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• W2105173637 abstract "Salivary gland obstruction can lead to recurrent and painful gland swelling, typically with eating and drinking, and can be complicated by bacterial sialadenitis and abscess formation. The common causes of obstructive sialadenitis are sialolithiasis, stenosis, inflammation, external compression, foreign bodies, or anatomical variation of the major salivary gland ducts. Prior to the advent of sialendoscopy, classic management of salivary duct obstruction involved conservative medical management followed by surgical transoral excision for stones or sialadenectomy.1 Sialendoscopy is a relatively new technique that is well described in the literature.2, 3 It provides a minimally invasive, gland-sparing approach for obstructive salivary duct disease diagnosis and management. The advent of endoscopic visualization of the major salivary ducts has reduced the need for sialadenectomy, thus avoiding the associated surgical risks of nerve injury, unattractive scar, salivary fistula, sialocele, and wound infection.4, 5 Luers et al. showed the learning curve for sialendoscopy was manageable, with a decrease in operative time and an increase in performance rating over 30 to 50 cases.6 During sialendoscopy, the papilla of Wharton's duct is typically dilated with probes of increasing diameter. For surgeons just starting to perform sialendoscopy, the time to identify and cannulate Wharton's duct papilla is longer than for the larger papilla of Stensen's duct.6 Submandibular papilla dilation failure has been described in 20% of cases for beginner sialendoscopists.7 Only a few techniques have been described for managing difficult submandibular papilla dilation and sialendoscope insertion.5 Application of methylene blue can help with identification of the papilla.8 Once the papilla has been cannulated, a guidewire can be placed into the duct lumen, followed by progressively larger dilators and the endoscope, which can be inserted over the wire.7 Others have described incising the papilla approximately 5 mm for duct cannulation; however, papillotomy risks the development of papilla stenosis and secondary iatrogenic obstruction.3, 9, 10 We describe a technique for limited distal submandibular sialodochotomy to allow for consistent endoscope introduction into the duct when standard papilla dilation is not possible. This technique is intended to provide both beginners and experts of sialendoscopy with an alternative method to allow access to Wharton's duct without the need for papillotomy. It also allows for endoscopic-assisted stone extraction without the need for a papillotomy to release a stone. We examined our use of limited distal sialodochotomy in 139 consecutive submandibular sialendoscopies performed at our institution. We reviewed the clinical data for all patients undergoing submandibular sialendoscopy at the University of California, San Francisco, from January 2005 to February 2012. We obtained study approval from the institutional review board of the Center for Human Research at the University of California, San Francisco, prior to performing our review. Clinical data were collected including patient age, gender, surgical indications, preoperative imaging results, intraoperative findings and procedures, and complications and their management. Statistical analysis was performed with the Student t test and χ2 analyses, with p < .05 denoting significance. All procedures were performed in the operating room, with the patient under general anesthesia. Preoperatively, the patients received intravenous antibiotics and 8 to 10 mg of dexamethasone. For each case, Wharton's duct papilla was serially dilated with standard salivary duct and conical dilators (Marchal dilators; Karl Storz, Tuttlingen, Germany). If the papilla could not be rapidly cannulated, a limited distal sialodochotomy was performed to allow placement of the rigid diagnostic 0.8-mm sialendoscope (Marchal sialendoscope: Karl Storz), followed by use of the therapeutic sialendoscope for stone extraction as needed. Limited distal sialodochotomy is performed by infiltrating the anterior floor of mouth with 1% lidocaine with 1:100,000 of epinephrine. The mucosa, posterior and lateral to the papilla and medial to the salivary crest, is incised sharply in the direction of the submandibular duct (Fig. 1). Blunt dissection is performed to identify the submandibular duct. Staying on the superficial surface of the duct, Metzenbaum scissors are then used to make a sialodochotomy partially through the wall of the distal duct (Fig. 2). The distal sialodochotomy site is then dilated, if necessary, in the standard fashion followed by introduction of the diagnostic or therapeutic sialendoscope (Fig. 3). The edges of the dochotomy incision are then sutured to the surrounding floor of mouth mucosa at several points using 4-0 Vicryl suture (Ethicon, Somerville, NJ), creating a new ductal opening (Fig. 4). Wharton's duct papilla is left intact. Following the procedure, no stents are used. Postoperatively, saliva is allowed to flow out the new sialodochotomy site (Fig. 5) or through the natural papilla. Patients are instructed to follow standard postoperative care with oral antibiotics, hydration, sialogogues, and gland massage. Injection of local anesthetic and anterior mucosal incision. (A) The anterior floor of mouth mucosa is injected with 1% lidocaine with 1:100,000 epinephrine. Wharton's duct papilla is identified, and standard dilation of the papilla is attempted. (B) If dilation is not possible, a mucosal incision is made along the lingual surface of the salivary crest posterior and lateral to the papilla, leaving the papilla intact. Duct identification and sialodochotomy. (A) The distal portion of the submandibular duct is exposed with blunt dissection. Care is taken to avoid disruption of sublingual gland ducts. (B) Sialodochotomy is performed by partially opening the duct. