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James A. Madura, MD; James A. Madura II, MD; Stuart Sherman, MD; Glen A. Lehman, MD

Arch Surg. 2005;140:504-512.

Hypothesis  Pancreaticobiliary sphincter disease is reliably diagnosed by endoscopic and intraoperative manometry.

Design  Retrospective review of prospectively collected data.

Setting  A 400-bed urban university hospital.

Patients  Between May 1, 1978, and March 27, 2002, 446 patients were treated surgically for dysfunction of the pancreaticobiliary sphincters. There were 376 females and 70 males (mean ± SD age, 41.6 ± 12.5 years). There were 372 patients with sphincter of Oddi dysfunction, and 74 with pancreas divisum. Symptoms included abdominal pain (100.0%), nausea/vomiting (80.5%), back pain (57.2%), and pancreatitis (22.4%).

Interventions  Perfusion manometry has evolved as the gold standard for diagnosis, and intraoperative manometry was done in 214 patients. All patients underwent transduodenal sphincteroplasty and biopsies of the ampullae and transampullar septa.

Results  Excellent or good results were seen in 86.8% of the patients with sphincter of Oddi dysfunction and in 63.5% of the patients with pancreas divisum. Common duct and sphincter of Oddi pressures were 0 mm Hg in all patients after sphincteroplasty. Pancreatic duct and pancreatic sphincter manometry results were improved in 82.4% of the patients. Biopsy results of the main and accessory sphincters demonstrated inflammation and/or fibrosis in 33.9% of ampullae and 43.5% of transampullar septa, but this did not correlate with outcome. There was 1 death from a duodenal leak. Complications occurred in 34.8% of patients, with pancreatitis (8.8%), asymptomatic hyperamylasemia (6.0%), and wound/abdominal infection (7.1%) the most common. Predictive factors for good outcome were reduction in pancreatic duct and sphincter pressures following sphincteroplasty.

Conclusion  Good to excellent results may be achieved by surgical sphincteroplasty when careful patient selection by manometry is used.

Author Affiliations: Departments of Surgery (Drs J. A. Madura and J. A. Madura II) and Medicine (Drs Sherman and Lehman), The Indiana University Medical Center, Indianapolis.

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Surgical Sphincteroplasty in 446 Patients—Invited Critique
Andrew L. Warshaw
Arch Surg. 2005;140(5):513.
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