The role of family physicians in cancer care: perspectives of primary and specialty care providers.

BACKGROUND: Currently, the specific role of family physicians (fps) in the care of people with cancer is not well defined. Our goal was to explore physician perspectives and contextual factors related to the coordination of cancer care and the role of fps. METHODS: Using a constructivist grounded theory approach, we conducted telephone interviews with 58 primary and cancer specialist health care providers from across Canada. RESULTS: The participants-21 fps, 15 surgeons, 12 medical oncologists, 6 radiation oncologists, and 4 general practitioners in oncology-were asked to describe both the role that fps currently play and the role that, in their opinion, fps should play in the future care of cancer patients across the cancer continuum. Participants identified 3 key roles: coordinating cancer care, managing comorbidities, and providing psychosocial care to patients and their families. However, fps and specialists discussed many challenges that prevent fps from fully performing those roles: ■ The fps described communication problems resulting from not being kept "in the loop" because they weren't copied on patient reports and also the lack of clearly defined roles for all the various health care providers involved in providing care to cancer patients.■ The specialists expressed concerns about a lack of patient access to fp care, leaving specialists to fill the care gaps. The fps and specialists both recommended additional training and education for fps in survivorship care, cancer screening, genetic testing, and new cancer treatments. CONCLUSIONS: Better communication, more collaboration, and further education are needed to enhance the role of fps in the care of cancer patients.

Multigene expression profile testing in breast cancer: is there a role for family physicians?

BACKGROUND: Family physicians (fps) play a role in aspects of personalized medicine in cancer, including assessment of increased risk because of family history. Little is known about the potential role of fps in supporting cancer patients who undergo tumour gene expression profile (gep) testing. METHODS: We conducted a mixed-methods study with qualitative and quantitative components. Qualitative data from focus groups and interviews with fps and cancer specialists about the role of fps in breast cancer gep testing were obtained during studies conducted within the pan-Canadian canimpact research program. We determined the number of visits by breast cancer patients to a fp between the first medical oncology visit and the start of chemotherapy, a period when patients might be considering results of gep testing. RESULTS: The fps and cancer specialists felt that ordering gep tests and explaining the results was the role of the oncologist. A new fp role was identified relating to the fp-patient relationship: supporting patients in making adjuvant therapy decisions informed by gep tests by considering the patient's comorbid conditions, social situation, and preferences. Lack of fp knowledge and resources, and challenges in fp-oncologist communication were seen as significant barriers to that role. Between 28% and 38% of patients visited a fp between the first oncology visit and the start of chemotherapy. CONCLUSIONS: Our findings suggest an emerging role for fps in supporting patients who are making adjuvant treatment decisions after receiving the results of gep testing. For success in this new role, education and point-of-care tools, together with more effective communication strategies between fps and oncologists, are needed.

Do current cancer follow-up care practices meet the needs of young adult cancer survivors in Canada? A qualitative inquiry.

PURPOSE: The purpose of the present study was to assess whether current cancer follow-up care practices meet the needs of young adult cancer survivors in Canada. METHODS: This qualitative study used a constructivist grounded theory framework to analyze telephone interviews with cancer survivors from across Canada diagnosed between the ages of 18 and 39 years. The focus was specifically on cancer follow-up care (cfc). RESULTS: Interviews were conducted with 55 participants, and 53 interviews were used for the analysis. The overall theme that emerged from the data was the lack of age-specific cfc. Some of the subthemes that emerged were the absence or inadequacy of fertility and infertility treatment options; of psychological services such as family, couples, and sexuality counseling; of social supports such as assistance with entry or re-entry into the education system or workplace; of access to supplemental health insurance; and of survivorship care plans. Based on the data resulting from the interviews, we developed a conceptual model of young-adult cfc incorporating the major themes and subthemes that emerged from our study. The proposed model aims to ensure a more age-appropriate and comprehensive approach to cfc for this group of cancer patients. CONCLUSIONS: Current Canadian cfc practices are inadequate and do not provide comprehensive care for young adult cancer survivors in Canada. The conceptual model presented here aims to ensure a more comprehensive approach to cfc that meets the needs of this unique cancer population and reduces further possible physical, psychological, or social cancer sequelae.

Using a positive self-talk intervention to enhance coping skills in breast cancer survivors: lessons from a community-based group delivery model.