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Sialendoscope insertion. Dilation of the sialodochotomy site is performed as needed and the sialendoscope is then introduced into the duct lumen. Sialodochoplasty. (A and B) After sialendoscopy, the edges of the incised duct are sutured at several points to the surrounding mucosa, stabilizing the new orifice in the floor of mouth. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Postoperative salivary flow. Saliva can continue to flow either through the natural papilla or the new sialodochotomy site. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Submandibular sialendoscopy was performed on 131 patients including 123 glands for sialolithiasis and 16 glands for chronic sialadenitis for a total of 139 procedures. All patients had preoperative clinical assessment and imaging with either computed tomography scan or magnetic resonance imaging. Sialolithiasis was diagnosed based on physical examination, imaging studies, and endoscopic findings. Chronic obstructive sialadenitis was diagnosed based on clinical history, physical examination, and the absence of stones on preoperative imaging and sialendoscopy. Four of 11 patients with chronic sialadenitis had prior radioiodine therapy. Thirteen of 16 cases (81%) with chronic sialadenitis without sialolithiasis required limited distal sialodochotomy for sialendoscopy compared to 47% (58 of 123) of sialolithiasis cases (Table 1). Bilateral gland involvement was seen in five patients with chronic sialadenitis (45%) and of these, four required bilateral distal sialodochotomy for sialendoscopy. Cases with sialolithiasis had an average stone size of 8.12 mm in maximal dimension. No significant difference in average stone size, patient gender, the number of cases with multiple stones, the need for transoral stone removal, multiple sialendoscopy procedures, or sialadenectomy was noted between cases requiring distal sialodochotomy and cases with successful standard papilla dilation (Table 2). Complications or failures of the technique were noted in three cases. Sialendoscopy could not be accomplished in one case (1%), even after limited distal sialodochotomy was completed. In this case there was complete atresia of the distal Wharton's duct and a posterior sialodochotomy was required for sialendoscopy and proximal stone removal. Two patients who underwent distal sialodochotomy for sialendoscopy developed postoperative ranulas. One of these cases was performed for sialolithiasis, and the other case for chronic sialadenitis therapy. Both ranulas presented 4 months after the initial sialendoscopy and were managed with transoral sublingual gland resections without further sequelae. Duct patency after the limited distal sialodochotomy technique was evaluated in six cases that required repeat sialendoscopy for recurrent symptoms or residual stone fragments. Four of the repeat cases (67%) had patent dochotomy sites allowing for easy introduction of the sialendoscope. Two cases (33%) required secondary repeat distal sialodochotomy to allow for sialendoscope insertion. Of these cases, one was treated for residual proximal stone fragments and had undergone laser lithotripsy during the first procedure 5 months prior, with noted duct wall trauma. The second case was treated for chronic obstructive sialadenitis and had developed a postoperative ranula. Minimally invasive endoscopic-assisted techniques for management of submandibular gland obstruction have enhanced our diagnostic abilities and reduced the need for sialadenectomy and its associated risks. During submandibular sialendoscopy, navigating and dilating the papilla, the narrowest portion of the submandibular duct, is one of the most challenging and time-consuming parts of the procedure. Reports of preliminary institutional experiences with sialendoscopy cite the use of a papillotomy in up to 25% of initial cases.9, 10 Performing a papillotomy, however, introduces the risk for papilla stenosis and subsequent duct obstruction. The aim of this study was to describe an alternative surgical approach for introducing the sialendoscope into the submandibular duct when standard papilla dilation is not possible. We reviewed the anatomy and described the steps for a limited distal sialodochotomy that allows for consistent endoscopic access to the submandibular duct. This technique avoids incision of the submandibular duct papilla and subsequent inflammation or stenosis. With the incorporation of this method in our series, sialendoscopy was successful in 99% of cases consistent with previous literature citing success rates of 96% to 98% for the submandibular duct.11, 12 In one