Is there a role for ampullectomy for refractory type 3 Sphincter of Oddi dyskinesia ?

Dominique Dempah, MD, Gabriel Arevalo, MD, Philip Karumen, MD, Kirpal Singh, MD, Maurice E Arregui, MD

St Vincent Hospital, Indianapolis, Indiana

Hypothesis: Sphincter of Oddi dyskinesia (SOD) refers to abnormal function of the sphincter of Oddi. Patients with symptoms consistent with SOD are traditionally classified in three types depending on the presence of a dilated common bile duct and/or abnormal liver chemistries. Patients with typical pain symptoms but no objective abnormalities are classified as type III SOD and pose the greatest therapeutic challenge. Patients refractory to endoscopic sphincterotomy have been found to benefit from transduodenal sphincteroplasty. However, it has been reported that only 54% of patients experience pain relief with operative shincteroplasty after endoscopic sphincterotomy (ES). A visceral hypersensitivity is thought to play a role in the chronic pain associated with type III SOD and may explain the relative poor results. Anatomical and immunohistochemical investigations have demonstrated that the sphincter of Oddi is richly innervated by cholinergic, adrenergic, and peptidergic neurons and has multiple complex neural connections with the gallbladder and the proximal gastrointestinal tract. We theorize that ampullectomy with choledochoduodenostomy and pancreaticoduodenostomy can combine the benefits of the transduodenal sphincteroplasty and additionally disrupt the neural networks responsible for the chronic pain syndrome as well as remove the scar tissue from previous manipulations that could also be causing chronic nerve entrapment and afferent hypersensitivity resulting in pain perception.

Materials and Methods: We report our early results on transduodenal ampullectomy for SOD refractory to ES. The purpose of this study is to determine how SOD patients refractory to medical and endoscopic therapies respond to transduodenal ampullectomy. Retrospective chart review of patients who underwent ampullectomy from April 2011 to September 2012 was done. Demographic data, preoperative interventions including number and types of endoscopic interventions, operative morbidity and technique, pain score prior and after ampullectomy, and duration of relief assessed based both on patient recollection and timing of first intervention after ampullectomy were obtained.18 patients were analyzed. 100 % were female and 94 % had type 3 SOD. On average, patients had undergone 5.6 ERCPs and 3.2 sphincterotomies prior to ampullectomy. 61% and 55% of patients had undergone respectively celiac plexus block and botox injection at the ampulla. Most had initially good response to sphincterotomy and sphincteroplasty. Marcaine injection of the ampulla provided pain relief in many of these patients suggesting that the ampulla was the sourse of the pain.

Results: 27% had mild to no pain improvement, 18 % had moderate improvement, and 54% of the patients noted significant improvement in their pain including 18% with complete resolution of their pain. Average age and duration of symptoms in this last group were respectively 33 and 7.5 years compared to 43 and 6.8 in the studied population. 67% of the patients with significant improvement had longer than 6 months follow up with average duration of pain relief over 7 months.

Conclusion: In this series, ampullectomy led to pain relief in a subset of patients with refractory SOD. However, the factors associated with pain relief after ampullectomy remain unclear and further follow up is needed to study the long term benefits.

Session: Poster Presentation

Program Number: P362