PURPOSE: Cancer survivorship is a distinct phase of the cancer continuum, and it can have myriad associated stresses and challenges. The purpose of the present study was to evaluate the effectiveness of a positive self-talk (pst) intervention in enhancing the coping skills and improving the psychological well-being of breast cancer survivors. METHODS: Participants (n = 38) were recruited from 5 support groups in a small eastern Canadian province. Support groups were randomly assigned to either a control (n = 18) or an intervention (n = 20) condition. Intervention participants were pre-tested, received a 2-hour pst in-person group workshop and a 10-minute "booster" session by telephone, and completed post-test questionnaires 1 month later. RESULTS: Intervention participants reviewed the workshop favourably. Nearly all participants used the intervention in everyday life, were able to accurately describe how pst works, and found that pst had a considerable impact on their ability to cope with cancer and related sequelae. However, the descriptive findings from the workshop evaluation did not translate into significant differences between the intervention and control groups on the psychometric measures. CONCLUSIONS: The pst intervention, delivered in a community group model, was positively received and effective in teaching participants about pst and how pst can be used to enhance coping skills for breast cancer patients. However, the intervention did not promote significantly greater levels of change in anxiety, depression, mood disturbance, or coping ability for intervention participants. The unique challenges of community-level psychological intervention are explored.

Transgastric biologic mesh delivery and abdominal wall hernia repair in a porcine model.

BACKGROUND AND STUDY AIMS: Incisional abdominal wall hernias currently require repair with open or laparoscopic surgery, which is associated with wound complications and recurrent hernia formation. Natural orifice transluminal endoscopic surgery (NOTES) techniques may have the potential to decrease the morbidity associated with hernia repair. The aim of this study was to repair a chronic ventral hernia with a biologic mesh placed transgastrically in a porcine model. MATERIALS AND METHODS: Six pigs underwent creation of an incisional abdominal wall hernia. At least 4 weeks later, transgastric repair was done using an underlay biologic mesh with at least 5 cm of overlap from the hernia fascial edge. The mesh was secured with transfascial sutures and the stomach was closed with a sutured gastropexy. Pigs were evaluated 2 weeks later by laparoscopy. Pigs were sacrificed and necropsy wa s performed 4 weeks after the repair. RESULTS: Six pigs underwent hernia repair lasting a mean (+/- SD) of 204 +/- 123 minutes, with one perioperative death. At 2 weeks after hernia repair, laparoscopy showed significant adhesions in all pigs; one pig had extensive mesh infection and was sacrificed. Necropsy on one pig at 2 weeks and four pigs at 4 weeks showed complete coverage of the hernia defect in all pigs. All pigs had mesh abscesses or a positive mesh culture. CONCLUSION: Transgastric repair of a chronic ventral hernia is technically feasible. Difficulties with mesh delivery and infection need to be overcome before this approach can be used in humans.

Retrorectus polyester mesh repair for midline ventral hernias.

PURPOSE: To evaluate the effectiveness of the retrorectus mesh repair for midline ventral hernias. METHODS: A retrospective review of all consecutive patients having a retrorectus mesh repair by a single surgeon in a standardized fashion from 1991 to 2005. All procedures used polyester (Mersilene) mesh with at least 5-cm overlap beyond the repair in all directions. RESULTS: Ninety patients were identified, 56% of which were female. Major postoperative complications occurred in 23 (26%) patients, including nine (10%) patients requiring reoperative treatment due to skin flap necrosis, wound infection, hematoma, or fascial dehiscence. Partial mesh excision was required in four patients. The hernia recurrence rate was 7% at a mean of 53 months. CONCLUSION: The retrorectus repair with polyester mesh is an effective and durable repair for midline ventral hernias. The disadvantage of this repair is the large number of wound complications.

"This is a kind of betrayal": a qualitative study of disability after breast cancer.

OBJECTIVE: We proposed to document the effect of arm morbidity and disability in 40 Canadian women who were 12-24 months post breast cancer surgery. METHODS: We completed 40 qualitative interviews as one component of a multidisciplinary national longitudinal study of arm morbidity after breast cancer (n = 745) involving four research sites (Fredericton/Saint John, Montreal, Winnipeg, Surrey). During semi-structured interviews, participants who had reported arm morbidity and disability in earlier surveys were asked to discuss the effects of these conditions on everyday life. RESULTS: The interviewees reported making major adjustments to paid and unpaid work, which often involved the assistance of family members, thus demonstrating the effect of disability. Interview data resulted in the creation of a model that addresses arm morbidity and disability, and that holds implications for health care professionals. CONCLUSIONS: Based on the interview findings, we conclude that a robust measure of disability after breast cancer should be developed. In the absence of a validated measure of the effect of disability, evaluating qualitative responses to questions about everyday activities could provide the impetus for provision of physical therapy and emotional support.

