Transduodenal sphincteroplasty and transampullary septectomy for sphincter of Oddi dysfunction

The diagnosis and management of sphincter of Oddi dysfunction are controversial issues. Both surgical and endoscopic series report modest success in the treatment of this condition. There is evidence from endoscopic series that the Milwaukee classification could predict the clinical outcome after sphincterotomy. We reviewed our long-term results of surgical sphincter ablation for sphincter of Oddi dysfunction, in order to correlate outcome with underlining pathology (biliary versus pancreatic) and Milwaukee biliary group classification.

During a 10 year period (1987-1996), 36 patients with either biliary (n = 26) or pancreatic (n = 10) presentation of suspected sphincter of Oddi dysfunction were selected for surgery according to a standard protocol of investigation and management. All patients were classified according to the Milwaukee classification for the biliary group or its version for the pancreatic group and had transduodenal sphincteroplasty and transampullary septectomy.

Despite a trend towards a better outcome in the biliary group (good result 62%, moderate 23%, poor 15%) compared to the pancreatic (good result 40%, moderate 40%, poor 20%) the difference was not statistically significant (P = 0.48). Milwaukee classification for the biliary group correlated well with a favourable outcome (P < 0.05).

The modest outcome despite careful patient selection for surgery emphasises the need for more objective diagnostic tools. Milwaukee classification appears to be of good predictive value, and a good result can be anticipated in type I or even type II patients. The trend towards a better outcome in the biliary group may reflect the weakness of a drainage procedure to treat patients with parenchymal pancreatic disease.