J., Csendes, A., Funch-Jensen, P. and Skjoldborg, H.: Intraoperative Pressure Measurements of the Choledochoduodenal Junction, Common Bile Duct, Cysticocholedochal Junction and Gallbladder in Patients with Gallstones. Surg. Gynecol. & Obstet. (in press).