The economic impact on families when a child is diagnosed with cancer.

OBJECTIVE: In a study conducted in New Brunswick and Newfoundland and Labrador, we examined the economic impact on families caring for a child with cancer. METHODS: We undertook semi-structured interviews with 28 French and English families with a child diagnosed with cancer in the last 10 years. RESULTS: Families who care for a child with cancer incur considerable costs during the diagnostic, treatment, and follow-up care phases of the disease. Four major themes emerged from this qualitative study as contributing factors for these expenses: necessary travel; loss of income because of a reduction or termination of parental employment; out-of-pocket treatment expenses; and inability to draw on assistance programs to supplement or replace lost income. In addition, many of the decisions with regard to the primary caregiver were gendered. Typically, the mother is the one who terminated or reduced work hours, which affected the entire family's financial well-being. CONCLUSIONS: For families with children diagnosed with cancer, financial issues emerged as a significant concern at a time when these families were already consumed with other challenges. This economic burden can have long-term effects on the financial security, quality of life, and future well-being of the entire family, including the siblings of the affected child, but in particular the mother. Financial assistance programs for families of seriously ill children need to be revisited and expanded.

Evaluation of a novel endoluminal stapling procedure to restrict the lower esophageal sphincter and reduce reflux.

BACKGROUND AND STUDY AIMS: An effective, safe, and long-lasting endoluminal treatment for gastroesophageal reflux disease (GERD) would be an attractive prospect. We developed an endoluminal technique to restrict and tighten the lower esophageal sphincter (LES), by using a transoral endoscopic stapling device in a porcine model. PATIENTS AND METHODS: Pre-interventional evaluation comprised endoscopy, manometry, and 48-hour pH measurement of the distal esophagus using the catheterless BRAVO pH capsule. By placing the endoluminal stapling device at the LES and firing a 2.5-cm staple line, a vertical plication was created. In five pilot pigs (phase 1), plications were placed in various locations at the LES. In another five pigs (phase 2), plications were placed uniformly at the mid level of the LES on the lesser curvature side. Measurements were repeated 2 weeks after the procedure. Necropsy and histological analysis were performed. RESULTS: Endoluminal stapling was successfully completed in all animals. In phase 2, the median procedure time was 15 minutes (range 10-55 minutes). LES pressure increased from 10.5 mmHg (+/- 2.5 mmHg) to 14.3 mmHg (+/- 3.8 mmHg) (P = 0.038). Median percentage of time with pH below 4 decreased from 6.6% (range 2.9%-48.8%) to 2.2% (range 0%-10.4%) (P = 0.043). Histology showed the staple line involving the muscular layer in all pigs. A gap was present in the central part of the staple line in three pigs resulting in a mucosa-muscular bridge of tissue. This bridge did not influence the results. CONCLUSION: This novel endoluminal technique is feasible and safe in a porcine model over 2 weeks. It is appealing due to its simplicity and ease of application. Further studies aimed at eliminating the gap in the staple line and investigating more animals over longer survival periods are needed.

Endoscopic colotomy closure after full thickness excision: comparison of T fastener with multiclip applier.

BACKGROUND AND STUDY AIMS: Safe, reliable, and efficient endoscopic closure of a colotomy is paramount for endoscopic full thickness excision of the colon. Two newly developed devices, the Tissue Apposition System (TAS) and the InScope Multi-Clip Applier (IMCA), may help to achieve this. The aim of this study was to determine the feasibility of using each device to close colotomies after full thickness wall excisions. MATERIAL AND METHODS: 12 pigs were used in the study. After laparoscopic full thickness excision of the colonic wall, the defect was closed using either the TAS or the IMCA. Closure was performed under laparoscopic vision. Success of colotomy closure, time taken for colotomy closure, postoperative infections, and complication rates were recorded. RESULTS: Complete closure was achieved in 6/6 pigs in the TAS group. In 5/6 pigs in the IMCA group closure was successful; in one pig laparoscopic assistance was used. Median closure time (range) was significantly lower in the TAS group at 48 minutes (15 - 51) vs. 76 minutes (43 - 145) in the IMCA group. There were no postoperative infections or complications. CONCLUSIONS: Endoscopic closure after full thickness colonic wall excision is feasible with both the TAS and the IMCA. Closure times are significantly shorter and handling is easier with the TAS. Combined use of both systems might be beneficial.

