Sphincter of Oddi Dysfunction (SOD) is a clinical syndrome characterized by biliary/ pancreatic pain from abnormal function or obstruction of the.
It is commonly considered after cholecystectomy when ongoing biliary-type pain or pancreatitis is present. SOD is classified into three Milwaukee/Rome types based on clinical, laboratory, and imaging criteria. Type I shows objective ductal dilation and enzyme abnormalities, type II has biliary pain with either dilation or enzyme elevation, and type III has biliary-type pain without objective abnormalities.
Diagnostic and classification
The SOD spectrum includes biliary, pancreatic, or combined sphincter dysfunction, with symptoms driven by dyskinesia or mechanical obstruction. The term SOD encompasses both functional motility disorders (biliary or pancreatic sphincter dysfunction) and mechanical obstructions such as papillary stenosis.
SOM has been considered the gold standard for diagnosing elevated basal sphincter pressure. It is invasive and carries complications, including pancreatitis. SOM can also not be done in those who have had gastric bypass or duodenal switch operations. Sphincterotomy outcome is not uniform. Consequently, many centers have moved toward empiric endoscopic therapy for appropriately selected patients and toward noninvasive or less invasive diagnostic approaches for others.
Treatment approaches
Endoscopic biliary sphincterotomy (EST) is the most established nonpharmacologic treatment for biliary SOD, particularly in type I and many type II patients with objective ductal dilation and/or enzyme elevation.
In type II SOD, outcomes after EST correlate with objective evidence of obstruction or sphincter hypertension on SOM. Empiric sphincterotomy without manometry is controversial.
Type III SOD has emerged as predominantly functional pain rather than a mechanical obstacle. Alternative management emphasizes risk stratification, noninvasive strategies, and multidisciplinary approaches.
Medical and non-sphincterotomy options (calcium-channel blockers, nitrates, antidepressants, and lifestyle modifications) have been discussed as potential adjuncts or alternatives.
Summary
SOD is a multifactorial biliary and pancreatic sphincter disorder with a spectrum from mechanical obstruction to pure dyskinesia. Type I and II retain treatment relevance, particularly EST for biliary obstruction. Type II management requires clear identification of the cause.
SOM is a diagnostic tool with significant limitations.
Endoscopic sphincterotomy offers meaningful symptom relief in type I and select type II with objective obstruction. It carries a risk of complications, including pancreatitis; risk mitigation strategies are integral to practice. In type III SOD, sphincterotomy generally has limited benefit, necessitating a move toward noninvasive management and careful patient counseling. Patients post- gastric bypass, or duodenal switch, can not have ERCP or SOM done.
Iron is critical for the production and action of red blood cells. Deficiency of iron may have many causes. These include bleeding from the GI track, inadequate absorption, inadequate intake, and menstrual losses in females.
It’s important to have at least yearly laboratory studies to surveil for abnormalities. Normal results of iron testing may be different for men, women, and children. Iron and TIBC are measured in micrograms per deciliter (mcg/dL). Normal results for iron are:
65 to 175 mcg/dL for men
50 to 170 mcg/dL for women
50 to 120 mcg/dL for children
Normal results for TIBC are 250 to 450 mcg/dL for men and women.
To correct or prevent IDA, iron supplementation is recommend in some patients. Iron absorption is very inefficient. It take a long time to develop IDA and as long if not longer to correct it with oral supplementation. This is why we recommend some patient condor getting iron infusion.
For most, oral supplements are adequate. There are different formulary of iron supplement with varying degree of absorption.
Heme iron and iron bisglycinate have been shown to have much better absorption than ferrous sulfate formulary.
Endoscopic sleeve gastroplasty (ESG) differs from Laparoscopic sleeve gastrectomy (LSG).
ESG (Endoscopic Sleeve Gastroplasty) is promoted and advocated as a low-risk, equal alternative to the Laparoscopic Sleeve Gastrectomy, but it is not.
