Oddi sphincterotomy

Oddi sphincter incision is used for intra-biliary drainage. Oddi sphincter incision is a commonly used procedure in biliary surgery to treat benign stenosis at the end of the common bile duct, such as Oddi sphincter stenosis, ampullary calculus incarceration, primary stenotic papillitis when combined with gallbladder and bile duct stones Wait. Oddi sphincter stenosis is often the main cause of "cholecystectomy syndrome". In addition, sphincter stenosis often causes chronic pancreatitis and pancreatic duct obstruction. Oddi sphincter surgery consists of two procedures, one is a short length (usually less than 1.5 cm) of the cephalic sphincterotomy, only the scalp sphincter is cut, and the lower sphincter of the common bile duct is still preserved, so there is still The function of a certain sphincter is that the intestinal fluid reflux to the bile duct is also mild or not after surgery; however, due to the short length of the incision, it is easy to reoccur the stenosis to regenerate the symptoms. This procedure is generally referred to as Oddi sphincterotomy of Oddi. Another procedure is to completely cut off the Oddi sphincter, including the lower common sphincter of the common bile duct. After the incision, the lower end of the common bile duct completely loses the sphincter control, which is actually equivalent to a low-level common bile duct duodenal anastomosis. The duodenal juice flows back into the bile duct. Because of the surgical suture of the sphincter, the duodenal mucosa should be sutured with the common bile duct mucosa, so this type of surgery is called sphincteroplasty of Oddi. Sphincter angioplasty requires a cut length of 2.0 to 2.5 cm. In patients with postoperative cholecystectomy syndrome, in addition to stenosis of the common end of the common bile duct, there may be stenosis of the pancreatic duct opening and pancreatic duct dilatation, chronic pancreatitis. At this time, the nipple and the lower end of the common bile duct are cut. The sphincter still can not completely remove the obstruction. It is necessary to open the pancreatic duct opening, that is, to cut the septum between the bile duct and the pancreatic duct to relieve the obstruction of the pancreatic duct. This is called double-cutting of the bile and pancreatic duct. Oddi sphincter incision is a technically demanding and quite difficult procedure. The usual method used in the past is duodenal sphincter angioplasty, which is traumatic, with chronic pancreatitis and pancreatic head. Swelling and obesity are technically difficult, and complications and sequelae are common, such as postoperative bleeding, acute pancreatitis, duodenal fistula, duodenal perforation, retroperitoneal infection, Serious complications such as duodenal stenosis and a certain mortality rate. Since the application of fiberoptic duodenoscopy and endoscopic surgery, most of the sphincter incisions have been replaced by endoscopic sphincterotomy. Endoscopic sphincter incision is simpler in the operation of experienced surgeons, with less trauma and satisfactory results. However, in complicated cases, such as the merger of the duodenal duodenal diverticulum, the inflammation of the nipple changes the difficulty of intubation, etc., still need to be solved by surgery. Endoscopic sphincter incision may also occur complications such as hemorrhage, acute pancreatitis, duodenal perforation, and nipple restenosis. Treatment of diseases: Audi sphincter dysfunction Indication Oddi sphinctertomy is available for: 1. Oddi sphincter stenosis and common bile duct expansion is not very obvious. 2. The nipple is incarcerated with stones. 3. Endoscopic sphincterotomy is difficult or incision after incision. 4. Combined with complicated complications of the duodenal duodenal diverticulum. 5. Oddi sphincter stenosis caused by postoperative cholecystectomy syndrome. 6. The patient's physical condition can tolerate the operation. Contraindications 1. The lower end of the common bile duct in the pancreatic segment has a narrow range of stenosis, and simple sphincter incision can not solve the problem. 2. Newly developed acute pancreatitis with enlarged pancreatic head. 3. The common bile duct is extremely dilated, with a diameter of >2.0cm. Simple sphincter incision can not solve the drainage of bile duct. 4. Older patients or those who cannot tolerate complicated surgery due to physical conditions. 5. Due to local changes in the previous surgery, it is difficult to fully dissipate the second segment of the duodenum, and it should be changed to other cholangioenterostomy. Preoperative preparation 1. There should be detailed past surgery and examination data. 2. Recent cholangiography photographs showing the morphology and extent of the stenosis of the common bile duct. 3. Comprehensive understanding of liver, kidney, heart and lung function, and add necessary treatment. 4. Actively improve the patient's systemic nutritional status, correct hypoproteinemia; maintain water, electrolyte and acid-base balance. 5. Improve the patient's coagulation function, apply vitamin K11. 6. Treatment of biliary tract infections, and attention to the bacteriological investigation of bile sweat. Rational use of antibiotics. Surgical procedure 1. Generally, the oblique incision of the right costal margin is used. However, if the previous operation is a right rectus abdominis incision and the healing is good, the original incision can also be used to enter the abdomen. 