On the Balloon Dilatation of Sphincter of Oddi
One of the main late complications after transpapillary procedures is reflux cholangitis that occures in 4.1–7.6 % of cases and is associates with changes in Oddi’s sphincter (OS) function after endoscopic papillosphincterotomy. Therefore an opportunity of balloon dilatation (BD) that provides endoscopic approach to bile ducts and intervention on major duodenal papilla (MDP) preserving its sphincter is of great interest. Among BD indications are stenosing papillitis, small concrements in bile ducts in young and coagulopathic patients.
Material and methods: In order to improve the results of treatment of patients with biliary obstruction the method of BD was introduced which allows performance of the whole specter of transpapillary procedures and prevents their major complications.
The method of BD is performed as follows: the superior part of ampulla of MDP is dissected to 2–3 mm adequate to introduce the catheter into the choledochus. After X-ray control of catheter location it is replaced with balloon dilator in the manner that the dilated part of the instrument should be placed at the level of sphincter of choledochus. Bile duct manometry is performed. The way the BD procedure is performed depends on the diameter of bile ducts, intraductal pressure and the concrement size. The balloon size (small 0.4, medium 0.6, large 0.8) is chosen on the basis of adequacy of biliodigestive shunt that is being formed. The ratio of the shunt’s diameter to the diameter of the choledochus should not be less then 0.47 (according to the Patent № 62499 (13) U (51) МПК (2011.01) А61В 17/00) «The method of biliodigestive shunting choice». The duration of the procedure depends on the results of manometry and the type of pathology. In case of choledocholithiasis the exposition of 3 minutes is enough. In a case of stenosing papillitis the exposition should be at least 2–3 times longer.
Results and discussion. Twenty three patients were treated using the method of BD. Among them 4 (17.4 %) patients (age 19–26 years old) had concrements 2–4 mm in diameter in choledochus (the gall bladder was preserved and free of concrements); 3 (13.0 %) patients (age 21–27 years old) had choledocholithiasis and cholecystolithiasis; 11 (47.8 %) patients (age 26–44) with single 3–6 mm in diameter residual concrements in bile ducts; 5 (21.8 %) patients (age 34–47) with stenosing papillitis (which caused external biliary fistula formation).
During the follow up time (14–28 months) no cases of obstructive jaundice appeared. Reduction of choledochus diameter from 10–12 mm to 5–6 was proved and absence of gall bladder pathology was proved sonography.
Conclusion. The therapeutic effect of BD procedure is limited only to dilation of sphincter of choledochus. The impact on ampullary structures of MDP is associated with risk of bleeding and acute pancreatitis.
Indication of BD are single small concrements in bile ducts in cholecystostomyzed or young patients without cholecystolithiasis, bile passage disorder in postoperative period in patients with external bile drainages or fistulas.
The most clinically beneficial application of BD was in patients with single small residual concrements in choledochus.
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