Surgery

[Sarsi]

Hi there gang,

This isn't strictly a gallbladder surgery question as I have had my gallbladder removed via lap in Dec 09.
I never recovered from the URQ pain after this surgery, and I had then eventually reached the diagnosis of sphincter of oddi dysfunction.
I have then had a sphincterotomy via ercp, which gave me short-lasting relief. Now I have had biliary stents placed for up to 3 months on a couple of occasions via ercp which have been giving me total relief.
My surgeons are now looking at options to provide me with permanent relief that the stents have been giving....their options given are transduodenal sphincteroplasty and choledochoduodenostomy.

My question is, does anybody know anything about these surgeries and their success rates....I am looking to have surgery next year at this point.

Any comments and advice would be greatly appreciated. :)

(Oh I'm a 34 year old female, healthy in every other regards, non smoker, non drinker)

Regards
Sarsi

[Christopher R Watters, MD]

Best to keep your eye on the horizon.

[Sarsi]

Thankyou again :)

It is good to hear another surgeon saying basically the same thing as my surgeon that I see.

I personally, at this point, do not mind either lap or open surgery options....I am after the long-term outcome and if the open method makes it easier for the surgeon to have a better result, then I'm prepared to do that - surgical recovery and pain will heal!! :)

[Christopher R Watters, MD]

Although there are reports of laparoscopic choledochoduodenostomies being done laparoscopically I would not recommend it. These have usually been done in patients with obstructed bile ducts leading to significant dilation. This makes the operation much simpler than one where the common bile duct is relatively normal in size. The fact is, a nondilated common bile duct would strongly favor the sphincteroplasty as the stricture rate would be lower.

[Sarsi]

Thankyou for your quick reply.

I thank you for sharing your knowledge. My surgeon is also preferential to the sphincteroplasty due to it having less complications.....
But he is going to do some research and also meet with my GI specialist who does the stenting to see what he recommends also.

I do have the stent in only the common bile duct. The GI who places them says that there is a nice space between the pancreatic and bile duct due to the excellent sphincterotomy that was done, and thankfully I have avoided acute pancreatitis from all of my ercp procedures.

The only other notable comment from my ercp notes is that I have a narrow bile duct, which is their thought that if the sphincter spasms, it creates high pressures which is what my constant pain is from....so creating a free-flowing environment for the bile would be the ultimate goal, whichever surgery option they choose....

I believe that both of these surgeries are extensive and generally done with the open surgery method....

Thankyou again for your expertise and advice

Sarah

[Christopher R Watters, MD]

My personal preference is the transduodenal sphincteroplasty. This has been the most commonly recommended procedure in this situation.  One question is whether you have had just biliary stents (up the bile duct) or have they also placed stents in the pancreatic duct? If they have had to stent the pancreatic duct and the common bile duct the decision is clear as the only way to decompress both systems is with the sphincteroplasty with division of the common septum between the two ducts. If stenting only the common bile duct results in ablation of the symptoms either one could be considered but I still favor the sphincteroplasty. There are several reasons for this. First, I believe that at least some of these patients' pain can come from spasm of the sphinter similar to the intense pain from spasm of the pylorus or esophageal spasm. Since the sphincteroplasty divides the sphincter permanently not only is the obstructive component dealt with but also this other avenue of pain creation. The other reason is that it is somewhat difficult for me to believe that only the portion of the sphincter related to the bile duct is so dysfunctional to require surgical intervention while the fibers that interconnect and are located 2 or 3 mm away work perfectly well meaning that the pancreatic duct will never be involved. Third, between the prior ERCP sphincterotomy and mechanical irritation of having stents across the ampulla, I worry about a choledochoduodenostomy resulting in good drainage of the biliary system while the ampulla scars down, potentially resulting in either obstruction of the pancreatic duct or forcing pancreatic-biliary reflux which has been shown to increase the risk of cancer in the bile duct.

[Sarsi]

Hi Dr Watters,

As a surgeon I would greatly appreciate any insight you could provide.

Thankyou