Transduodenal Sphincteroplasty Steps, Technique, Recovery, Indications | Transduodenal sphincteroplasty vs sphincterotomy

The procedure of transduodenal sphincteroplasty is a simple and effective way to treat benign biliary tract illness. This procedure helps in the creation of a wide-open stoma between the common bile duct and the duodenum. It is achieved by complete division of the muscular sphincteric mechanism. Permanent protection against future stones in the CBD is provided by TDS, which opens the papilla to allow ongoing unrestricted outflow of bile. 

The non-calculous blockage of pancreatic and biliary secretions at the pancreaticobiliary junction is known as the Sphincter of Oddi dysfunction. Endoscopic sphincterotomy is used to treat the majority of cases. However, if this does not work, surgical intervention is required.

Sphincteroplasty can be used in conjunction with bile duct exploration in the treatment of calculous biliary tract illness. When it is performed, the distal bile duct opens up significantly, allowing for the removal of impacted stones from the ampulla of Vater. It is expected that any stones that remain in the digestive tract’s upper ductal system will simply flow through this new opening into the duodenum.

Transduodenal Sphincteroplasty Steps

Sphincteroplasty is used to treat recurrent pancreatitis on rare occasions. The following steps are followed in the procedure of transduodenal sphincteroplasty:

1.  Complete duodenal mobilisation.
2. Perform a choledochotomy and insert a probe into the ampulla.
3. Palpate the ampulla’s position and apply two stay sutures in the duodenum.
4. A longitudinal incision is made over the ampulla.
5. Place stay sutures in the incision after inserting the probe and ampulla.
6. To avoid the pancreatic duct, the cut will be made at 10 o’clock or 11 o’clock.
7. Intravenous administration of secretin is recommended.
8. Potts scissors are used to incise the ampulla for roughly 2 mm.
9. Use interrupted sutures on both sides of the wound to close it up.
10. Cut for an additional 2 mm, then suture the wound.
11. Continue until the ampulla spreads into the bile duct.
12. Numerous drops of clear pancreatic juice should flow from the visible mouth of the pancreatic duct.
13. Apply apex suture.
14. Close the duodenotomy in two layers, if possible, and make it as straight as possible.
15. T-tube is not necessary to close the choledochotomy.
16. Omentum should be placed in the subhepatic area and over the duodenotomy.
17. Maintain a normal abdominal closure without drainage.

Transduodenal Sphincteroplasty Technique

Transduodenal sphincteroplasty is performed in the normal manner, with a longitudinal duodenal incision centered above the main ampulla. During the biliary sphincteroplasty, a metallic probe is used to locate the pancreatic opening and prevent pancreatic ductal blockage. 

Fine absorbable sutures are used to close the mucosae of the choledochal and duodenum. Following the manometry of the pancreatic ducts and sphincters, the results are recorded. In the next step, the pancreatic ductal aperture is opened and the borders of the choledochal mucosa are sewed together using synthetic nonabsorbable sutures to close the wound.  Finally, pressure measurements of the pancreatic duct and pancreatic sphincter zone are taken to check that these pressures have been decreased to normal levels.

Transduodenal Sphincteroplasty Recovery

It is critical to highlight some aspects of postoperative care to aid the patient’s recovery. The nasogastric tube should be remained in place for about 2 days or until peristalsis is visible with the passing of the flatus. The serum amylase level should be checked every 2 days or whenever there is a clinical picture of pancreatitis. Antibiotics should be taken for 72 hours after surgery unless the patient has cholangitis, in which case they should be taken for at least 7 days. 

It becomes important to conduct a cholangiography on the seventh postoperative day. If the results are satisfactory, that is, if there is adequate contrast flow into the duodenum and no fistula occurs, the negative suction can be stopped that day. The T-tube drain can be removed after 14 days.

The most common and significant consequence is a duodenal fistula, which can be deadly if the flow is too high, necessitating reoperations such as a Billroth II gastrectomy with vagotomy or possibly a Roux-en-Y hepaticojejunostomy.

Transduodenal Sphincteroplasty Indications

Transduodenal Sphincteroplasty is indicated by the following conditions:

1. Duct stones or “sludge”.
2. Stenosis of the sphincter of Oddi.
3. Primary biliary calculi.
4. Impacted ampullary stones.
5. Immovable intrahepatic stones.

Transduodenal Sphincteroplasty vs Spincterotomy 

A sphincterotomy, also known as a lateral internal sphincterotomy, is a procedure for cutting the anal sphincter. The anal sphincter is a set of muscles that are attached to the rectum at the end of the digestive tract and convey bowel movements through it. On the other hand, transduodenal sphincteroplasty is a well-known procedure for the treatment of benign biliary tract illness. 

Sphincterotomy is used when earlier therapies have failed to improve an anal fissure (a break in the skin of the anus) while transduodenal sphincteroplasty is a surgical procedure for creating a wide-open stoma between the common bile duct and duodenum.

Both the procedures have certain steps and indications that need to be followed by the surgeon for long-lasting treatment for the stones or fissures.