A prospective trial of primary inguinal hernia repair by surgical trainees.

The main hypotheses were that the Lichtenstein inguinal hernia repair has a lower recurrence rate and similar incidence of chronic groin pain compared to sutured repairs when performed by surgical trainees. In a U.S. Veterans Administration Hospital, 150 primary hernia repairs were randomized to a Lichtenstein, McVay, or Shouldice repair. The Shouldice repair included a routine relaxing incision. First- and second-year residents, under the supervision of an experienced general surgeon, performed the procedure. Long-term follow-up was obtained in 81% of patients. Hernia recurrence rate was Lichtenstein 8%, McVay 10%, Shouldice 5% ( P>0.1) at 6-9 years follow-up. More patients had chronic groin pain following Lichtenstein repair (38%) than after Shouldice repair (7%) ( P<0.05). More information is needed on long-term groin pain following anterior mesh repair. The Shouldice inguinal hernia repair may have a role in open primary herniorrhaphy to decrease the risk of chronic groin pain.

Jejunal manometry predicts tube feeding intolerance in the postoperative period.

Postoperative nutrition is best provided enterally; however, patients often develop intolerance to enteral feedings. Our aim was to prospectively identify abdominal examination and jejunal pressure activity associated with postoperative intolerance of enteral feedings. Twenty-nine patients underwent abdominal operation and needle catheter jejunostomy placement. Elemental tube feedings were started on the day after surgery and advanced to the caloric goal rate over three days. Patients whose feedings were slowed at the attending surgeon's discretion were defined as intolerant. Jejunal manometry and a standardized abdominal exam were performed on postoperative days 1, 3, and 5. Fifteen patients (52%) were intolerant of tube feedings and had decreased jejunal motor activity but more active bowel sounds prior to feedings. After feedings, intolerant patients developed abdominal distension, but other abdominal findings were inconsistent. A marked decrease in phase II of the migrating motility complex (MMC) and the lack of a fed response were present in both groups. The overall jejunal motility present on day 1 following surgery identifies patients that will not tolerate enteral feedings. The abdominal examination, MMC parameters, and motor response to feeding did not predict feeding intolerance.

Guidelines 2000 for colon and rectal cancer surgery.

BACKGROUND: Oncologic resection techniques affect outcome for colon cancer and rectal cancer, but standardized guidelines have not been adopted. The National Cancer Institute sponsored a panel of experts to systematically review current literature and to draft guidelines that provide uniform definitions, principles, and practices. METHODS: Methods were similar to those described by the American Society of Clinical Oncology in developing practice guidelines. Experts representing oncology and surgery met to review current literature on oncologic resection techniques for level of evidence (I-V, where I is the best evidence and V is the least compelling) and grade of recommendation (A-D, where A is based on the best evidence and D is based on the weakest evidence). Initial guidelines were drafted, reviewed, and accepted by consensus. RESULTS: For the following seven factors, the level of evidence was II, III, or IV, and the findings were generally consistent (grade B): anatomic definition of colon versus rectum, tumor-node-metastasis staging, radial margins, adjuvant R0 stage, inadvertent rectal perforation, distal and proximal rectal margins, and en bloc resection of adherent tumors. For another seven factors, the level of evidence was II, III, or IV, but findings were inconsistent (grade C): laparoscopic colectomy; colon lymphadenectomy; level of proximal vessel ligation, mesorectal excision, and extended lateral pelvic lymph node dissection (all three for rectal cancer); no-touch technique; and bowel washout. For the other four factors, there was little or no systematic empirical evidence (grade D): abdominal exploration, oophorectomy, extent of colon resection, and total length of rectum resected. CONCLUSIONS: The panel reports surgical guidelines and definitions based on the best available evidence. The availability of more standardized information in the future should allow for more grade A recommendations.

Distal margin requirements after preoperative chemoradiotherapy for distal rectal carcinomas: are < or = 1 cm distal margins sufficient?