case, sialendoscopy could not be achieved due to atresia of the distal portion of Wharton's duct requiring posterior duct exposure for sialodochotomy. Others have also reported experience with sialendoscopy failure due to inflammation and complete duct fibrosis requiring duct marsupialization.10, 11 In our series, most cases were performed for sialolithiasis with 47% of these cases requiring distal sialodochotomy for sialendoscopy. A smaller set of patients had chronic sialadenitis symptoms without sialolithiasis and displayed a more frequent need for distal sialodochotomy in 81% of cases. It appears that cases with chronic sialadenitis symptoms from radioiodine therapy or idiopathic chronic inflammation are more likely to have pathology and narrowing in the region of the papilla preventing standard papilla dilation. Chronic symptoms were also associated with a higher rate of bilateral gland involvement. Interestingly, 80% (four of five) patients with bilateral chronic sialadenitis required bilateral distal sialodochotomy, suggesting that systemic inflammatory etiologies may contribute to duct narrowing and subsequent obstructive symptoms.13 The duration of salivary duct obstruction or inflammation may also contribute to the degree of stenosis. Further studies are required to understand the connection between medical comorbidities such as prior radioiodine therapy, autoimmune or infectious disorders, and salivary duct papilla pathology. Therapeutic sialendoscopy for sialolithiasis can be accomplished through a variety of techniques. Mobile stones, smaller than 5 mm, can often be extracted using the basket or endoscopic forceps. Large proximal stones require the combined transoral approach for removal.14 Often, endoscopic stone removal with a basket will require a papillotomy or sialodochotomy to release the stone and prevent trauma to the papilla or trapping of the basket.5 In our series, a focal sialodochotomy was performed for cases utilizing endoscopic basket retrieval to avoid incising the papilla. In cases that had a limited distal sialodochotomy for sialendoscope insertion, however, the sialodochotomy site was often sufficiently enlarged to allow for basket and stone release, thus avoiding a separate releasing incision. The benefit of the use of intraductal stents and irrigation with steroids is unclear.5 We did not use stents or steroid flushes in any of our cases and had excellent outcomes based on clinical follow-up that ranged from 1 month to more than 2 years. The stricture rate after sialendoscopy has been reported to be about 2.5% and is typically managed with repeat endoscopy and dilation. Some experts have recommended the routine use of stents and intraoperative and postoperative steroid irrigation to prevent duct stenosis15; however, no randomized clinical trials have been completed to study their benefit. Two cases in our series developed postoperative ranulas. A ranula is a rare complication of sialendoscopy and may be related to the extent of the procedure or need for posterior transoral stone removal.15 Our complication rate for ranula and stricture formation is within the expected range after standard sialendoscopy procedures. It is thought that ranula formation can be avoided by avoiding excessive dissection near the sublingual gland ductules. Ninety percent of our patients did not report recurrent symptoms or complications related to the sialendoscopy procedure. We were able to examine a small subset of patients, however, with repeat sialendoscopy for residual stone fragments or recurrent obstructive symptoms. Three cases that were performed via standard papilla dilation did not require distal sialodochotomy on the repeat endoscopy. Most of the cases that underwent distal limited sialodochotomy revealed patent sialodochotomy sites. Only two of these patients required a second distal sialodochotomy due to ductal complications from ranula formation in one case, and a laser-related duct stricture in the other case. This suggests that anatomic and pathologic variations are specific to each individual and can contribute to the need for sialodochotomy. Furthermore, secondary endoscopy procedures rarely require distal sialodochotomy. Our study is limited by its retrospective design and lack of long-term follow-up. This technique, however, is an option for introduction of the sialendoscope into the submandibular duct when standard dilation of the papilla is not possible. Limited distal submandibular sialodochotomy is a facile technique for consistent placement of a sialendoscope into the submandibular duct. In our experience, this technique was more frequently necessary in patients with chronic sialadenitis compared to those with sialolithiasis. Careful tissue management allows distal sialodochotomy to be performed with a very low complication rate and without the need for routine stent placement. Further experience with this technique and more complete long-term follow-up data will further delineate the benefits of its use." @default.
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• W2105173637 date "2013-04-02" @default.
• W2105173637 modified "2023-10-16" @default.
• W2105173637 title "Limited distal sialodochotomy to facilitate sialendoscopy of the submandibular duct" @default.
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