2. Separate the intra-abdominal adhesion after the abdomen, do the necessary intra-abdominal exploration and understand the pathological changes of the biliary tract and the pancreas. Choosing the right surgical plan, the necessary fashion can be combined with intraoperative cholangiography. 3. Isolation of the hepatoduodenal ligament, free small retinal pores; separation of colonic hepatic flexion and liver right lobe adhesion. 4. Push the transverse mesenteric membrane down, cut the duodenum and the posterior peritoneum, bluntly separate, and separate the second and third segments of the duodenum forward until the duodenum and pancreatic head can be lifted to the operation. In the shallow part of the wild, a saline gauze pad is temporarily placed behind the duodenum and the head of the pancreas. 5. Open the common bile duct, remove the stones in the bile duct, and probe upwards to determine the residual stones in the liver or the main hepatic duct stenosis; down-exploration to determine the location of the stenosis and the position of the duodenal papilla. At this time, if the common bile duct can still pass the F8 catheter, leave it in place to facilitate the search for the nipple when the duodenum is incision; otherwise, use a Bakes probe to the lower end of the common bile duct, in the twelve fingers The position of the probe touched outside the intestine is where the main nipple of the ten finger is located. 6. According to the position of the probe, 2 traction sutures are disposed 1~2cm below it. The author advocates to make a transverse incision about 2cm long on the outer side wall of the duodenum, and open the traction line to open the 12 fingers. In the intestine, you can find the location of the nipple; or the Bakes probe can be used with a little force, and the duodenal nipple can protrude outside the duodenal incision when the posterior wall of the duodenum is fully free. If the duodenal nipple cannot be accurately positioned due to the local lesion or the enlargement of the pancreatic head, a longitudinal 3 to 4 cm incision can be made outside the middle part of the duodenal descending section to facilitate the search for the nipple. . However, it must be noted that surgery is often more difficult in this situation. 7. On both sides of the duodenal papilla and below, the sutures can be pulled to the incision on the duodenum with a pull line and a little traction. 8. Cut at about 11 o'clock above the opening of the nipple. After cutting, clamp the sides with a mosquito vascular pliers, cut from the middle of the two pliers, clamp 1 to 2 mm each time, and then use 3-0. The line (preferably a synthetic single fiber line) sutures the duodenal mucosa and the bile duct mucosa at a distance of 2.0 to 2.5 cm, which has reached the bile duct wall at the lower end of the common bile duct. The cut top must be carefully stitched. Because the length of the lower end of the common bile duct obliquely across the duodenal wall varies from person to person, the top may have been cut through the duodenal wall, so it is necessary to suture carefully to prevent duodenal fistula. 9. After the sphincter is cut, the sutures that cut the two edges are pulled, so that the incision can be carefully checked for bleeding and proper blood. Need to check the opening of the pancreatic duct. The opening of the pancreatic duct is generally located inside and below the opening of the nipple, often at 3 o'clock, and pancreatic juice is seen to flow out. A thin catheter can be placed in the pancreatic duct to check for obstruction or stenosis. Sometimes the opening of the pancreatic duct may be mutated, such as a high opening or a separate opening, making it difficult to find. However, it must be determined that the pancreatic duct opening is not blocked by suture. 10. Separate the duodenal incision in two layers. The suture must be carefully combined to prevent duodenal stenosis or duodenal fistula. The author generally uses cross-cutting transverse and straight-cut straight seams; however, when the duodenum is freely free, and the longitudinal incision on the duodenum is not too long, there is also a method of using longitudinal slitting. In more complicated cases, the gastrointestinal decompression tube should be placed in the duodenum through the pylorus for continuous decompression after surgery. 11. Oddi sphincter incision, it is generally appropriate to remove the gallbladder at the same time, and placed T-tube drainage in the common bile duct, but does not advocate the use of long-arm T-tube into the duodenum to prevent blockage of the pancreatic duct. In the case of chronic pancreatitis, a catheter is placed in the pancreatic duct and is drawn through the T-shaped lumen. 12. If the patient has a stenosis of the pancreatic duct and chronic pancreatitis, the interval between the pancreatic duct and the bile duct can be cut during surgery to enlarge the opening of the pancreatic duct. 13. After the incision on the duodenum is sutured, it can be covered with the omentum or transverse mesenteric membrane, and the abdominal drainage can be placed in the subhepatic area and the small omentum. complication 1. Early gastrointestinal bleeding. 2. Duodenal fistula and acute peritonitis. 3. Acute peritonitis. 4. Acute pancreatitis. 5. Retroperitoneal infection, abscess. 6. Late incision restenosis, acute cholangitis.