Post written by Yonghui Huang, MD, from the Department of Gastroenterology, Peking University International Hospital & Peking University Third Hospital, Beijing, China.
An innovative endoscopic strategy was demonstrated for preserving the function of Oddi sphincter after large endoscopic sphincterotomy (EST) in a patient with a large stone of the CBD. After successful extraction of CBD stones, a 7F stent was placed to prevent accidental clipping of CBD right before endoscopic endoclip papilloplasty. Sphincter of Oddi manometry (SOM) was performed to evaluate the efficacy after retrieving the biliary stent, and results were inspiring and promising.
Since the introduction of endoscopic retrograde cholangiopancreatography (ERCP) in 1968 and endoscopic sphincterotomy (EST) in 1974, EST has become a widely accepted technique for the treatment of patients with bile duct stones. EST combined with endoscopic papillary large-balloon dilation (EPLBD) has been introduced in large stone cases. Large EST or EST combined EPLBD may cause SO function damage completely or partly for a long time. Permanent loss of SO function could cause duodenobiliary reflux, bacterial colonization of the biliary tract and stone recurrence, cholangitis, or liver abscess. Repairing the destructive ampulla and Oddi sphincter may well reduce long-term adverse events, especially stone recurrence. However, there has been no efficient strategy up to now. This case provided a new endoscopic method for preserving function of SO.
We have been inspired by surgery that places sutures by hand uniformly to invoke an inflammatory response, yet staple lines incite a minimal inflammatory response. Wounds closed with stapling devices regain strength more rapidly than those closed with traditional surgical techniques. So we assumed that the incised Oddi sphincter could be “sutured” with special staples called clips under endoscopy, and the sphincter function could be preserved after suturing. How to prevent long-term adverse events due to dysfunction of Oddi sphincter is a complicated issue to solved.
The 2 main adverse events of large EST were perforation and bleeding. Papilla located deep within the diverticulum and small papilla with short intramural segments may be not suitable for large EST and endoclip papilloplasty. Bleeding related to EST may benefit from closure of the incision with repositionable clips. Long-term follow-up and large-scale randomized controlled trials are needed to identify its future prospective.
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7 thoughts on “Endoclip papilloplasty for a patulous and incompetent biliary papilla”
Congratulations! This is a very wonderful idea after EST has been reported in 1974, because this is the first attempt to repair the function of SO using endoscopic technique. At the same time, I believe this idea can reduce the rate of perforation and bleeding after large EST considerably. If there is an opportunity to make multi-center research among different constitutions and nations further, I think the effectiveness and safety of this skill perhaps can be demonstrated all over the word. If so, this will be a revolutionary leap in ERCP idea.
That is “not only destruction，but also repair”.
Im looking forward seriously.