BACKGROUND: Sphincter-sparing alternatives to abdominoperineal resection (APR) in the treatment of rectal cancer often are underused out of concern for inadequate distal margins and local failure. The present study addresses whether sphincter-sparing techniques with distal margins < or = 1 cm adversely influence oncological outcome in patients given preoperative chemoradiotherapy. METHODS: Thirty-seven patients with rectal cancer < or = 8 cm from the anal verge were enrolled in the study. Preoperative external beam radiotherapy (5400 Gy) was administered together with continuous infusion of 5-fluorouracil (300 mg/m2/day). Surgical resection was performed in 36 patients with pathological assessment of tumor response and margins. Patients with sphincter-sparing resection and distal margins > 1 cm or < or = 1 cm and those who underwent APR were compared. RESULTS: Thirty-six patients completed preoperative chemoradiotherapy, with successful sphincter-preservation in 28 patients. At a median follow-up of 33 months, there were 12 recurrences overall, which included 11 distant failures and four pelvic failures. Disease-free survival (DFS) was not different between those who had an APR compared with sphincter-sparing resection with distal margins < or = 1 cm. DFS was worse (P < .02) when radial margins were < or = 3 mm compared with > 3 mm. CONCLUSIONS: Sphincter preservation is feasible in more than 75% of patients with tumors < or = 8 cm from the anal verge after preoperative chemoradiotherapy. Sphincter-sparing surgery with distal margins < or = 1 cm can be used without adversely influencing local recurrence or DFS. Limited radial margins (< or = 3 mm), however, are associated with increased disease recurrence.

A randomized, pharmacokinetic and pharmacodynamic, cross-over study of duodenal or jejunal administration compared to nasogastric administration of omeprazole suspension in patients at risk for stress ulcers.

OBJECTIVES: The aim of this study was to characterize absorption and pH control of simplified omeprazole suspension (SOS), 2 mg/ml in 8.4% sodium bicarbonate, administered via the nasogastric versus jejunal or duodenal route. METHODS: Nine critically ill surgical patients, NPO and mechanically ventilated, were enrolled in this randomized cross-over study. Patients received a single 40 mg dose of SOS by the nasogastric and either the jejunal or duodenal route. Twenty-four-hour continuous intragastric pH monitoring was performed during the study period. Sequential blood samples were collected over 24 h to characterize SOS absorption and pharmacokinetic parameters. RESULTS: Nasogastric administration of SOS resulted in lower maximum mean +/- SD serum concentrations compared to jejunal/duodenal dosing (0.970 +/- 0.436 vs 1.833 +/- 0.416 microg/ml, p = 0.006). SOS absorption was significantly slower when administered via nasogastric tube (108.3 +/- 42.0 vs 12.1 +/- 7.9 min, p < 0.001). However, all routes of administration resulted in similar SOS area under the serum concentration-time curves (AUC(0-infinity)) (415.1 +/- 291.8 vs 396.7 +/- 388.1 microg x min/ml, p = 0.91) [corrected]. Mean intragastric pH values remained >4 at 1 h after SOS administration and remained >4 for the entire 24-h study (6.32 +/- 1.04, 5.57 +/- 1.15, nasogastric vs jejunal/duodenal, p = 0.015), regardless of administration route. CONCLUSIONS: In critically ill surgical patients, pharmacokinetic parameters and subsequent pH control after the administration of SOS are similar by the jejunal, nasogastric, or duodenal route. SOS suspension offers an alternative acid control measure when patients are unable to take oral medications, yet have an enteral tube in place.

Uroguanylin treatment suppresses polyp formation in the Apc(Min/+) mouse and induces apoptosis in human colon adenocarcinoma cells via cyclic GMP.

The enteric peptides, guanylin and uroguanylin, are local regulators of intestinal secretion by activation of receptor-guanylate cyclase (R-GC) signaling molecules that produce cyclic GMP (cGMP) and stimulate the cystic fibrosis transmembrane conductance regulator-dependent secretion of Cl- and HCO3-. Our experiments demonstrate that mRNA transcripts for guanylin and uroguanylin are markedly reduced in colon polyps and adenocarcinomas. In contrast, a specific uroguanylin-R-GC, R-GCC, is expressed in polyps and adenocarcinomas at levels comparable with normal colon mucosa. Activation of R-GCC by uroguanylin in vitro inhibits the proliferation of T84 colon cells and elicits profound apoptosis in human colon cancer cells, T84. Therefore, down-regulation of gene expression and loss of the peptides may interfere with renewal and/or removal of the epithelial cells resulting in the formation of polyps, which can progress to malignant cancers of the colon and rectum. Oral replacement therapy with human uroguanylin was used to evaluate its effects on the formation of intestinal polyps in the Min/+ mouse model for colorectal cancer. Uroguanylin significantly reduces the number of polyps found in the intestine of Min/+ mice by approximately 50% of control. Our findings suggest that uroguanylin and guanylin regulate the turnover of epithelial cells within the intestinal mucosa via activation of a cGMP signaling mechanism that elicits apoptosis of target enterocytes. The intestinal R-GC signaling molecules for guanylin regulatory peptides are promising targets for prevention and/or therapeutic treatment of intestinal polyps and cancers by oral administration of human uroguanylin.