Anatomically speaking:
Endoscopic Sleeve Gastroplasty is an endoscopic procedure performed under general anesthesia. During this procedure, a specialized endoscope is inserted through the mouth into the stomach. Multiple plastic “H”-type anchors are used to create a fold in the stomach, thereby reducing its size. No part of the stomach is removed. Initial limited weight loss occurs as the patient feels full after consuming small volumes of food. This effect resembles what happens with the lap band and gastric balloon, and we know how the story ends with those.
LSG is performed laparoscopically with incisions on the abdomen under general anesthesia. Seventy-five to eighty-five percent of the stomach, along its greater curvature, is removed, eliminating the part of the stomach that produces the Ghrelin hormone, which controls and modulates hunger. This is why patients feel fuller with a smaller volume of food and experience significantly reduced hunger.
Results:
Please read the fine print
The summary results indicate
“Our results suggest that ESG is safe and effective for the treatment of obesity, with durable
long-term results for at least up to 5 years after the procedure. “
When you look at the details of the results, however, it states:
“At 5 years, mean TBWL was 15.9% (95% CI, 11.7-20.5, p < .001) and 90 and 61% of
patients maintained 5 and 10% TBWL, respectively.”
This means that five years after ESG, 90% of the patients have only lost 10% of their TBWL (total body weight loss), and 61% would have lost 10% of their TBW (Total Body Weight).
This serves as an illustration of how actual outcomes are obscured within the fine print, resulting in a lack of attention from individuals seeking the optimal outcome devoid of perceived risk. The same principle applies to the ongoing discourse regarding GLP-1 medications. The genuine risk associated with ESG and PLG-1 is that patients have undergone alterations to their anatomy and physiology without demonstrable results. Several years into contemplating a treatment promising sustained outcomes, we find that the alterations have increased the overall risk.
As a surgeon, I encourage people to always ask questions and demand that scientific proof be provided. I am not opposed to progress; considering the nature of our practice, we have witnessed and have unrgone significant evolution over the past 30 years, transitioning from performing open cases necessitating a hospitalization period of 4 to 6 days to performing the same cases laparoscopically and robotically in some cases outpatient procedures.
Patients are frequently asked to explain why they take high fat- or water-soluble vitamin doses. They are have often been scared by their well meaning healthcare providers that their higher levels of vitamin supplements will end up with vitamin toxicity.
Let’s clarify one point: there is such a thing as too much vitamin.
However, the point that is often overlooked in teaching within professional schools (medical, nursing, pharmacy, etc.) and drug manufacturers is that recommendations are based on “how much to take” and not how much is needed to keep a patient’s blood level in the normal range.
This table highlights how toxicity is described and what requirements are recommended. Vitamin toxicity is seen rarely in post-weight loss surgical patients who take them proactively in as many doses as needed to get their blood levels in the normal range. I see more patients in the office who suffer from low vitamin levels, such as vitamin D and A levels (duodenal switch and sleeve), than any patient with high or toxic levels of any vitamins.
Not too long ago, I saw an old patient who had seen me years ago after having had a lap band placed for weight loss. At the time, I recommended that the lap band be removed and that alternative plans be made. I suspected a slipped band. We discussed the reality that after the band removal, weight gain is to be expected. Several surgical options were discussed, and the patient dismissed them as “too radical.” The patient decided to “deal” with the ongoing nausea and vomiting since it was a small price to pay for the weight loss. I warned the patient that elective removal of the band is much safer than an emergency procedure in the middle of the night when it is least convenient. The patient did end up with an emergency lap band removal and was started on GLP-1 Agonists (Wegovy) because of the weight gain that followed the band removal. The side effects of the medication were debilitating, with nausea, dizziness, and fainting due to low blood sugar. The drug has all been stopped, and most, not all, of the side effects are resolved. The plan is to get this patient in a better shape and, reevaluate the esophagus and the stomach, and formulate a strategy based on the blood work, upper endoscopy, upper GI study findings and decide if the patient will be a good candidate for the Laparoscopic sleeve or the duodenal switch operation.
