The prevention and treatment of recurrent bile duct stones by transduodenal sphincteroplasty.

Abstract

AbstractSphincteroplasty is a transduodenal method of producing a terminal choledochoduodenostomy as wide as the supraduodenal common duct. The sphincters affecting common and pancreatic ducts are destroyed, making the opening noncontractile and permanent. To achieve this, the common and duodenal walls are divided between clamps and oversewn. The resulting stoma differs anatomically and physiologically from that of sphincterotomy, which leaves functioning sphincter behind. This is demonstrable by postoperative T‐tube pressure and flow studies before and after morphine, and free reflux and stomal permanence after sphincteroplasty. Such an opening prevents trapping of overlooked stones or bile stasis with stone formation.Sphincteroplasty has been performed in a series of 312 patients with a mortality of 0.96% and a morbidity of 4.7%. There have been no deaths in the last 200 patients. There were 211 operations performed for obstructive biliary disease, on the basis of 1 or more indications: multiple common duct stones were present in 187, irremovable hepatic duct calculi in 4, and residual stone in 22 referred patients. In addition, miscellaneous indications for operation included papillary stenosis, strictures, irremovable calculi, and mud and sludge. All 211 patients were relieved of bile duct obstruction and there were no residual stones following sphincteroplasty.It is stressed that sphincteroplasty is one of several ways to achieve free bile duct drainage. These methods should not be considered competitive. The operation selected should be tailored to meet the specific situation at hand.