Percutaneous cholecystostomy is an effective treatment for high-risk patients with acute cholecystitis.

We sought to determine the safety, efficacy, and outcome of percutaneous cholecystostomy (PC) in all patients undergoing the procedure at our institutions. We reviewed 53 consecutive cases of acute cholecystitis seen at our hospitals over 5.5 years in which PC was performed at the initial treatment. Follow-up was obtained by chart review and telephone questionnaire. Acute cholecystitis was the primary admitting diagnosis in 18 cases. In the remaining 35, cholecystitis developed during hospitalization. All patients were considered high surgical risks on the basis of the presence of comorbid conditions. The gallbladder was successfully catheterized under radiologic guidance in all patients and with no immediate procedure-related morbidity. Acute cholecystitis resolved in 44 of 53 patients (83%), whereas nine patients (17%) did not improve clinically after PC and died during the same hospitalization. A total of 33 (62%) eventually survived hospitalization. Elective cholecystectomy was done in 25 patients with no mortality. After cholecystectomy, three of these patients subsequently died of other causes, whereas 22 are alive. Eight patients did not undergo cholecystectomy because of underlying medical conditions or because they had acalculous cholecystitis. These patients remained free of biliary problems after removal of their cholecystostomy tube, but two have subsequently died of nonbiliary conditions. Percutaneous cholecystostomy is a safe, effective treatment for high-risk patients with acute cholecystitis. Cholecystostomy can be followed by elective cholecystectomy at a later time if the patient's condition permits or by expectant conservative management in patients who have had acalculous cholecystitis or have a very high mortality risk with surgery.

Role of basement membrane collagen and elastin in the autofluorescence spectra of the colon.

BACKGROUND: Autofluoresence can be used to detect neoplasia in the colon. Two known fluorophores, collagen and elastin, are probably partly responsible for colonic emission spectra. Their contribution to colonic autofluorescence was investigated. METHODS: Autofluorescence spectra of normal, dysplastic, and malignant colonic tissue were studied by using excitation wavelengths from 280 nm to 350 nm. The wavelengths of peak emission and their widths at half maximum intensity were measured. Similar measurements were performed on collagen types I, III, IV, V, IX, and elastin. Colonic spectra were compared to those of collagen and elastin. Spectral differences between collagen types IV (basement membrane) I, III, V, and IX were studied. RESULTS: Four major emission peaks were noted whose wavelength of peak emission and full widths at half maximum intensity were independent of tissue histology. The emission spectra of type IV collagen differed markedly from that of nonbasement membrane collagens and elastin. CONCLUSIONS: Type IV (basement membrane) collagen is most likely responsible for the emission peak at 365 nm. The spectra of basement membrane collagen and not other types of collagen should be used in studies of epithelial tissue spectra. Elastin did not appear to be responsible for any of the four autofluorescence peaks observed in colonic tissue.

Intrasphincteric botulinum toxin type A for the diagnosis of sphincter of Oddi dysfunction: a case report.

Biliary-type pain from sphincter of Oddi dysfunction is not uncommon after cholecystectomy. An increased basal pressure of sphincter of Oddi manometry establishes the diagnosis and treatment is usually by endoscopic sphincterotomy. Both procedures carry a significant complication rate. A few patients with elevated sphincter pressure do not respond to therapy; the source of their pain may be elsewhere. This case report describes the use of intrasphincteric botulinum toxin injection for the diagnosis of sphincter of Oddi dysfunction in a patient after repeated attempts at manometry had failed. This may provide a safe and easy method of determining whether sphincter of Oddi dysfunction may be the cause of biliary pain in post/ cholecystectomy patients and help select patients who would benefit from subsequent sphincter ablation, without the risks of sphincter of Oddi manometry. Prospective studies are first needed.