Here are my recommendations:
Patients should avoid lap bands. Those with lap bands, regardless of how they feel and whether they are having issues with them, should have the lap band removed immediately before they end up in the emergency room or have irreversible changes to the cells or function of the stomach and esophagus.
Patients who have the lap band removed will have less weight loss with the sleeve than those who have the sleeve as the primary procedure (the lesson here is that a less invasive, seemingly easy solution is much worse long term; more on this below). Lap Band patients should be revised to the duodenal switch, SPIS, SADI, or Gastric bypass if they have substantial weight to lose.
GLP-1 agonist medication should be avoided. It is not a solution to the underlying problem but a band-aid covering the metabolic derangement.
GLP-1 agonist medication needs to be taken long term, and there is no exit strategy– when the patients stop taking the drug, the weight comes back, in addition to the complication associated with it.
I have also heard that “if it were bad, then the FDA would not approve it.” well, let’s think about it: the FDA approved the Lap band and Phen-Fen, and we all know how these worked out.
There are no shortcuts, simple injections, or a pill for the complex, multifaceted condition of obesity. Advocating solutions with no long-term outcome, significant complications, and safety concerns is irresponsible.
A diabetic patient should take the medication LIFELONG to control their blood sugars, including the GLP-1 agonist class of drugs. The concerns are for these medications being used for the treatment of obesity
Radiology film of normal position and a slipped LapBand
SUMMARY: Buyers beware- those who choose to embark on the dangerous load of GLP-1 agonist medications should be prepared to deal with the short and long-term complications of the medication and its withdrawal. This is like the problems that are being seen with patients who choose to have a lap band because it was advocated as simple, reversible, and the Phen fen medication for weight loss with the associated cardiac complication.
The Lap Band was approved in the US in 2001 (BMI> 40). The following studies used only small samples and examined short-term efficacy and safety. They were then performed to consider the utility of the Laob band for patients with lower BMI (BMI 30-40).
Noe the frequent complications of nausea, difficulty swallowing, pain, and reflux-which may sound familiar to a lot of patients who have had and still have the Lap Band.
Numerous US and international studies have been published over the years, including short-term and long-term studies. The summary outcome has been the same, with only a few exceptions.
The Lap Band does not result in long-term sustained weight loss.
Lap band has significant complications, some of which may not be reversible.
The lap band can be removed, but eroding the banc to the stomach is not easy.
Let’s ask the question: why would the slogan of a product be that “it’s easily reversible”? Under what circumstances would anyone want the life-saving device to be removed for the original condition (obesity) return? The answer is when the complications are worse than the condition itself.
Adjustable Gastric Band Easily Reversible?
Removing the band is not easy, and extensive dissection is often needed to remove the capture (scar tissue) that forms around the band.
My recommendation is: With much better and safer alternative surgical procedures available (Sleeve Gastrectomy) (Duodenal Switch), no one should get the LAp Band placed. For those of you who have it, take it out as soon as possible before it becomes an emergency while causing irreversible dilation of the esophagus
Similar to many previous attempts, the simple and cheap route does not necessarily produce sustained desirable results. This recent article below summarizes a presentation made at the 2024 Annual Meeting for ASMBS. I may not agree with some of the researcher’s conclusions, but the data presented supports what we have said all along: that the GLP-1 class of medication does not produce durable and adequate weight loss.
SAN DIEGO-Bariatric surgery far outperforms lifestyle interventions and glucagon-like peptide-1 (GLP-1) medications at maintaining weight loss, according to a meta-analysis presented at the 2024 annual meeting of the American Society for Metabolic and Bariatric Surgery.
With results from six randomized controlled trials, three systematic reviews, and more than 40,000 patients, the study is the first synthesis of its kind.
“The analysis included two systematic reviews of bariatric surgery, one of Roux-en-Y gastric bypass including8,665 patients and one of sleeve gastrectomy including 6,095 patients: a single systematic review or lifestyle interventions including 723 patients; and six randomized controlled trials of GLP-1 medications, including four studies of semaglutide with a total of 11,871 patients and two of tirzepatide with 3,209 patients.
Lifestyle interventions were the least effective treatment, the investigators found, producing a mean total body weight loss of 7.4% at the end of the treatment period, followed by a mean per-month weight regain of 0.14%, with participants reaching their pre-intervention weights within 4.1 years.
GLP-1 medications proved more effective. Weekly semaglutide injections for 20 weeks and tirzepatide for 36 weeks produced a mean total body weight loss of 10.6% and 21.1%, respectively. Roughly half of the weight lost was regained within a year after stopping injections; with continued injections, weight loss plateaued after 17 to 18 months, at 14.9% for semaglutide and 22.5% for tirzepatide.
Outcomes after surgery were significantly better. Gastric bypass surgery and sleeve gastrectomy resulted in a mean total body weight loss of 31.9% and 29.5%, respectively, one year after surgery. Accounting for weight regained in the decade after surgery, both procedures produced a stable total body weight loss of approximately 25%.
While the results demonstrate a striking difference favoring surgery, lead investigator Megan Jenkins, MD, a bariatric surgeon at NYU Langone Medical Center in New York City, emphasized that surgery and medication ought to be viewed not in opposition but through a holistic lens as options and potential complements based on the needs of each patient.
“One of the big benefits of these new medications is that it’s helped us to treat obesity as a chronic disease,” Dr. Jenkins said. “We’ve always treated it that way, but I think the medical field has had trouble truly seeing it as a chronic disease. Like diabetes and high blood pressure, for example, which have always been treated with a combination approach.
I was asked if my opinion of SIPS-SADI has changed since ASMBS endorsed it.
Let me remind everyone that ASMBS also endorses Adjustable Gastric Banding. We know what happened to the story. Is anyone considering Lap Band, even though ASMBS endorses it?
I am a member of ASMBS. The endorsement of the ASMBS does not unequivocally validate the outcome of a procedure; it only states that is an available alternative.
As stated previously, patients should be clear that SIPS-SADI procedures are not Duodenal Switch operations. Any suggestion is misleading. The physiology of SIPS-SADI is very different than that of the duodenal switch operation. Complications are associated with them, as reflected by the revisions we do to convert them to a Duodenal switch with percentage-based measurement of the small bowel.
In our practice, we have had to revise SIPS-SADI to duodenal switch operation due to compilation such as bile reflux gastritis and inadequate weight loss.
Semaglutide (Ozempic, Rybelsus, Wegovy, Saxenda) and tripeptide (Mounjaro) treat type II diabetes. They work thru several complex pathways. An observed side effect that has been noted in diabetic patients has been weight loss.
Some have been advocating using the class of medications for weight loss. However, Wegovy is the only medication approved for weight loss in non-diabetic patients.
There is a lot to be discussed here:
1-the use of the medications for weight loss is an off-label use (except Wegovy)- meaning that the FDA did not approve the medication as a weight loss drug.
The practical implication is that the medication’s safety and complication profile in non-diabetic patients looking to lose weight may be unknown and has not been studied.
2-The medication has become available thru compounding pharmacies. It is crucial to appreciate that compounding medications do not meet the same rigor and standards and may, in fact, not be the same formula as the FDA has stated.. This also means that a compounding pharmacy does not approve the medications in several states.
3-The most critical issue for me is the lack of a “long-term plan.” It is not clear what would happen when the patient stopped the medication. Will the patient experience weight regain? Will the patient require higher doses of the medication to maintain the weight loss, or will the medication stop working altogether? Unfortunately, we do not have these answers. For those skeptical about my questions, let me remind you that phentermine has significant side effects, and almost all patients experience weight gain when they have to stop the medication because of the cardiovascular complication of medication.
The Lap Band was approved in the US in 2001 (BMI> 40). The following studies used only small samples and examined short-term efficacy and safety. They were then performed to consider the utility of the Laob band for patients with lower BMI (BMI 30-40). 
